Kaiser Family Foundation Survey on State Medicaid Managed Care ...

More documents

Recommendations

Info

traded, and whether it is a local or national (i.e., multi-state) company.Overall, in FY 2011, 63 percent of Medicaid enrollees in MCOs were in plans that specialize in servingMedicaid. For-profit health plans accounted for a little over half of all Medicaid MCO enrollment (53percent). Non-publicly traded plans accounted for 58 percent of enrollment. Medicaid MCO enrollmentwas distributed about equally between national and local plans (Figure 2). 8Appendix 3 provides state-by-state detail on MCO contracts, plan characteristics, and enrollment.Most states require Medicaid MCOs to be licensed as HMOs. Federal regulations generally requirethat Medicaid MCOs meet state solvency standards established for private HMOs, or be licensed orcertified by the state as a risk-bearing entity. 9 The vast majority of the 33 states responding (of 36states with MCOs) reported that they require Medicaid MCOs to be licensed as HMOs or otherwiselicensed by the state insurance regulatory body, with specified, limited exceptions. Two states(Arizona and Maryland) indicated that they have no insurance licensure requirements. Six statesreported that they allow exemptions from state solvency requirements for Medicaid HMOs aspermitted by federal law, or for Provider Service Networks or Provider-Sponsored Organizations(PSNs/PSOs), or Health Insuring Organizations (HIOs).More than a third of states with MCOs provide for an external appeals process for MCO enrollees.Fourteen states with MCOs (of 34 responding) reported that, in addition to the state fair hearingprocess required by federal regulations, they provide for an external appeals process for MCOenrollees. 10Outreach, marketing, and health plan selectionMost states allow MCOs to conduct permissible outreach and marketing activities. A total of 28 states(of 34 responding) allow MCOs to conduct outreach and marketing to Medicaid beneficiaries withinfederal rules, while six states do not allow plans to conduct outreach or marketing.A substantial majority of states with MCOs 11 use enrollment brokers. Twenty-five states (of 35responding) reported that they contract with a third-party enrollment broker to provide planinformation to beneficiaries and assist them in choosing an MCO. Vendors listed by more than one stateinclude Maximus (11 states), Automated Health Systems (five states), ACS (three states), and HPEnterprise Services (two states).States’ auto-assignment algorithms typically reflect both beneficiary-based considerations and statepolicy objectives vis-à-vis MCOs. States prefer that beneficiaries make a choice from the health plansoffered. However, Medicaid programs with any mandatory managed care must have a system forassigning Medicaid beneficiaries who do not select a plan within the required timeframe (although thestates allow these beneficiaries an opportunity to opt out of the assigned MCO and into a different one).8 MCO enrollment information was not reported for Kansas or Nebraska.9 See 42 CFR §438.116. Exceptions apply to federally qualified HMOs, public plans, plans that are (or are controlledby) one or more federally qualified health centers, and those whose solvency is guaranteed by the state.10 The 14 states are California, Colorado, Delaware, DC, Florida, Hawaii, Illinois, Indiana, Michigan, New Jersey,Pennsylvania, Rhode Island, Washington, and West Virginia.11 Only states with MCOs were asked to report on enrollment broker arrangements.20 00
States have “auto-assignment” algorithms for this purpose. The criteria in a state’s auto-assignmentalgorithm provide some indication of that state’s policy priorities. Two of the most common criteria –the MCO assignment of a related family member and geographic considerations – take into accountwhat might be most practical and desirable from the beneficiary’s perspective. However, states may alsodesign their algorithms to support programmatic objectives, such as balancing enrollment among plansand incentivizing improved plan performance. Figure 3 shows selected criteria used in auto-assignmentalgorithms and in how many states they are used.Figure 3Auto-Assignment Algorithm Factors(33 states responding)Related family member assignmentGeographic considerationsPrevious plan assignmentBalancing enrollment among plansPlan capacityPrior PCP in networkPlan quality performanceEncouraging entry of new plansPlan costNote: 36 states contract with MCOs.SOURCE: KCMU/HMA <strong>Survey</strong> of Medicaid