A Number Of Large Health Insurance Companies Have A Significant Stake In The Medicaid Managed Care Market
States contracted with a total of 282 Medicaid MCOs as of July 2019. MCOs represent a mix of private for-profit, private non-profit, and government plans. As of July 2019, a total of 16 firms operated Medicaid MCOs in two or more states ,6 and these firms accounted for 63% of enrollment in 2019 . Of the 16 parent firms, seven are publicly traded, for-profit firms while the remaining nine are non-profit companies. Six firms UnitedHealth Group, Centene, Anthem, Molina, Aetna/CVS, and WellCare each have MCOs in 12 or more states and accounted for 51% of all Medicaid MCO enrollment . All six are publicly traded companies ranked in the Fortune 500.7 KFF analysis of more recent MCO enrollment data, from the subset of states that make these data available, showed that five for-profit parent firms accounted for almost 60% of the pandemic-related increase in MCO enrollment from March 2020 to March 2021 in these states. Earnings reports from Q4 2021 for these five for-profit parent firms showed year-over-year growth in Medicaid membership ranging from 10 to 20% and for the three firms that provided Medicaid-specific revenue information growth in Medicaid revenues ranging from 13 to 43%.8
How To Choose A Health Plan
When picking a plan, think about the following:
- Are doctors you already use and like covered by the plan?
- How is the plan rated on issues that are important to you and your family?
- What value-added services are available through the plan?
We also provide tools to help you choose the best plan for you and your family.
In Fy 2020 Payments To Comprehensive Risk
In FY 2020, state and federal spending on Medicaid services totaled over $662 billion. Payments made to MCOs accounted for about 49% of total Medicaid spending , an increase of almost three percentage points from the previous fiscal year. The share of Medicaid spending on MCOs varies by state, but over three-quarters of MCO states directed at least 40% of total Medicaid dollars to payments to MCOs . The MCO share of spending ranged from a low of about 2% in Colorado to 88% in Kansas. State-to-state variation reflects many factors, including the proportion of the state Medicaid population enrolled in MCOs, the health profile of the Medicaid population, whether high-risk/high-cost beneficiaries are included in or excluded from MCO enrollment, and whether or not long-term services and supports are included in MCO contracts. As states expand Medicaid managed care to include higher-need, higher-cost beneficiaries, expensive long-term services and supports, and adults newly eligible for Medicaid under the ACA, the share of Medicaid dollars going to MCOs will continue to increase.
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What Happened To Medicaid Under The Affordable Care Act Or Obamacare
The Affordable Care Act expanded who was eligible for Medicaidmostly to childless, working-age, non-disabled adults. Specifically, individuals who make less than 153 percent of the federal poverty level were not eligible to receive Medicaid. The federal poverty level is an income level set by the government that determines if someone is eligible for federal benefits. In 2021, the federal poverty level is $12,880 for individuals. So, 153 percent of $12, 880 would mean people who earn up to $19,706 are now eligible for Medicaid.
The ACA gave states the decision of whether or not to expand Medicaid to this newly eligible group. When the legislation passed, it promised states it would pay 100 percent of the cost of expanding this new group for three years. After those three years were up, the federal assistance fell to 95 percent in 2017, and then 90 percent in 2020where it remains today and will remain in the future.
State Medicaid Plans And Waivers
State Medicaid plans or state plan amendments often indicate what types of services Medicaid covers in your state. You can find more information about state Medicaid plans on Medicaid.gov.
You can also contact your state Medicaid office to determine which services are covered. Under a Medicaid waiver, a state can waive certain Medicaid eligibility requirements, covering care for people who might not otherwise be eligible for Medicaid.
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Medicaid Health Plan Changes
Louisiana Medicaid has a new health plan beginning January 1, 2023. This includes the current five health plans Aetna Better Health, AmeriHealth Caritas, Healthy Blue Louisiana, Louisiana Healthcare Connections, and UnitedHealthcare, plus a sixth health plan, Humana Healthy Horizons. Members may be assigned to a different health plan but this does not affect Medicaid coverage. Members dental health plans will not change.
