Why will MCOs be necessary with PHE unwinding?
Medicaid managed care organizations (MCOs) ship care to greater than two-thirds of all Medicaid beneficiaries nationally. Medicaid MCOs (additionally known as managed care plans) might keep up a correspondence with enrollees as they supply care coordination and different member companies (e.g., well being training and promotion, name heart help) and will conduct periodic outreach to advertise acceptable use of care (e.g., to encourage prevention, wellness, and early intervention). All through the pandemic, states have labored with managed care plans to answer altering public well being circumstances and new developments, together with to advertise the take-up of COVID-19 vaccinations.
Medicaid MCOs have seen development of their membership in the course of the pandemic that tracks general Medicaid enrollment traits. Enrollment development displays downturns within the financial system because of the pandemic and provisions within the Households First Coronavirus Response Act (FFCRA) that require states to make sure steady enrollment for present Medicaid enrollees to entry a short lived enhance within the Medicaid match price in the course of the Public Well being Emergency (PHE) interval. It’s anticipated that the PHE might be prolonged by means of at the least mid-July 2022 for the reason that Biden administration indicated it will give states 60 days-notice earlier than the PHE is terminated or is allowed to run out (the present PHE is ready to run out in mid-April). If the PHE ends in mid-July, the continual enrollment requirement would expire initially of August 2022.
Medicaid managed care plans can help state Medicaid companies in speaking with enrollees, conducting outreach and help, and finally, in enhancing protection retention (together with facilitating transitions to the Market the place acceptable). After the PHE ends, state Medicaid companies might want to full a lot of eligibility and enrollment duties and actions, together with processing renewals, redeterminations (primarily based on modifications in circumstance), and post-enrollment verifications. Present CMS steering signifies states should provoke all renewals and different excellent eligibility actions inside 12 months after the PHE ends. Medicaid managed care plans have a monetary curiosity in sustaining enrollment, which may additionally stop disruptions in take care of enrollees, together with prescription drug advantages. 4 for-profit dad or mum companies that account for about 40% of Medicaid enrollment nationally (Anthem, Centene, Molina, and UnitedHealth Group) reported on This fall 2021 earnings calls that they anticipate modest enrollment declines of their Medicaid membership after the continual enrollment requirement ends. Nevertheless, these companies additionally indicated anticipating to choose up/seize many people who transition from Medicaid by means of their different traces of enterprise (i.e., the Reasonably priced Care Act Market and employer sponsored insurance coverage (ESI)). Managed care plans have lengthy cited lack of steady eligibility, or churn, as a key problem in making certain entry to care and for care continuity.
How can states have interaction MCOs to assist people retain Medicaid protection or transition to different protection?
CMS launched steering for state Medicaid companies on resuming regular operations together with outlining methods for working with managed care plans to advertise continuity of protection when the continual enrollment requirement in the course of the PHE ends. Within the steering, CMS notes that the federal Medicaid managed care advertising and marketing guidelines (42 CFR 438.104) don’t prohibit plans from offering data and conducting normal outreach on behalf of states. States should develop an “unwinding operational plan” to doc their complete plan to renew regular operations of their Medicaid and Kids’s Well being Insurance coverage Program (CHIP) packages. CMS is encouraging states to collect enter on their unwinding plans, together with from managed care plans. Key methods from the CMS steering embrace:
- Working with plans to acquire and replace beneficiary contact data. States might direct MCOs to hunt up to date contact data from enrollees. Plans should affirm the accuracy of updates acquired from a 3rd celebration (e.g., supplier) with enrollees straight. MCOs might share this data with the state or might instruct or help people in offering their up to date contact data to the state. States might settle for up to date enrollee contact data from MCOs together with mailing addresses, phone numbers, and electronic mail addresses supplied the state complies with sure beneficiary discover necessities (to substantiate the accuracy of up to date contact data) or the state receives a waiver of such necessities from CMS. Whereas steering expects plans to assist in updating contact data, plans have traditionally cited problem reaching members and inaccurate member contact data as key limitations to partaking enrollees in care coordination actions. Whereas state plans are evolving, as of January 2022, about half of states reported working with managed care plans to replace beneficiary mailing addresses earlier than the tip of the PHE.
