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

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are expected to rely heavily on managed care to serve the millions of adults who will become newlyeligible for Medicaid in 2014.In light of the large and growing role of managed care in Medicaid, and the implications for Medicaidbeneficiaries, the <strong>Kaiser</strong> Commission on Medicaid and the Uninsured (KCMU) and Health ManagementAssociates (HMA) conducted a special survey of Medicaid programs to assess the state of Medicaidmanaged care, identify current issues, and gain perspectives on the directions Medicaid managed caremay take in the coming years. This report presents data and findings based on that survey.Key FindingsNearly all states operate comprehensive Medicaid managed care programs, covering about 66 percentof all Medicaid beneficiaries. Across all 50 states and DC, only three states (Alaska, New Hampshire andWyoming) reported that they did not have any Medicaid managed care as of October 2010. Overall, 36of the 48 states with comprehensive managed care programs reported contracting with risk-basedmanaged care organizations (MCOs) and 31 reported operating a primary care case management(PCCM) program. Over 26 million Medicaid beneficiaries are enrolled in MCOs and 8.8 million areenrolled in PCCM programs; together, these beneficiaries in comprehensive managed care represent65.9 percent of all Medicaid beneficiaries. When Medicaid beneficiaries who receive a limited set ofservices through a managed care plan (as discussed next) are also counted, the share of all beneficiarieswho are enrolled in managed care is larger.Half the states with MCOs and/or PCCM programs also contract with non-comprehensive prepaidhealth plans (PHP) to provide specific categories of services. The types of services most commonlyprovided by non-comprehensive PHPs, which are risk-based, limited-benefit plans, are inpatient andoutpatient behavioral health services and substance abuse treatment. A number of states also contractwith non-comprehensive PHPs to provide dental care, non-emergency transportation, or prescriptiondrugs – all services that are frequently carved out of MCO contracts.States are increasingly mandating managed care for previously exempt or excluded Medicaidbeneficiaries. States have long mandated that most children, pregnant women, and parents and othercaretaker adults in Medicaid enroll in managed care. A majority of states reported that, for at least oneMedicaid managed care program and/or geographic area, they also mandate enrollment in managedcare for children with disabilities receiving Supplemental Security Income (SSI), children with specialhealth care needs, and seniors and people with disabilities who are not dually eligible for Medicare andMedicaid.Risk-based comprehensive managed careAlmost two-thirds of Medicaid MCO enrollees are in health plans that primarily or exclusively serveMedicaid. In addition, for-profit plans account for a little over half of all Medicaid MCO enrollment.Roughly 60 percent of Medicaid MCO enrollees are in non-publicly traded plans. Medicaid MCOenrollment is distributed about evenly between local and national plans.Auto-assignment rates appear to vary widely. Auto-assignment rates may provide a useful signal ofhow well Medicaid beneficiaries understand the managed care system and their choices within it. Acrossthe 26 states that reported auto-assignment rates, half (13 states) reported rates of 20 percent or less;four states reported rates higher than 50 percent. More than two-thirds of states with MCOs use third-2 00
party enrollment brokers to provide plan information to beneficiaries and assist them in choosing anMCO; a small number of vendors dominate the market. Most states allow MCOs to conduct outreachand marketing to Medicaid beneficiaries within federal rules.Most states set MCO capitation rates administratively and risk-adjust their rates. Three-quarters ofthe states with MCOs reported that they used administrative rate-setting with actuaries to establishMCO rates. Other approaches states reported using are negotiation and competitive bidding, and somestates combine multiple methods. Most states adjust their capitation rates for age and eligibilitycategory, and about two-thirds adjust for health status. Risk-sharing arrangements with MCOs, such asstop-loss/reinsurance or risk corridors, are in place in half the states.Over half the states with MCOs include a pay-for-performance (P4P) component in their payment toplans. Capitation withholds and bonus payments were reported most frequently. Examples of otherapproaches are shared savings, auto-assignment preference, and enhanced capitation.A limited number of states have a minimum medical loss ratio (MLR) requirement for MCOsparticipating in Medicaid. Eleven states indicated that they have a minimum MLR requirement forplans, 21 states reported that they do not, and three states said they plan to establish one in the future.Minimum MLRs ranged from 80 percent in three states to 93 percent in one state for MCOs serving agedand disabled Medicaid beneficiaries.All states but one “carve out” at least one acute-care benefit from their MCO contracts, but severalstates are carving some benefits back in. More often than not, dental care and outpatient and inpatientbehavioral health care are carved out and provided either on a fee-for-service basis or by a noncomprehensiveprepaid health plan (PHP) – a risk-based, limited-benefit plan. Other common carve-outsare outpatient substance abuse treatment, non-emergency transportation, and pharmacy services.Some states that previously carved out the pharmacy benefit or other Medicaid services are carvingthem back into their MCO contracts or plan to do so.States use a variety of network adequacy standards. States typically use provider-to-population ratiosand distance and travel-time maximums as standards to ensure that MCO networks are adequate. Theygenerally apply different standards for primary and specialty care and frequently apply differentstandards for rural and urban areas. The standards states use vary widely. In most states, in addition toprimary care physicians, providers such as ObGyns, nurse practitioners, federally qualified healthcenters, and physician groups/clinics are recognized as primary care providers (PCP) for MCO enrollees..Many but not all states reported that Medicaid MCO enrollees sometimes face access problems. Overtwo-thirds of responding states with MCOs reported that Medicaid beneficiaries enrolled in MCOssometimes experience access problems. Problems with access to dental care, pediatric specialists,psychiatrists and other behavioral health providers, and other specialists (e.g., dermatologists, ear-nosethroatdoctors, orthopedists and other surgeons, neurologists, cancer and diabetes specialists) were allcited. At the same time, improved access to care – both primary and specialty care – was the mostfrequently cited perceived benefit of managed care relative to fee-for-service. Some states indicatedthat where an access problem existed, it usually paralleled a similar problem encountered by personswith other types of insurance, for example, due to provider shortages and other market factors. Thesurvey, however, did not directly collect information on access problems in fee-for-service Medicaid.3
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Page 5 and 6: Table of ContentsExecutive Summary
Page 7: EXECUTIVE SUMMARYMedicaid, the publ
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 and 26: States with Medicaid MCOsKey Sectio
Page 27 and 28: States have “auto-assignment” a
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
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APPENDIX 2: Summary of Medicaid Man
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Program Name(e.g., Popular Name, 19
Page 63 and 64:
APPENDIX 3: MCO Contracts, Plan Cha
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State(No. ofcontracts)NameEnrollmen
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State(No. ofcontracts)NameEnrollmen
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APPENDIX 5: MCO Capitation Rate-Set
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APPENDIX 7: MCO Network Adequacy Re
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State Primary Care Obstetric Care S
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APPENDIX 9: Providers Recognized as
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APPENDIX 11: PCCM Administrative Se
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APPENDIX 13: Initiatives to Improve
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I. MANAGED CARE OVERVIEW1. Total Ma
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4. Enrollment Requirements.a. We ar
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ii. Please indicate whether the fac
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c. Required Providers: We are inter
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IV. NON-COMPREHENSIVE PREPAID HEALT
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. Does your state use CAHPS© surve
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VI. SPECIAL INITIATIVESAll states s
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Appendix I: Managed Care Contracts1
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Appendix II: Clinical Quality Perfo
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1330 G S T R E E T NW, W A S H I N
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