All members will get a letter from Healthy Louisiana in November explaining any changes. Before the January 1, 2023 launch, most Medicaid members will be auto-assigned a health plan. The letter will tell members what their current health plan is and what their auto-assigned health plan is. The letter will also tell members how and when they can make changes to their health plan.
In this auto-assignment, some members may be assigned to a health plan that is different from their current health plan. The auto-assignment changes will not be effective until January 1, 2023, and the member will have an opportunity to make changes. Changes made to enrollment between November 8 and December 29, 2022, will be effective starting January 1, 2023. Members will be able to make changes to their health plan until March 31, 2023.
Should I Get Additional Coverage For Care When I’m Older
Medicare and Medicaid are not the only plans you should consider for your healthcare needs when you prepare for retirement. Even with Medicare, you may be left with out-of-pocket costs to pay for your medical services. Medigap plans have additional monthly premiums that can cover the costs of care that are not covered by Medicare or your Medicare Advantage plan.
In addition to medical care for older people, people of any age should consider how to care for themselves and their families. Wills, trusts, living wills, and other estate planning tools can help you care for aging parents and protect your adult children. In many cases, there are low-cost do-it-yourself wills, living wills, and powers of attorney that can be found on our companion site, FindLaw.com.
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Within Broad Federal And State Rules Plans Often Have Discretion In How To Ensure Access To Care For Enrollees And How To Pay Providers
To help ensure participation, many states require minimum provider rates in their contracts with MCOs that may be tied to fee-for-service rates. In a 2021 KFF annual survey of Medicaid directors, about two-thirds of responding states with MCO and/or limited benefit contracts reported a minimum fee schedule that sets a reimbursement floor for one or more specified provider types . Additionally, over half of responding states that contract with managed care plans reported a uniform dollar or percentage increase payment requirement in place as of July 2021, most commonly for hospitals. In response to the COVID-19 pandemic, states have options and flexibilities under existing managed care rules to direct/bolster payments to Medicaid providers and to preserve access to care for enrollees. More than one-third of responding MCO states implemented new provider payment and/or pass-through requirements on MCOs in response to the COVID-19 emergency in FY 2021.
Differences Between Medicaid And Medicare
The main difference between Medicare and Medicaid is that Medicare is a medical insurance program administered at the federal level, and Medicaid is a medical assistance program handled by the states. See below to learn more:
- Medicare Program: Medicare is funded by money contributed to trust funds as part of payroll taxes, similar to Social Security. When workers and their spouses reach age 65, they become eligible for Medicare benefits to pay for many of their hospital costs. Medicare also provides other medical insurance benefits for a monthly premium, including outpatient services and prescription drug coverage.
- Medicaid Programs: Medicaid is a government assistance program that covers people with a limited income. Medicaid can cover low-income people of any age, from older adults to families and children. There are no premiums for most medical services, and participants need to establish eligibility every year.
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Roles Of States And The Federal Government
The states and federal government play different roles in administering Medicare and Medicaid, according to the U.S. Department of Health and Human Services.
Medicare
Medicare is a federal program that the Centers for Medicare & Medicaid Services runs, so it is consistent across states.
Funding for Medicare comes from general federal revenues, payroll tax revenues, and beneficiaries premiums.
History Of Medicaid And Medicare
Congress amended the Social Security Act in 1965, creating health care programs for older adults and those receiving public assistance.
- Providing health care aid for low-income people, Title XIX formed Medicaid.
- Title XVII established Medicare, offering public health insurance for people aged 65 and older In 1973, the legislature widened the scope of Medicare to help certain disabled persons and individuals with kidney disease.
