Leaders from organizations representing providers of housing, care and services for older adults say they continue to scrutinize the 653-page proposal of reforms to Medicaid managed care plans that the Centers for Medicare & Medicaid Services (CMS) issued yesterday, but they shared their initial reactions with Long-Term Living.
The document represents the first time in more than 10 years that CMS has addressed such plans. The proposed changes would develop guidelines related to private plan profits, would mandate that states create quality ratings for Medicaid managed care plans and would require states to ensure adequate healthcare provider access for beneficiaries. Another change would ease restrictions on marketing efforts undertaken by insurers that sell Medicaid coverage as well as insurance coverage via the marketplace initiated under the Affordable Care Act.
“It is encouraging to see the CMS address several issues that matter to both providers and consumers of long-term services and supports [LTSS] covered by Medicaid through managed care plans,” Cheryl Phillips, senior vice president of public policy and advocacy for LeadingAge, said in a statement. “These include the adequacy of provider networks, since so-called skinny networks may exclude the nursing home that a Medicaid recipient calls home.”
Phillips (right) said that LeadingAge is pleased that the regulations, if approved as written, would provide a Medicaid beneficiary with more freedom to change plans if his or her nursing home or home care provider no longer was part of his or her managed care network. The organization also agrees that states need to be more transparent in the way they set Medicaid reimbursement rates; most reimburse providers of LTSS at “far below the actual cost of services,” Phillips said. And the proposed rule may improve beneficiaries’ options for home and community-based services, she added, because managed care plans would have to act in a manner consistent with the U.S. Supreme Court’s Olmstead decision, permitting people to live in their homes or community-based settings if they are able. The proposed rule states that payment systems should support goals that include a beneficiary’s integration into the community.
Regarding the proposed guidelines on medical loss ratios, however, Phillips said that CMS should consider the non-medical LTSS typically covered by Medicaid. “Expenses like transportation for home care workers are not ‘medical,’ but they are essential to the provision of services covered under the program,” she said. “Unlike Medicare and regular health insurance plans that cover only medical services, managed Medicaid plans have to factor in these kinds of costs.”
Greg Crist, senior vice president for public affairs at the American Health Care Association (AHCA), told Long-Term Living that “the key issue we have stressed in the past is reminding policymakers and plans that those we serve are a unique population with myriad clinical needs that rarely fit a template of any kind.” Maintaining or improving quality, he added, “can be challenging when cost considerations seem to drive certain policies.”
Crist said that AHCA is carefully reviewing the regulations with these points in mind.