Most Medicare enrollees today are part of a Managed Care plan. Each state determines which populations are part of this plan and which services they receive. This can be confusing to individuals, particularly when they move between states. Fortunately, the federal government realizes this problem and has released Medicaid Managed Care Access, Finance, and Quality regulations.
These rules are complex and extensive. They are designed to strengthen the standards to ensure timely access to healthcare, but many people need assistance with managing your Medicaid. What should these men and women know about this vital healthcare service?
Risk-Based Managed Care Organizations
Risk-based managed care organizations remain the most common way Medicaid beneficiaries receive care. Approximately 74% of beneficiaries are covered by one of these organizations. Managed care plans help people use and keep their coverage. Strategies are in place to ensure terminations for paperwork or procedural problems are reduced. These organizations can help individuals complete certain parts of renewal forms while extending automatic re-enrollment to 120 days.
Younger Individuals First
Medicaid primarily benefits children and adults under 65. However, more states include individuals aged 65 and older with complex needs. These plans also cover individuals with disabilities. Other groups, such as pregnant women, may also be covered under certain conditions.
MCOs and Medicaid Spending
Over half of Medicaid spending in fiscal year 2022 went to managed care organizations. State and federal governments spent over $804 billion that year on Medicaid services, and 52% of this money went to managed care organizations. Totals varied by state. Experts believe this percentage will continue to increase as more people become eligible for Medicaid, and those already enrolled need expensive services and support over the long term.
State Determinations
Each state determines which services will be included in its managed care organization contracts. These organizations provide comprehensive services, but specific services may be carved out to fee-for-service systems. Behavioral health and pharmacy are two services that are frequently carved out. However, this may be changing. More states are choosing to include the services in managed care organization contracts.
Publicly Traded Firms
Five publicly traded companies serve 50% of all Medicaid managed care organization participants, gaining a larger share of enrollees than other organizations. Today, hundreds of Medicaid-managed care organizations exist in the country, many of which fall under one of the five parent firms. Enrollees benefit from knowing who is managing their care.
Managed Care Rules
2024 saw changes to Medicaid access standards and authorizations. Routine appointments must be completed within the specified period, secret shopper surveys must be done to ensure organizations comply with these standards, and the organizations must conduct annual enrollee experience surveys. These are only a few changes in Medicaid managed care organization standards.
Financial Incentives
States provide managed care organizations with financial incentives if they meet specific quality measures. Performance bonuses are one way they incentivize improved quality. Two areas were financial incentives, commonly seen in perinatal/birth outcomes, and chronic disease management. Non-financial incentives, including quality rating systems, are also being used.
The more people know about Medicaid and how to manage it effectively, the more participants will get the most from the program. However, most people are unaware of how these organizations are run and cannot advocate for themselves. This needs to change, as informed patients lead to better health outcomes and lower healthcare costs overall.
