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Posts Tagged ‘Medicaid managed care plans’

Nevada joins with federal proposals to roll in non-group market

June 8th, 2017 Comments off

There are efforts at the federal level and now the state level to integrate the problem step child of non-group medical insurance into other forms of insurance to offering greater access at lower cost. The federal proposals would allow individuals not covered in the employer group or other government insurance programs to purchase employer group coverage via the District of Columbia health benefit exchange’s Small Business Health Options (SHOP) and the Federal Employees Health Benefits Program. Pending legislation recently sent to the desk of Nevada Gov. Brian Sandoval takes a different tack. It would authorize the state to seek federal waivers in order to allow Nevadans to purchase Medicaid managed care plan coverage though its health benefit exchange as Vox reported this week. Implicit in both of these moves is a lack of confidence that adequate spread of risk can be achieved in the non-group insurance segment, particularly in smaller states like Nevada.

Noticing the close household income eligibility nexus between its subsidized health benefit exchange and Medicaid populations, Nevada provides Medicaid managed care plans incentive to offer qualified health plans (QHPs) on its exchange to ensure adequate availability of QHPs as Vox’s Sarah Kliff reported in May. With Medicaid enrollments strongly outpacing commercial QHP enrollments in state health benefit exchanges, a number of factors began aligning in 2015 to set the stage for policymakers to allow Medicaid managed care plans to be offered on the exchanges alongside individual Qualified Health Plans (QHPs).

A major question is whether those who enroll in Nevada’s proposed “Medicaid for all” Nevada Care Plan will be able to find medical providers who will accept their plan given the historical shortfall between state Medicaid reimbursement levels and those of Medicare and commercial plans.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Observations and questions on exchange plan losses

May 2nd, 2016 Comments off

Reading media accounts of health plan issuer complaints of losses on plans sold through state health benefit exchanges, one might think all individual plans are sold through the exchanges. That false perception has implications for gauging the success of the Patient Protection and Affordable Care Act’s individual market reforms since the exchanges are only one element of them. Other key components affect all individual (and small group) plans regardless of whether they are sold on the exchanges or outside of them such as modified community based rating barring medical underwriting of individuals and pooling all individuals and small employers into single state risk pools.

The tendency to view the individual market as one and the same with the exchanges appears driven at least in part by too little data on the off-exchange individual market as compared to exchange qualified health plans. Even though the number of off-exchange plans exceeds those sold on the exchanges in many states, “[th]e lack of transparency about this market will be a growing problem for consumers and regulators,” noted Joel Ario of Manatt Health Solutions and Katherine Hempstead of the Robert Wood Johnson Foundation at the winter meeting of the National Association of Insurance Commissioners (NAIC).

Another aspect of the complaints of exchange plan losses hasn’t been covered in any detail. While some health plan issuers say exchange plans are a money loser due to high medical utilization, they could also dislike having to meet additional compliance and plan administration requirements for exchange participation that makes them unattractive. Particularly if they don’t also offer Medicaid managed care plans serving a demographic more closely aligned with those who purchase coverage through the exchanges.

Finally, more examination and reporting are needed on what’s driving reported losses among plans sold on the exchanges. The frequently reported rationale is it’s because exchange plans enrolled people who are “sicker than expected.” Sicker with what, exactly? Are the losses being incurred by those eligible for cost sharing subsidies in silver plans given that most exchange plans purchased are higher deductible bronze and silver-rated plans? Are those enrollees not eligible for out of pocket cost sharing burning through the deductibles with high cost care such as outpatient surgeries and hospitalization?

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Direct primary care finding potential market among employers, Medicaid managed care plans

January 13th, 2016 1 comment

Direct primary care is much less pricey. Patients pay $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that doctors can focus on treating patients, since they no longer have to wade through heaps of insurance paperwork. They spend less on overhead, driving costs down. And physicians say they can give care that’s more personal and convenient than in traditional practices.It’s legal under the Affordable Care Act, which identifies direct primary care as an acceptable option. But since it doesn’t cover specialists or emergencies, consumers still need a high-deductible health plan. Still, the combined cost of the monthly fee and that plan is often still cheaper than traditional insurance.

