Healthfirst’s Post

The new federal Medicaid managed care rules include a focus on access to care. Rules will be implemented over time and may have significant implications for states, plans, and enrollees. Here are 10 things to know about managed care:

Big news for NC residents! 🌟The Medicaid expansion now covers an additional 600,000 people, offering essential health services to those in need. Unsure about your eligibility? We break it down in our latest blog. https://bit.ly/3w4ILGo #NCMedicaidExpansion #HealthcareForAll

As a local or regional managed care organization (LRMCO), being “ready” means proactively addressing all the areas where your organization can get tripped up, or worse, lose your contract with a state Medicaid agency. LRMCOs are heavily reliant upon government funded programs. These include Medicaid, Medicare, and Marketplace business. Most LRMCOs are not as heavily involved in the commercial market, either on a fully insured or self-insured basis, and even when they are, these areas comprise smaller parts of their overall product offerings. National MCOs have looked to Medicaid managed care to fuel growth, strengthen relationships with government partners, and leverage infrastructure. Read more: https://lnkd.in/gTibp_5S

Centers for Medicare & Medicaid Services' new guidance begins by clarifying the scope of Medicaid transportation services. The guidance outlines that Medicaid coverage includes two key transportation benefits: emergency and non-emergency medical transportation (NEMT). Both benefits are established via Medicaid’s transportation assurance, an element of Medicaid law and regulations that require states to provide access to transportation for Medicaid beneficiaries who have no other means of transportation to receive a covered service. Read more on CMS's guidance on Medicaid Transportation Assurance on our blog: https://ow.ly/r7en50Q8wPx

I covered a conference in person for the first time in a long time last week, and I remembered why it's so valuable: If you listen to enough sessions, people sometimes say something juicier than "value-based care is the future." Take Jay Ludlam, head of North Carolina's Medicaid program, who had a ton of great soundbites but none so interesting as this "saying the quiet part out loud" quote: Ludlam told a packed, lunching audience at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum that "the pressures are different on a Medicaid managed care company than they are on a classic government service organization like ourselves. Sometimes when I have colleagues who transition from the private sector, part of their question is, what is the motivating, organizing principle in government? Because it’s clear in private [firms], and that’s profit. It is a shining, bright star. In government services, it’s nonprofit. And that, I think, is a large part of the tension between our organization and our partners.” Ludlam went on to warn insurers (including private Medicaid plans) that providers are reaching their breaking point when it comes to things like prior authorization...and if they don't self-impose reform, politicians will. It was a surprising (and dare I say, refreshing) amount of "real talk" for an industry conference. I tell people all the time that most Americans have no idea how privatized both Medicare and Medicaid have become, and it's fascinating to hear state leaders who are in the trenches be frank about the natural tensions that breeds — especially in Medicaid, which is one of our largest, spendiest (and yes, most politicized) social safety nets. Read more about what Ludlam and his fellow speaker, Illinois Medicaid Administrator Kelly Cunningham, said, in my full article for Health Plan Weekly (warning: paywall):

North Carolina expanded Medicaid only seven weeks ago, and over 300,000 residents, many in rural areas of the state, are already covered and receiving care. Over 120,000 prescriptions have been filled through Medicaid since expansion, and over $2.5 million worth of dental claims have been filed among the expanded population. Medicaid expansion helps rural communities stay healthy and thrive, but there are still 10 states that haven’t expanded coverage. It’s time for other states to expand Medicaid so that rural communities can access affordable, quality care. Read more from WRAL here > https://bit.ly/47OKwET

Kansas recently announced a major shift in its Medicaid program, KanCare. Three Managed Care Organizations (MCOs) were chosen to serve the state's 458,000 Medicaid members starting in 2025. Key takeaways: - The players: Healthy Blue, a collaboration between Blue Cross and Blue Shield of Kansas and Blue Cross and Blue Shield of Kansas City, joins the team alongside Sunflower Health Plan and United Healthcare Community Plan. - Focus on vulnerable populations: The state aims to improve prenatal and postpartum care with the new contracts. - Rural access a priority: Increasing provider recruitment and retention in rural areas is a key focus. Learn more: https://hubs.ly/Q02y9jjG0

Cityblock Health, a leader in Medicaid value-based care, has announced a new collaboration with Sunshine Health, a subsidiary of Centene Corporation. This partnership aims to improve access to healthcare for Medicaid beneficiaries in central Florida. Key takeaways: - Focus on accessibility: Cityblock will provide primary care and care coordination services to members in 11 counties, with options for in-home or clinic-based care. - Serving complex needs: The partnership targets Medicaid beneficiaries with complex medical and behavioral health conditions. - Expanding reach: This builds on Cityblock's existing partnerships with Centene subsidiaries in other states. Learn more: https://hubs.ly/Q02y9m9t0

The CMS 80/20 rule is going to change the Home Care industry and more importantly it sets a precedent on how CMS influences the Home Care market, not just Medicaid but all payor sources: "This goes to the heart of who decides what a Medicaid program looks like in a state, and how it’s operated...The broad parameters that are in the federal law clearly set a standard for the structure. But this goes to unprecedented depths of micromanaging that I think you’re going to find the states concerned that, alright, this is the first chapter of micromanaging. What’s the next chapter? What’s the next chapter after that?”

Many providers don't realize they can negotiate better denial and appeal terms in their MCO contracts. What if your organization could reduce claim denials and appeals by half? Last Friday MACPAC endorsed a series of steps to overhaul the appeal process when beneficiaries are denied access to care my Medicaid MCOs. This comes after a July 2023 report from the OIG that found many MCOs had high rates of prior authorization denials. The report found 115 managed care organizations in 37 states denied about one in eight requests for prior authorization. Twelve MCOs surveyed had denial rates above 25%. Regardless of what MACPAC and Congress does here, providers should start NOW reviewing their Medicaid and MA contract terms to seek better terms and better performance. https://aboutblaw.com/bctC