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Types Of Medicaid For Medicare Beneficiaries
Certain individuals are eligible for both Medicare and Medicaid. This is known as dual eligibility. There are four different types of Medicare Savings Programs available to Medicare beneficiaries who meet certain eligibility requirements.
In some states, you may qualify for one of the following Medicare Savings Programs even if you dont qualify for Medicaid in your state.
How Is The Medicaid Program Paid For And How Much Does It Cost
Both the states and the federal government pay for Medicaid. In FY 2019, the government spent $627 billion on Medicaid. The federal government spent $405 billion and the states spent $222 billion.
The federal government reimburses states for a portion of their Medicaid costs. Notably, there is no spending cap on this reimbursementwhich means theres no limit to how much federal money a state can receive from the federal government for Medicaid. How much money the federal government spends versus the state government varies by state. The amount is determined by something called the federal medical assistance percentage ratewhich is established by comparing a states per capita income with the US per capita income.
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Hcbs 1915 Waiver Programs
Through certain waivers, states can target services to people who need LTSS. These waivers are called home- and community-based services 1915 waivers.
All of the HCBS 1915 waiver programs:
- Are fee-for-service programs, meaning that the provider is paid for each service the patient receives
- Require individuals to meet criteria set by the state and based on level of need
Over Time The Expansion Of Risk
States incorporate quality metrics into the ongoing monitoring of their programs, including linking financial incentives like performance bonuses or penalties, capitation withholds, or value-based state-directed payments to quality measures. In a 2021 KFF annual survey of Medicaid directors, over three-quarters of responding MCO states reported using at least one financial incentive to promote quality of care as of July 2021 . Financial incentive performance areas most frequently targeted by MCO states include behavioral health, chronic disease management, and perinatal/birth outcomes. These focus areas are not surprising given the chronic physical health and behavioral health needs of the Medicaid population, as well as the significant share of the nations births funded by Medicaid. A number of states reported making changes to their quality incentive programs due to the COVID-19 pandemic, as the pandemic has likely affected clinical practices and timely reporting of quality data. Despite activity in this area, detailed performance information at the plan-level is not frequently made publicly available by state Medicaid agencies, limiting transparency and the ability of Medicaid beneficiaries to assess how plans are performing on key indicators related to access, quality, etc.
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Florida Medicaids Health Plan Resources
- Behavioral Health
- Utilization Management
The Agencys goals with this initiative are to improve communication and coordination between plans and providers generally, and more specifically: to reduce readmissions by improving communication among health plans and providers to improve members access to timely and appropriate services post-discharge and to streamline the coordination of behavioral health services for members, especially those with substance use disorder and opioid use disorder .
If you experience issues connecting with any of the plans’ provider resources, please contact the Agency by using the Florida Medicaid Complaint Form or call our Medicaid Helpline at 1-877-254-1055.
Opting For Part A Only
Some people choose only to have Medicare Part A coverage so that they dont have to pay the monthly premiums for Medicare Parts B and D. If you still have insurance through a current employer , you can add the other parts later with no penalty.
However, if you decline Parts B and D and don’t have another insurance plan in place, you’ll face a late enrollment penalty when you add the other parts later, and you’ll be limited in terms of when you can enroll in them.
In the past, Medicaid programs typically didn’t offer a lot of choice in terms of plan design. But today, most states utilize Medicaid managed care organizations . If there’s more than one MCO option in your area of the state, you will likely be given the option to select the one you prefer.
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Can I Lose Medicare Or Medicaid
Most Medicare recipients qualify when they turn 65 and are then covered for life. However, if you are still working or return to work and receive health insurance benefits through your employer, Medicare generally provides secondary coverage after your employer’s primary coverage.
Medicaid eligibility is based on income levels, and participants generally must renew for Medicaid at least every 12 months. If your income level exceeds the qualifying limit or you are no longer eligible, you can lose Medicaid coverage.
