MC25 medicaid managed health Care

Question 1

Federal waiver authority

Answer 1

1. States can waive freedom of choice by enrolling Medicaid consumers into HMOs
2. Home and community based services waivers (HCBS)
   
   2. 1 allow states to make waiver applicable to particular cohorts, not the Medicaid population at large
   3. 2 program requirements
      
      2. 2.1 waiver services less or equal to cost in an institution
   4. 2.2 Ensuring the health and welfare of consumers
3. Combining 2 Waivers above
   
   3. 1 States can provide LTC services in a MC environment
   4. 2 May include nontraditional community-based services
   5. 3 States must comply with separate application and reporting requirements for each waiver

Question 2

Barriers that can affect access to care

Answer 2

1. Physicians Supply - low payment, low physician to population ratio, inadequate diversity of physicians, imbalance of physicians in urban and rural
2. Social determinants that negatively affect access to health care
   
   2. 1 Poverty
   3. 2 Health literacy
   4. 3 gender bias
   5. 4 racial bias
   6. 5 complex health care needs
   7. 6 unemployment
   8. 7 poverty and health literacy are two of the most important

Question 3

Key characteristics of an effective Medicaid Managed Health Care Plan

Answer 3

1. Comprehensive network of providers
2. Effective utilization programs
3. Disease mgmt programs
4. Case mgmt programs
5. Excellent call center support
6. Effective outreach that is culturally sensitive
7. Coordination of any services carved out
8. Patient-centered medical home capability
9. Robust quality program
10. Operational excellence for providers
11. Electronic medical records; compassion

Question 4

Medicaid MC Complex Populations

Answer 4

1. LTC
   
   1. 1 Population: the broadest populations should be included
   2. 2 benefits: the broadest possible spectrum of benefits should be considered
   3. 3 State program authority
   4. 4 Program design
   5. 5 Rate design: structured to incentivize appropriate utilization
   6. 6 Clinical delivery: care managers develop care plans
   7. 7 identification and intervention
   8. 8 Comprehensive care mgmt
   9. 9 transition mgmt
   10. 10 network development and increased access
2. Behavioral care
3. Dual eligible (Details on separate card)
4. Specialty populations
   
   4. 1 Behavioral health
   5. 1.1 most complex beneficiaries have both behavioral and physical needs
   6. 1.2 Fragmentation in most states between behavioral and physical health
   7. 2 Specialty populations
      
      4. 2.1 Developmental disabilities, hiv, spinal cord injuries, children with special needs

Question 5

Medicaid MC complex populations: dual eligible

Answer 5

1. Those who qualify for both Medicare and Medicaid
2. Programmatic complexity
3. 1 beneficiaries access hospitals, physicians through Medicare
4. 2 Medicaid responsible for Medicaid benefits outside of the Medicare benefit set, Medicare cost-share, and LTC
5. 3 Medicare and Medicaid work with very little interaction - leads to increased reliance on LTC
6. 4 Beneficiary subject to 2 processes for enrollment, grievances and member materials
7. Obstacles to state program development
   
   3. 1 State program savings have been returned to Medicare
   4. 2 Lack easy waiver process to develop integrated programs
   5. 3 Admin inefficiencies of the combined program

Question 6

Medicaid and the ACA

Medicaid expansion in 2014

Answer 6

1. ACA Medicaid eligibility is 133% of federal property level (FPL)
2. Eliminated categories of eligibility and state by state variation
3. Simplified application and eligibility determination criteria
4. Medicaid programs have been struggling. Expansion increases the strain

Question 7

Medicaid and the ACA

Medicaid and health insurance exchanges

Answer 7

1. No wrong door approach ensures individuals directed to the program for which they are eligible:
   Step 1: application
   Step 2: information verification
   Step 3: eligibility determination. Includes subsidy determination
   Step 4: enrollment. Includes Medicaid and exchange plan
   Step 5: renewal and reconciliation
2. Options to address the movement between Medicaid and the exchange
   2.1 allowing a period of continuous eligibility on the exchange and/or Medicaid
   2.2 allow managed Medicaid plans to participate in the exchange
   2.3 allow commercial exchange plans to participate as Medicaid plans
   2.4 establishing a state Basic Health Plan, discuss next

Question 8

Medicaid and the ACA

Basic Health Plan (BHP) and LTC

Answer 8

1. BHP
   
   1. 1 ACA allows states to offer a BHP to uninsured with income between 133% and 200% FPL otherwise eligible to receive premium subsidies in the exchange
   2. 2 states receive 95% of the federal subsidies that would have been provided to an individual
   3. 3 BHP may improve continuity of care by:
      
      1. 3.1 offering the same plans and networks offered to Medicaid and CHIP enrollees
      2. 3.2 Reducing churn between Medicaid and the exchange
      3. 3.3 Allowing families to enroll in the same plan
      4. 3.4 offering a low or no cost option
2. The ACA and LTC
   
   2. 1 Community based services waiver (HCBS)
   3. 2 Medicaid community first choice option: community based LTC state plan amendment rather than HCBS waiver
   4. 3 LTC balancing incentives: rebalance between community based LTC and NH
   5. 4 Health homes for chronic conditions
   6. 5 payment demonstrations
   7. 6 the federal coordinated health care office