Why will MCOs be essential with PHE unwinding?
Medicaid managed care organizations (MCOs) ship care to greater than two-thirds of all Medicaid beneficiaries nationally. Medicaid MCOs (additionally referred to as managed care plans) could keep up a correspondence with enrollees as they supply care coordination and different member companies (e.g., well being training and promotion, name middle assist) and should conduct periodic outreach to advertise acceptable use of care (e.g., to encourage prevention, wellness, and early intervention). Throughout the pandemic, states have labored with managed care plans to reply to altering public well being situations and new developments, together with to advertise the take-up of COVID-19 vaccinations.
Medicaid MCOs have seen progress of their membership throughout the pandemic that tracks total Medicaid enrollment tendencies. Enrollment progress displays downturns in the economic system as a result of the pandemic and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to make sure steady enrollment for present Medicaid enrollees to entry a brief enhance in the Medicaid match charge throughout the Public Health Emergency (PHE) interval. It is predicted that the PHE might be prolonged by at the very least mid-July 2022 since the Biden administration indicated it might give states 60 days-notice earlier than the PHE is terminated or is allowed to run out (the present PHE is about to run out in mid-April). If the PHE ends in mid-July, the steady enrollment requirement would expire at the starting of August 2022.
Medicaid managed care plans can help state Medicaid companies in speaking with enrollees, conducting outreach and help, and finally, in enhancing protection retention (together with facilitating transitions to the Marketplace the place acceptable). After the PHE ends, state Medicaid companies might want to full a lot of eligibility and enrollment duties and actions, together with processing renewals, redeterminations (based mostly on adjustments in circumstance), and post-enrollment verifications. Current CMS steerage signifies states should provoke all renewals and different excellent eligibility actions inside 12 months after the PHE ends. Medicaid managed care plans have a monetary curiosity in sustaining enrollment, which may additionally stop disruptions in look after enrollees, together with prescription drug advantages. Four for-profit mum or dad companies that account for about 40% of Medicaid enrollment nationally (Anthem, Centene, Molina, and UnitedHealth Group) reported on This fall 2021 earnings calls that they count on modest enrollment declines of their Medicaid membership after the steady enrollment requirement ends. However, these companies additionally indicated anticipating to choose up/seize many people who transition from Medicaid by their different traces of enterprise (i.e., the Affordable Care Act Marketplace and employer sponsored insurance coverage (ESI)). Managed care plans have lengthy cited lack of steady eligibility, or churn, as a key problem in guaranteeing entry to care and for care continuity.
How can states interact MCOs to assist people retain Medicaid protection or transition to different protection?
CMS launched steerage for state Medicaid companies on resuming regular operations together with outlining methods for working with managed care plans to advertise continuity of protection when the steady enrollment requirement throughout the PHE ends. In the steerage, CMS notes that the federal Medicaid managed care advertising guidelines (42 CFR 438.104) don’t prohibit plans from offering data and conducting normal outreach on behalf of states. States should develop an “unwinding operational plan” to doc their complete plan to renew regular operations of their Medicaid and Children’s Health Insurance Program (CHIP) applications. CMS is encouraging states to collect enter on their unwinding plans, together with from managed care plans. Key methods from the CMS steerage embrace:
- Working with plans to acquire and replace beneficiary contact data. States could direct MCOs to hunt up to date contact data from enrollees. Plans should affirm the accuracy of updates acquired from a 3rd celebration (e.g., supplier) with enrollees immediately. MCOs could share this data with the state or could instruct or help people in offering their up to date contact data to the state. States could settle for up to date enrollee contact data from MCOs together with mailing addresses, phone numbers, and e mail addresses supplied the state complies with sure beneficiary discover necessities (to substantiate the accuracy of up to date contact data) or the state receives a waiver of such necessities from CMS. While steerage expects plans to assist in updating contact data, plans have traditionally cited problem reaching members and inaccurate member contact data as key obstacles to partaking enrollees in care coordination actions. While state plans are evolving, as of January 2022, about half of states reported working with managed care plans to replace beneficiary mailing addresses earlier than the finish of the PHE.