- Sharing renewal recordsdata with MCOs to conduct outreach and supply help to people enrolled in Medicaid throughout their renewal interval. States can present month-to-month recordsdata to MCOs containing details about beneficiaries for whom the state is initiating the renewal course of, or beneficiaries who’ve but to submit renewal types or different documentation and are vulnerable to shedding protection, to allow plans to conduct outreach and supply help with the renewal course of. Previous to sharing data with managed care plans (e.g., renewal recordsdata), states might have to establish and tackle attainable methods or operational challenges, together with to make sure information accuracy.
- Enabling MCOs to conduct outreach to people who’ve not too long ago misplaced protection for procedural causes. States can present MCOs month-to-month termination recordsdata to allow plans to conduct outreach to people terminated from Medicaid for procedural causes (e.g., not returning renewal types well timed). CMS notes states might have to expedite evaluation of plan outreach messaging or might need to contemplate creating customary language for use by Medicaid managed care plans to make sure compliance with federal advertising and marketing necessities in addition to any state-specific legal guidelines or contract necessities that will apply. Inside two months or much less after Medicaid protection loss, managed care contracts should present for automated re-enrollment into an enrollee’s authentic plan. Nevertheless, in the course of the PHE unwinding interval, CMS will approve state waivers to increase this automated re-enrollment interval as much as 120 days.
- Allowing plans to help people to transition to and enroll in ACA Market protection if ineligible for Medicaid or CHIP. States might encourage MCOs that additionally provide a Certified Well being Plan (QHP) within the ACA Market to share data with their very own enrollees who’ve been decided ineligible for Medicaid to help within the switch of people to Market protection (which has larger earnings eligibility thresholds than Medicaid). To keep away from gaps in protection, managed care plans might attain out to people earlier than they lose protection to permit them to use for Market protection upfront. CMS notes that federal Medicaid managed care advertising and marketing guidelines (and Alternate laws) don’t prohibit Medicaid managed care plans that provide a QHP from offering details about the QHP to enrollees who may probably enroll within the QHP as a result of lack of eligibility; nonetheless, plans should adjust to state-specific legal guidelines and/or contract necessities that will prohibit this exercise.
Along with methods recognized within the CMS steering, Medicaid managed care plans may additionally contemplate including employees to assist handle the unwinding course of. Further employees may work proactively to establish members at-risk for disruptions in care and disenrollment (e.g., people with restricted English proficiency, folks with disabilities). Managed care plans may also work in partnership with suppliers (together with group well being facilities) and community-based organizations to additional bolster efforts to succeed in and help members to make sure protection retention or transitions to Market protection.
What to look at?
Understanding how managed care plans are concerned within the improvement of state unwinding operational plans and what’s included within the operational plans themselves might be key areas to look at. When steady enrollment requirement ends, states will start processing renewals and redeterminations and thousands and thousands of individuals may lose protection if they’re not eligible or face administrative limitations in the course of the course of regardless of remaining eligible. The numerous quantity of labor that states face will place a heavy burden on eligibility and enrollment employees and will contribute to protection loss associated to procedural errors. Medicaid managed care plans could also be effectively positioned to help states in conducting outreach and offering help to enrollees who might want to navigate the renewals or redeterminations.
As mid-April approaches, extra details about the timing of the tip of the PHE might turn into obtainable. The Biden administration indicated it will give states 60 days-notice earlier than the PHE is terminated or is allowed to run out. The present PHE is ready to run out in mid-April. On February 8, 2022, the Medicaid Well being Plans of America (MHPA), a nationwide commerce affiliation representing greater than 130 MCOs, despatched a letter to Congressional leaders asking Congress to offer at the least 120-days lead time earlier than the tip of the continual enrollment requirement. States are creating unwinding operational plans however it isn’t clear that these plans might be made publicly obtainable. The insurance policies adopted and the implementation of methods to advertise continuity of protection will fluctuate throughout states and plans and may have main implications for Medicaid and broader protection because the PHE unwinds.