Do Medicaid Or Medicare Fund Long
While Medicare covers hospitalizations, short-term care in a skilled nursing facility, and hospice care, it does not fund long-term care. Medicaid covers long-term care in nursing homes, according to the American Council on Aging.
Some older adults can enroll in both Medicare and Medicaid for greater coverage of their health care needs. For instance, one might have Medicare covering hospitalizations and Medicaid covering long-term care.
To learn more about qualifying for Medicare or Medicaid, contact a Zacharia Brown Elder Law attorney at 724.942.6200 or visit pittsburghelderlaw.com to schedule an appointment.
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Health Plans And Program
In Florida, most Medicaid recipients are enrolled in the Statewide Medicaid Managed Care program. The program has three parts: Managed Medical Assistance, Long-Term Care, and Dental. People on Medicaid will get services using one or more of these plan types:
Managed Medical Assistance : Provides Medicaid covered medical services like doctor visits, hospital care, prescribed drugs, mental health care, and transportation to these services. Most people on Medicaid will receive their care from a plan that covers MMA services.
Long-Term Care : Provides Medicaid LTC services like care in a nursing facility, assisted living, or at home. To get LTC you must be at least 18 years old and meet nursing home level of care .
Dental: Provides all Medicaid dental services for children and adults. All people on Medicaid must enroll in a dental plan.
What Medicare Covers
Medicare coverage can be complicated because there are many different parts of Medicare. The original Medicare is made up of Medicare Part A and Medicare Part B. Part A is hospital insurance that covers inpatient care, skilled nursing facility care, and hospice care. Part B is for outpatient services, including health care provider visits, durable medical equipment, home health care, mental health services, and ambulance services.
Medicare patients can also add Medicare Part D for prescription drug coverage and purchase supplemental insurance coverage or Medigap to cover other costs not covered by Medicare, like copays and deductibles. Supplemental coverage is available through private insurance companies, including Medicare Advantage, also known as Medicare Part C.
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Can You Have Both
People who qualify for both Medicare and Medicaid are considered dual eligible. In this case, you may have original Medicare or a Medicare Advantage plan , and Medicare will cover your prescription drugs under Part D.
Medicaid may also cover other care and drugs that Medicare doesnt, so having both will probably cover most of your healthcare costs.
Choosing A Health Plan
When choosing a health plan beneficiaries must know that this is a way to get Medicaid Services. When you are in a health plan you will have your own doctor or clinic.
Choose a Plan that is Best for YouThere are three health plans in MississippiCAN. Below are tips for members when choosing a plan:
- Medicaid beneficiaries should choose a health plan that is best for them and meets their medical needs.
- Compare the benefits that each health plan offers.
- Check to see if your doctor and/or hospital accept the health plan.
- You can only see your regular primary care physician or specialist if they accept your plan.
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As Of July 2019 More Than Two
As of , 53.7 million Medicaid enrollees received their care through risk-based MCOs. Twenty-five MCO states covered more than 75% of Medicaid beneficiaries in MCOs .
Although 2019 data are the most current national data available on Medicaid MCO enrollment, enrollment in Medicaid overall has grown substantially since the start of the coronavirus pandemic in February 2020. This enrollment growth reflects both changes in the economy as well as provisions in the Families First Coronavirus Response Act that require states to ensure continuous coverage for current Medicaid enrollees to access a temporary increase in the Medicaid match rate during the PHE period. KFF analysis of more recent MCO enrollment data, from the subset of states that make these data available, shows growth in Medicaid MCO enrollment during the pandemic tracks overall Medicaid enrollment trends. When the continuous coverage requirements end, states will begin processing redeterminations and renewals and millions of people could lose Medicaid coverage if they are no longer eligible or face administrative barriers during the process despite remaining eligible. CMS has released guidance and strategies for states to help maintain coverage of eligible individuals after the end of continuous enrollment requirements, including guidance outlining how managed care plans can support states in promoting continuity of coverage.
