What provider should know about transition to Medicaid Managed Care?

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What provider should know about transition to
Medicaid Managed Care?
Managed Care plays important role in the delivery
of healthcare and it is used to describe a health
insurance plan or health care system that
coordinates the provision, quality, and cost of
care for its enrolled members. Traditionally
States have utilized a fee-for-service (FFS)
payment system to cover enrollees but now states
are also making the transition to Medicaid
managed cares prospective payment model as a
superior cost-saving alternative to traditional
fee-for-service Medicaid. It is observed that
from 1990 there is a gradual increase in the
share of Medicaid enrollees covered by the
managed care model. According to a research
study, it is observed that nationwide 69 of
Medicaid beneficiaries enrolled in comprehensive
Medicaid managed care plans. Lets understand
the major categories services provided by
Medicaid managed care plans Medicaid Managed
Care Plans
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What provider should know about transition to
Medicaid Managed Care?
Today many states design and administer their
own Medicaid programs within federal rules and
states will decide deliver and pay for care for
Medicaid beneficiaries. Mostly all states have
some form of managed care which includes
comprehensive risk-based managed care
and/or primary care case management (PCCM)
programs. The five major categories in Medicaid
Managed Care plans and what each plan include is
given below
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What provider should know about transition to
Medicaid Managed Care?
1 Enroll Engagement and Service Outreach and engagement Benefits information Health education Appeals and grievances
2 Provider Access and Availability Work development and contracting Provider service and education Claims processing Value-based arrangements
3 Care Management Assessment and care planning Longitudinal and transitions care management Utilization management and medical review
4 Financial Management and Reporting Value-based payment arrangements Service utilization and cost, other financial information Fraud, waste, and abuse detection, monitoring, and reporting
5 Quality Improvement Quality metrics data collection and analysis Quality improvement projects to improve performance
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What provider should know about transition to
Medicaid Managed Care?
After knowing about plans, lets understand about
reimbursement in detail. Medicaid Managed Care
Reimbursement While making reimbursement managed
care, states are signed contracts with managed
care organizations (MCOs). This contract includes
coverage for specific services to enrolled
Medicaid beneficiaries and for covering those
services, MCOs are paid a set monthly capitation
payment.   Now, Managed care organizations
negotiate with providers to provide services to
their enrollees, either on a fee-for-service
(FFS) basis or through arrangements under which
they pay providers a fixed periodic amount to
provide services. Current MCO capitation rates
may have been developed and implemented prior to
the onset of the COVID-19 pandemic and hence in
response to COVID-19, CMS has asked states to
rework managed care contracts as well as rates,
including adjusting capitation rcoviates, risk
mitigation strategies, covering COVID-19 costs on
a non-risk basis, etc.
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What provider should know about transition to
Medicaid Managed Care?
COVID-19s Impact on Medicaid Managed Care More
than 27 million Americans have lost their health
insurance coverage following a job loss during
the COVID-19 crisis and to protect themselves as
well as their family they are turning to
Medicaid. States have started to recognize the
value of Medicaid managed care plans to provide
quality care and help control costs. These
factors are important as budgets face the strain
of COVID-19. Moreover, these plans have secured
and distributed personal protection equipment to
local hospitals and health care providers and
partnered with public and county health systems
to administer COVID-19 tests. Finally, we can
say that managed care arrangements facilitate and
monitor access to needed care, measure and
strengthen the quality, and deliver
cost-effective care hence the transition to
Medicaid Managed Care is recognized.