Managed Care, September 2011.Number of states using factor:Auto-assignment rates appear to vary greatly. Autoassignmentrates may provide a useful signal of how wellMedicaid beneficiaries understand the managed care systemand what their choices are within it.Other auto-assignment criteria include planquality performance measures, such astimely EPSDT check-ups, and measures ofplan administrative performance, such assubmission of encounter data.Appendix 4 provides additional state-bystatedetail on auto-assignment algorithmfactors.Twenty-six of the 36 states with MCOs provided informationon their auto-assignment rates. These states reported widely different average monthly autoassignmentrates, ranging from a low of 3 percent to a high in two states of 80 percent. However, half(13 states) reported auto-assignment rates of 20 percent or less; four states reported rates exceeding 50percent. 12MCO payment methodologies and practices3591415232424Pennsylvania reported usingdifferent auto-assignmentalgorithms in different areas of thestate. In one area, auto-assignmentis tied to plan quality performancemeasures. In two other areas withnew MCO entrants, the state autoassignsmost new members to thenew plans, but once theirenrollment reaches state-definedthresholds, subsequent autoassignmentis based on the qualityperformance measures.Most states set MCO capitation rates administratively. To be in compliance with federal regulations,the capitation rates that states pay MCOs must be “actuarially sound.” 13 Three-quarters of MCO states(27 of 35 responding) indicated that, for FY 2011, they set capitation rates administratively usingactuaries (Figure 4). Smaller numbers of states reported setting capitation rates by negotiation (11states), by competitive bid within actuarially determined ranges (10 states), and by simple competitivebid (five states).2812 These are the auto-assignment rates reported for states’ acute care programs only.13 42 CFR 438.6(c)(1).21
Page 1 and 2: kaisercommission onmedicaidand theu
Page 3 and 4: kaisercommission onmedicaidand theu
Page 5 and 6: Table of ContentsExecutive Summary
Page 7 and 8: EXECUTIVE SUMMARYMedicaid, the publ
Page 9 and 10: party enrollment brokers to provide
Page 11 and 12: HEDIS©, CAHPS©, and state-specifi
Page 13: ConclusionFor over 30 years, state
Page 16 and 17: from the recession and the slow rec
Page 18 and 19: A note on Medicaid managed care ter
Page 20 and 21: Managed caremodelTable 1: Medicaid
Page 23 and 24: States are increasingly mandating m
Page 25: States with Medicaid MCOsKey Sectio
Page 29 and 30: excess of a specified threshold for
Page 31 and 32: Dental care and outpatient and inpa
Page 33 and 34: the second trimester, and within th
Page 35 and 36: eported that they limit PCP panel s
Page 37 and 38: States with non-comprehensive PHPsK
Page 39 and 40: Measuring, monitoring, and improvin
Page 41 and 42: seven states required 10 measures o
Page 43 and 44: CAHPS© surveys. North Carolina is
Page 45 and 46: Special initiatives to improve qual
Page 47 and 48: public health efforts to reduce dis
Page 49 and 50: Medicaid managed long-term care and
Page 51 and 52: (e.g., need to credential Adult <st
Page 53 and 54: In many states, broader efforts foc
Page 55 and 56: Looking ahead: Medicaid managed car
Page 57 and 58: ConclusionFor over 30 years, state
Page 59 and 60: APPENDIX 2: Summary of Medicaid Man
Page 61 and 62: Program Name(e.g., Popular Name, 19
Page 63 and 64: APPENDIX 3: MCO Contracts, Plan Cha
Page 65 and 66: State(No. ofcontracts)NameEnrollmen
Page 67 and 68: State(No. ofcontracts)NameEnrollmen
Page 69 and 70: APPENDIX 5: MCO Capitation Rate-Set
Page 71 and 72: APPENDIX 7: MCO Network Adequacy Re
Page 73 and 74: State Primary Care Obstetric Care S
Page 75 and 76: APPENDIX 9: Providers Recognized as
Page 77 and 78:
APPENDIX 11: PCCM Administrative Se
Page 79 and 80:
APPENDIX 13: Initiatives to Improve
Page 81 and 82:
I. MANAGED CARE OVERVIEW1. Total Ma
Page 83 and 84:
4. Enrollment Requirements.a. We ar
Page 85 and 86:
ii. Please indicate whether the fac
Page 87 and 88:
c. Required Providers: We are inter
Page 89 and 90:
IV. NON-COMPREHENSIVE PREPAID HEALT
Page 91 and 92:
. Does your state use CAHPS© surve
Page 93 and 94:
VI. SPECIAL INITIATIVESAll states s
Page 95 and 96:
Appendix I: Managed Care Contracts1
Page 97:
Appendix II: Clinical Quality Perfo
Page 100:
1330 G S T R E E T NW, W A S H I N
show all

Kaiser Family Foundation Survey on State Medicaid Managed Care ...

Create successful ePaper yourself

Delete template?

Save as template?