More state ex­pan­sion fights … man­aged-care reg­u­la­tion … fate of dual-el­i­gi­ble demon­stra­tions

Modern Healthcare - - NEWS - By Vir­gil Dick­son

The strug­gle to per­suade Repub­li­can state of­fi­cials across the coun­try to ex­pand Med­i­caid to mil­lions of unin­sured, low-in­come adults un­der the Af­ford­able Care Act will con­tinue in 2016, even as GOP pres­i­den­tial can­di­dates head­ing into the Novem­ber elec­tions prom­ise to re­peal the law.

Mean­while, Med­i­caid man­aged-care plans, providers and pa­tient ad­vo­cacy groups will be watch­ing anx­iously to see how the CMS plans to tighten over­sight of Med­i­caid plans in its sweep­ing reg­u­la­tions ex­pected to be re­leased this spring.

Un­der new Demo­cratic Gov. John Bel Ed­wards, Louisiana is ex­pected to be the first state to se­ri­ously pursue Med­i­caid ex­pan­sion in 2016, though the Repub­li­can-con­trolled Leg­is­la­ture wants to hear how it will be fi­nanced when states have to pick up a small per­cent­age of the ex­pan­sion fund­ing start­ing in 2017. More than 300,000 Louisianans could qual­ify for cov­er­age, and the state’s hos­pi­tals are ea­ger for quick ac­tion. So far, 30 states plus the Dis­trict of Columbia have ex­panded Med­i­caid.

Next up could be South Dakota, where Repub­li­can Gov. Den­nis Dau­gaard has in­cluded Med­i­caid ex­pan­sion in his pro­posed bud­get. But he has ac­knowl­edged it will be an up­hill bat­tle per­suad­ing the GOP-con­trolled Leg­is­la­ture. Alabama Repub­li­can Gov. Robert Bent­ley has said his ad­min­is­tra­tion is con­sid­er­ing ex­pan­sion through a state­spe­cific waiver model.

On the other hand, there could be some set­backs for ex­pan­sion supporters in states that pre­vi­ously ex­tended cov­er­age. Arkansas’ Repub­li­can lead­ers are con­sid­er­ing ask­ing the Obama ad­min­is­tra­tion to let the state im­pose pre­mium pay­ments, cov­er­age lock­outs for non­pay­ment, as­set tests and work re­quire­ments. In Ken­tucky, newly elected Repub­li­can Gov. Matt Bevin, who cam­paigned on a prom­ise to roll back the Med­i­caid ex­pan­sion, has sug­gested he also would like to add per­sonal-re­spon­si­bil­ity fea­tures such as pre­mium pay­ments and lock­outs to the state’s pro­gram. And in Michi­gan, state Repub­li­can lead­ers will have to de­cide whether the Obama ad­min­is­tra­tion’s re­vi­sion of their Med­i­caid ex­pan­sion waiver pro­posal goes far enough in making ben­e­fi­cia­ries more per­son­ally re­spon­si­ble. Pa­tient ad­vo­cacy groups are ner­vously watch­ing how far the ad­min­is­tra­tion is will­ing to go in ap­prov­ing th­ese states’ waiver pro­pos­als, which they warn will re­duce en­roll­ment.

On Med­i­caid man­aged-care reg­u­la­tion, the CMS’ pro­posed rules would cap how much pre­mium rev­enue plans could al­lo­cate for ad­min­is­tra­tion and profit; re­quire states to more rig­or­ously su­per­vise the ad­e­quacy of plans’ provider net­works; en­cour­age states to es­tab­lish qual­ity rat­ing sys­tems for plans; al­low more be­hav­ioral health­care in in­sti­tu­tional set­tings; and en­cour­age the growth of man­aged long-term care. About 73% of ben­e­fi­cia­ries re­ceive cov­er­age through man­aged-care plans, ac­cord­ing to con­sult­ing group Avalere Health.

An­other key is­sue in 2016 will be the fate of the Obama ad­min­is­tra­tion’s 12-state demonstration to bet­ter co­or­di­nate cov­er­age and care for peo­ple who are du­ally el­i­gi­ble for Med­i­caid and Medi­care. So far, par­tic­i­pat­ing health plans have strug­gled with high rates of ben­e­fi­cia­ries choos­ing not to par­tic­i­pate and with re­sis­tance from providers. There are ques­tions about how many states will ex­tend their par­tic­i­pa­tion af­ter the ini­tial three-year demonstration pe­riod.

Many will be watch­ing Cal­i­for­nia, where Gov. Jerry Brown said in his bud­get pro­posal that the pro­gram was cost­ing the state rather than saving money. He said, “If th­ese fac­tors are not im­proved by Jan­uary 2016, the (demonstration) would cease op­er­at­ing ef­fec­tive Jan­uary 2017.”

Jeff My­ers, pres­i­dent of the trade group Med­i­caid Health Plans of Amer­ica, said that if Cal­i­for­nia ends the pro­gram, “it would be a sig­nal that the dual demon­stra­tions are a fail­ure.”


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