Faced with expanding caseloads and declining revenues, however, states are in the process of sharply expanding managed care enrollments among seniors and people with disabilities. A state survey of Medicaid managed care programs found that states expect to substantially increase their reliance on managed care delivery systems in the years ahead. Of the 45 states responding to the survey, 27 reported plans to expand the use of managed care. Of these 27 states, six indicated that they plan to extend mandatory managed care enrollment to additional Medicaid populations California, Kentucky, Louisiana, Michigan, New Jersey, and South Carolina , and four states reported plans to expand managed care to additional geographic areas of the state Florida, Texas, Kentucky, and Virginia.
In a separate, state-by-state survey, the authors found that 17 states in and 24 states in intended to expand the geographic areas and populations served by managed care programs. States also reported that they are expanding disease and care management programs as well as patient-centered medical home initiatives to improve coordination of care and increase the focus on high-need, high-cost Medicaid recipients.
Efforts to enroll dual eligible beneficiaries also are moving forward swiftly, spurred by statutory provisions of the ACA aimed at improving the quality and cost-effectiveness of services to this high-cost target population. The deadline for submitting applications was May 30, The initial awards to states were to be announced in early October, with a projected start date of January 1, , for some of the participating states and later start dates for others.
House of Representatives, January 16, Public Law , as amended by Public Law Ku, P. MacTaggart, F. Pervez, and S. CMS, Ibid. Gifford et al. Saucier, J. Kasten, B. Burwell, and L. Smith, K. Gifford, E. Ellis, R. Rudowitz, and L. If you have a question or comment, please let us know. Employment Opportunities. Skip to main content. Skip to Page Content Medicaid plays an integral role in financing health care services in the United States, accounting for 16 percent of total health spending and providing coverage for one out of every six Americans.
Among the methods commonly used by managed health care plans to control costs and thus remain financially viable are the following: Contracting exclusively with providers willing to offer their services at discounted rates. Monitoring the use of basic and ancillary services furnished by network providers and using incentives to reward below-average use and disincentives to discourage excess above-average use.
These techniques are generally referred to as utilization review. Discouraging the excessive use of tests and prescription medications. Requiring plan participants to obtain a referral prior authorization from their primary care physician to gain access to specialty services reimbursable under the plan. Requiring providers to assume part of the financial risk of cost overruns for services they control, directly or indirectly.
Differences Between Private and Public Sector Managed Care Arrangements Managed care arrangements within the Medicaid program differ from managed care in the private sector, as well as from Medicare managed care plans, in the following ways: The role of provider networks.
Limited cost sharing. Cost sharing is frequently used in commercial managed care plans to discourage overutilization of services; but because the Medicaid program serves a low-income population, Medicaid managed care plans use cost sharing sparingly.
Under federal law, states are allowed to impose only nominal cost-sharing requirements, and deductibles are rarely used. Since such cost-sharing requirements are unlikely to serve as an effective deterrent to using expensive out-of-network providers, states usually elect to establish defined provider networks and hold MCOs responsible for ensuring that beneficiaries gain access to needed services within the network and at negotiated payment rates. Choice of plans and enrollment processes.
States are required under federal law to offer Medicaid beneficiaries a choice of at least two health plans if enrollment in managed care is mandatory with the exception of certain rural areas.
Similarly, Medicare recipients who elect to enroll in a Medicare Advantage plan may do so at initial enrollment or during a subsequent annual open enrollment period.
Medicaid beneficiaries, unlike participants in private and Medicare managed care plans, often move in and out of managed care plans because of changes in income that affect their eligibility for Medicaid benefits. Comprehensive risk-based plans are the most commonly used type of Medicaid managed care arrangement. Typically, states employ an HMO model in which qualified health plans receive fixed per member per month PMPM payments from the state for furnishing a defined range of health services to plan enrollees.
Enrollees receive services through a network of participating providers. If aggregate expenditures exceed total income, the health plan is responsible for absorbing the losses, although sometimes the health plan passes on a portion of the financial risk to participating providers. In addition, states sometimes agree to share financial risk with the health plan by assuming losses in excess of a specified level e. In , 7. These plans typically cover only a single type of benefit. In , 69 percent of Medicaid enrollees had this type of plan.
In this model, states contract with MCOs to provide a full package of benefits to Medicaid enrollees. In turn, states typically pay the MCOs using a capitated payment system, or one where the MCO is paid a fixed monthly rate per enrollee to provide their healthcare services. The primary care provider usually receives a monthly case management fee per enrollee for coordinating care in addition to a fee-for-service payment for the medical services provided.
Limited benefit plans Limited benefit plans are similar to MCOs in structure in that states typically contract with a plan and pay based on a capitated payment system. However, limited benefit plans only provide certain Medicaid services such as dental or behavioral health services instead of providing a full range of health services. Comprehensive care More and more states are adopting Medicaid managed care, particularly the use of MCOs.
Of the 38 states employing managed care, 17 had at least 90 percent of their Medicaid population in MCOs. In order to keep costs down, MCOs focus on the quality of care enrollees receive instead of the quantity of services, which is known as a value-based payment model. Expanding Medicaid population In the past, states limited managed care arrangements to certain groups like children and pregnant women but they have increasingly expanded this approach to more enrollees, including those with complex medical needs.
For instance, Medicaid is the primary payer for institutional and community-based long-term services and supports since there is limited coverage in Medicare. Seniors and people with disabilities make up 25 percent of Medicaid enrollees, yet account for almost two-thirds of program spending. August Managed Care , Provider Payment.
The Medicaid managed care rule created a new option for states to require managed care plans to pay providers according to specific rates or methods, referred to as directed payments. Common types of directed payment arrangements include those that establish minimum payment rates for certain types of providers and those that require participation in value-based ….
March Managed Care. Although not all state Medicaid programs contract with MCOs, a large and growing majority do, and states are also rapidly expanding their use of MCOs to serve more medically complex beneficiaries, deliver long-term services and supports, and, in states that have expanded Medicaid under the Affordable Care Act ACA , to serve millions of newly eligible low-income adults.
Using this report source allows us to show MCO enrollment data for all states that contract with comprehensive risk-based MCOs. We will continue to post more current MCO plan-level enrollment data for a subset of states that post this data on their state Medicaid websites.
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