Source: Concierge Medical Care Comes To the Middle Class : Shots – Health News : NPR

This is an interesting trend that could at least in theory coincide with the shift back to the “major medical” model common in the 1950s and 1960s where people paid out of pocket for primary care, using health insurance for high cost, major medical care events.

But whether pre-paid primary care bundled with a high deductible plan ends up costing less than, say, a gold or platinum rated Obamacare individual plan designed for the frequent user of primary care (such as families with young children) looking to minimize out of pocket costs is an open question. Unless perhaps monthly cost of pre-paid medical care falls to $40 as discussed in this analysis, which sees that as unlikely to pencil out for direct primary care practices. And as a practical matter as suggested in the analysis, not many people visit primary care docs frequently enough to make the arrangement worthwhile.

Where direct primary care makes better sense financially and where it has gained traction is among employers who offer it as part of their health benefit package. These employer groups can bring more belly buttons to the table in negotiating rates with direct primary care providers. Even larger economies of scale can be had with Medicaid managed care plans, where direct primary care practices offer Medicaid beneficiaries who typically bounce among various providers and emergency rooms much needed medical homes. From the NPR article:

In Seattle, a company called Qliance, which operates a network of primary care doctors, has been testing how to blend direct primary care with the state’s Medicaid program. They started taking Medicaid patients in 2014. So far, about 15,000 have signed up. They get a Qliance doctor and the unlimited visits and virtual access that are hallmarks of the model.

“Medicaid patients are made to feel like they’re a burden on the system,” said Dr. Erika Bliss, Qliance’s CEO. “For them, it was a breath of fresh air to be able to get such personalized care – to be able to talk to doctors over phone and email.”

The article goes on to report that Qliance contracts with Medicaid managed care provider Centene. Other states including North Carolina, Idaho and Texas are keeping an eye on the Washington arrangement and considering similar programs, according to the article.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Medicaid managed care plans could be sold on state health benefit exchanges

August 24th, 2015 Comments off

With Medicaid enrollments strongly outpacing commercial individual plan enrollments in state health benefit exchanges, a number of factors are aligning to set the stage for policymakers to allow Medicaid managed care plans be offered on the exchanges alongside individual Qualified Health Plans (QHPs). They include:

  • A rulemaking issued in June by the federal Center for Medicare & Medicaid Services that would apply requirements similar to those for commercial individual and Medicare Advantage plans to Medicaid managed care plans, including allowing plan issuers to advertise products offered across the Medicaid and exchange markets (Click here for a summary of the proposed regulations posted at the Health Affairs blog);
  • The need to assure operational sustainability among state health benefit exchanges, particularly in states that have expanded Medicaid eligibility standards to households earning up to 138 percent of federal poverty levels and single childless adults. Beginning in 2015, federal establishment grant funding began drying up, leaving exchanges reliant on generating fees from participating plan issuers. Adding Medicaid managed care plans to commercial QHPs assessed exchange participation fees would bolster exchange revenues and reduce fiscal uncertainty;
  • The success of the Arkansas “private option” in expanding coverage under a federal Section 1115 waiver permitting adults that would have otherwise been eligible for expanded Medicaid coverage under the Affordable Care Act to purchase exchange QHPs;
  • Substantial and ongoing difficulties fully integrating exchange eligibility and enrollment IT platforms with legacy state Medicaid eligibility and enrollment systems to meet the Affordable Care Act’s mandate of a single application process for QHP and Medicaid eligibility determinations and enrollment;
  • Financial considerations in the distribution channel: insurance producers are wary of enrolling households eligible for Medicaid since they earn commissions only on commercial individual plans sold on and off the exchanges. The role of brokers and agents relative to Medicaid enrollments is currently under evaluation by California’s exchange, Covered California.

Sections 1301(a) and 1311(c) of the Patient Protection and Affordable Care Act defining a QHP eligible for sale on the exchanges would appear to allow Medicaid managed care plans be deemed QHPs in the exchanges provided the plan issuer also offers individual plans on the exchange that also meet state requirements (The Affordable Care Act requires a minimum of one silver and one gold level plan be offered). Indeed, the QHP requirements set forth in Section 1311(c) have some overlap with those proposed for Medicaid managed care plans in the June CMS proposed rulemaking, including provisions requiring provider network adequacy standards, plan quality improvement programs and clinical care quality management.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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