Medicaid care expansion: Two test cases

Although they're not expanding Medicaid under the Affordable Care Act, Texas, Florida and other states are expanding managed care. These expansions offer challenges as well as opportunities.

Yasser Fahmy Zeid, MD, an OB/GYN at Zeid Women's Health Center in Longview, Texas, has mixed feelings regarding the expansion because it has disadvantages and advantages from the both the provider and patient points of view. 

"One problem is that patients can change from one managed care company to another almost on a monthly basis," Zeid said. "Each company has its own rules and regulations to comply with. Oftentimes, you don't know which company a patient is insured by until they arrive for an appointment. It takes a lot more staff time to verify which company they are with and that we're complying with each specific company's procedures." In addition, there are "a lot more" denials for authorizations, he said.

According to Zeid, the main advantage of managed care expansion is that some services are now covered, such as home healthcare for pregnant women in pre-term labor. 

In Texas, Superior and Amerigroup have received the bulk of managed care organization (MCO) contracts over the past few years. "There are many more regulations we have to comply with; I wish they were uniform," lamented Zeid. "But there are still a few patients on traditional Medicaid, which are easiest to take care of."

Planet Texas

In Texas, the unduplicated enrollment numbers in Medicaid managed care programs total approximately 2.84 million. Linda Edwards Gockel, a spokesperson for the Texas Health and Human Services Commission (HHSC) in Austin, said that, as of January 1, 2014, the enrollments break down as follows: 2,402,175 enrolled in STAR; 410,659 enrolled in STAR+PLUS; 30,666 enrolled in STAR Health; and 2,401,441 enrolled in Medicaid Dental.

HHSC's managed care contracts include requirements that organizations must have sufficient capacity to serve the expected enrollment, meet service area needs with geographic distribution of preventative, primary care, and specialty service providers, and report how often members go out of network for health care services.

In order to provide services in Medicaid managed care, a provider must first apply to become a Medicaid provider through Texas' fee-for-service claims administrator, the Texas Medicaid and Healthcare Partnership (TMHP). The application requires the provider to submit everything from information on ownership in the provider's practice to details on employees.

Each provider must receive a provider number from the state before they can submit an application to a MCO or dental managed care organization (DMO). The application process with the MCO/DMO is generally more abbreviated than the application process with TMHP. Although credentialing varies from plan to plan, most of the plans use a national credentialing organization to approve the provider and add them to the network.

The Florida approach

Jamie Sowers, outreach coordinator at the Florida Agency for Health Care Administration in Tallahassee, reported that the Statewide Medicaid Managed Care (SMMC) program would be rolled out in two phases in Florida. The first phase, known as the Long-term Care program, serves recipients who are disabled and/or over the age of 65. This portion of the SMMC program was completed on March 1, 2014, and has a total enrollment of approximately 90,000 recipients.  

The second phase of SMMC, referred to as the Managed Medical Assistance program, provides acute care services such as inpatient and outpatient hospital services or prescription drug coverage to eligible recipients of all ages. The rollout for the Managed Medical Assistance program will begin on May 1, 2014, and should be completed on August 1, 2014. Upon completion, the projected enrollment for the Managed Medical Assistance program is anticipated to be slightly more than three million recipients.

Currently in Florida, there aren't any pending contract decisions. "We published an invitation to negotiate, went through an extensive, competitive procurement process, and executed the contracts earlier this year (for Managed Medical Assistance)," Sowers said.

During its competitive procurement process, the Florida Agency for Health Care Administration negotiated and is requiring managed care plans in the state of Florida to have robust provider networks that will meet the needs of their enrollees. The network requirements for the SMMC program are the most comprehensive that the Florida Medicaid program has required.

"We are confident that the provisions of the SMMC program will provide recipients with better access to both primary care physicians and specialists than they had under the previous fee-for-service delivery system," Sowers said. If a managed care plan violates any portion of the contract, including network adequacy standards, it may be sanctioned or have liquidated damages imposed for lack of compliance."

In addition, Sowers said Florida managed care plans must enter into provider contracts with at least one full-time equivalent (FTE) primary care physician per 1,500 enrollees. The managed care plan may increase the ratio by 750 enrollees for each FTE advanced registered nurse practitioner or physician's assistant affiliated with a primary care physician. 

Patient advocacy concerns 

According to the HHSC's Gockel, when expanding Texas managed care into new areas there have been concerns about the adequacy of some health plan networks, as well as fears that health plans would deny or reduce benefits. Some advocates also worry that patients may not understand the changes. 

"HHSC works closely with providers, clients, and advocates to address concerns and explain everything the state does related to client outreach, measurement of network adequacy, and transitions of prior authorizations and benefits from the fee-for-service system to managed care," Gockel said. "HHSC staff travel to cities across the state and present information sessions for providers and consumers. And we continue to meet with stakeholders on a regular basis to work through questions and concerns."

The Florida Agency for Health Care Administration has worked closely with advocacy groups to answer questions and provide information as it works to implement both the Long-term Care and Managed Medical Assistance components of the SMMC program. Sowers said the primary questions from advocacy groups have regarded managed care plan assignment; whom to contact if patients want to change plans or if they have questions on being required to enroll in a plan; eligibility for specialty plan enrollment; and, for long-term care program enrollees, care plan development.

Those who champion Medicaid managed care say it is superior to simple Medicaid expansion, as it offers better coordination of services that address patients' needs. Managed care also helps states better manage costs, its supporters say. Given their bet against ACA Medicaid expansion, Texas and Florida hope those claims prove accurate.