One major concern has been about disruption in care for very low income individuals who may “churn” between Medicaid and exchange eligibility; however, if the same health plans operate in both Medicaid and exchanges, it could minimize that disruption and improve continuity of care.
Avalere tracking shows that in 62% of states where data is available, there will be at least one plan that acts both as a Medicaid managed care organization (MMCO) and a qualified health plan (QHP) in the exchange. In 18 states there will be more than one plan acting as both an MMCO and a QHP, meaning consumers may have a choice among carriers straddling both markets. Some states, including California and Nevada, are currently pursuing strategies to further encourage plans to participate in both the Medicaid and exchange markets.
Importantly, about half of these Medicaid-focused carriers serve only Medicaid beneficiaries today and have not previously provided coverage to privately-insured individuals, causing some new challenges in the QHP market. Carriers must set rates on an individual basis for a new population and potentially collect premiums and cost sharing for the first time. Furthermore, for all plans serving patients in both Medicaid and the exchanges, maintaining networks with separate provider payment rates and meeting different requirements for network adequacy may prove challenging.
This article was excerpted from the September issue of Medicaid Monthly, which tracks the latest federal and state Medicaid activity in one comprehensive source. For access, contact Tiernan Meyer.