- Sharing renewal recordsdata with MCOs to conduct outreach and supply assist to people enrolled in Medicaid throughout their renewal interval. States can present month-to-month recordsdata to MCOs containing details about beneficiaries for whom the state is initiating the renewal course of, or beneficiaries who’ve but to submit renewal types or different documentation and are vulnerable to shedding protection, to allow plans to conduct outreach and supply help with the renewal course of. Prior to sharing data with managed care plans (e.g., renewal recordsdata), states could have to establish and handle attainable techniques or operational challenges, together with to make sure knowledge accuracy.
- Enabling MCOs to conduct outreach to people who’ve just lately misplaced protection for procedural causes. States can present MCOs month-to-month termination recordsdata to allow plans to conduct outreach to people terminated from Medicaid for procedural causes (e.g., not returning renewal types well timed). CMS notes states could have to expedite evaluation of plan outreach messaging or could need to think about creating commonplace language for use by Medicaid managed care plans to make sure compliance with federal advertising necessities as nicely as any state-specific legal guidelines or contract necessities that will apply. Within two months or much less after Medicaid protection loss, managed care contracts should present for automated re-enrollment into an enrollee’s authentic plan. However, throughout the PHE unwinding interval, CMS will approve state waivers to increase this automated re-enrollment interval as much as 120 days.
- Permitting plans to help people to transition to and enroll in ACA Marketplace protection if ineligible for Medicaid or CHIP. States could encourage MCOs that additionally supply a Qualified Health Plan (QHP) in the ACA Marketplace to share data with their very own enrollees who’ve been decided ineligible for Medicaid to help in the switch of people to Marketplace protection (which has increased revenue eligibility thresholds than Medicaid). To keep away from gaps in protection, managed care plans could attain out to people earlier than they lose protection to permit them to use for Marketplace protection prematurely. CMS notes that federal Medicaid managed care advertising guidelines (and Exchange laws) don’t prohibit Medicaid managed care plans that provide a QHP from offering details about the QHP to enrollees who may doubtlessly enroll in the QHP as a result of lack of eligibility; nevertheless, plans should adjust to state-specific legal guidelines and/or contract necessities that will prohibit this exercise.
In addition to methods recognized in the CMS steerage, Medicaid managed care plans might also think about including workers to assist handle the unwinding course of. Additional workers may work proactively to establish members at-risk for disruptions in care and disenrollment (e.g., people with restricted English proficiency, individuals with disabilities). Managed care plans may work in partnership with suppliers (together with group well being facilities) and community-based organizations to additional bolster efforts to succeed in and help members to make sure protection retention or transitions to Marketplace protection.
What to observe?
Understanding how managed care plans are concerned in the growth of state unwinding operational plans and what’s included in the operational plans themselves might be key areas to observe. When steady enrollment requirement ends, states will start processing renewals and redeterminations and hundreds of thousands of individuals may lose protection if they’re now not eligible or face administrative obstacles throughout the course of regardless of remaining eligible. The important quantity of labor that states face will place a heavy burden on eligibility and enrollment workers and will contribute to protection loss associated to procedural errors. Medicaid managed care plans could also be nicely positioned to help states in conducting outreach and offering assist to enrollees who might want to navigate the renewals or redeterminations.
As mid-April approaches, further details about the timing of the finish of the PHE could grow to be obtainable. The Biden administration indicated it might give states 60 days-notice earlier than the PHE is terminated or is allowed to run out. The present PHE is about to run out in mid-April. On February 8, 2022, the Medicaid Health Plans of America (MHPA), a nationwide commerce affiliation representing greater than 130 MCOs, despatched a letter to Congressional leaders asking Congress to offer at the very least 120-days lead time earlier than the finish of the steady enrollment requirement. States are creating unwinding operational plans however it’s not clear that these plans might be made publicly obtainable. The insurance policies adopted and the implementation of methods to advertise continuity of protection will differ throughout states and plans and can have main implications for Medicaid and broader protection as the PHE unwinds.