Public Payers News

CMS Rule Renovates Coverage beyond ACA’s Medicaid Expansion

The federal government has sought to focus the Medicaid program – especially after the increase in coverage due to Medicaid expansion – on improving the consumer experience and delivering better quality care.

By Vera Gruessner

- The Medicaid program has greatly changed since the passage of the Obama administration’s Affordable Care Act. Most importantly, more than half of the states throughout the nation have implemented Medicaid expansion, which means that more low-income families and individuals are now eligible for the Medicaid program and greater access to medical care.

Medicaid Payment Program

Andy Slavitt, Centers for Medicare & Medicaid Services (CMS) Acting Administrator, and Vikki Wachino, CMS Deputy Administrator and Director for the Center for Medicaid and CHIP Services, wrote for the CMS Blog that 72 million Americans are Medicaid beneficiaries this year, which is an increase of 14 million people when compared to the number of Medicaid beneficiaries in October 2013. This increase is largely due to the Medicaid expansion that the Affordable Care Act stimulated.

The Medicaid program has been around for decades to provide low-income families with the type of health coverage they require including ensuring children have check-ups and follow-up care and pregnant women receive the right prenatal care. Additionally, the Medicaid program is there to help recently unemployed adults who lose their employer-sponsored healthcare coverage and disabled people who are unable to work either temporarily or indefinitely.

“Medicaid is there when you need it, for working class families, working Americans, people falling on temporary hard times, or living with a disability. Take Todd, a full time student with two part time jobs in Utah who was recently profiled by the Kaiser Family Foundation. He and his wife, Erin, were uninsured but had a new baby. They learned that Erin and their baby Jane were eligible for Medicaid,” Slavitt and Wachino stated in The CMS Blog.

“It’s because of people like Todd and Erin and people like you that we have invested so heavily and thoughtfully in Medicaid and put forward the rules we have today, which will also support physicians and hospitals and states in improving service, quality and health for millions of Americans.”

Slavitt and Wachino explain that in more recent years, the federal government has sought to focus the Medicaid program – especially after the increase in coverage due to Medicaid expansion – on improving the consumer experience, delivering better quality care, and ensuring improved access to medical services.

CMS Acting Administrator Slavitt also announced that the federal agency is finalizing a new rule that will reform how the Medicaid program handles about two-thirds of beneficiaries obtaining insurance through private managed care plans.

Renovations to managed care plans are expected to assist the Children’s Health Insurance Program (CHIP) and the Medicaid program continue to stabilize healthcare spending and deliver high-quality care.

The new CMS rule helps improve states’ ability to reform healthcare delivery and even established the first Medicaid and CHIP quality rating system. The opportunity to rate these state-based health plans will allow consumers to be able to select plans based on publicly-reported plan quality information.

The CMS rule also established the importance of utilizing new tools to improve communication with consumers such as through online provider directories or providing electronic notices to constituents.

Slavitt and Wachino also stated that the new ruling will strengthen healthcare delivery among children from low-income families who are CHIP beneficiaries.

“This final rule modernizes the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems,” the legislation stated the summary of the rule.

“The final rule aligns, where feasible, many of the rules governing Medicaid managed care with those of other major sources of coverage, including coverage through Qualified Health Plans and Medicare Advantage plans; implements statutory provisions; strengthens actuarial soundness payment provisions to promote the accountability of Medicaid managed care program rates; and promotes the quality of care and strengthens efforts to reform delivery systems that serve Medicaid and CHIP beneficiaries.”

Along with the new CMS rule, the Medicaid program has been modified tremendously in recent years. For instance, enrolling in Medicaid is now more streamlined and modernized. In the past, this process required quite a bit more paperwork and in-person interviews. Today, those eligible for Medicaid coverage are able to apply online, on the phone, or at a convenient location, reports The CMS Blog.

Paper documentation is no longer necessary because eligibility can be verified electronically today. Utilizing automated processes to enroll in Medicaid has led to a more streamlined, efficient approach.

Other renovations that CMS has accomplished has been to create new regulations that improves access to quality medical care for Medicaid beneficiaries, according to a press release from the federal agency.

“Maintaining beneficiaries’ access to care is vital to the health of our nation and health of those who may not otherwise have access to essential health care services,” Vikki Wachino said in a public statement. “Through this rule, beneficiaries will have greater confidence in the services they receive from their Medicaid health care coverage.”

Specifically, CMS is seeking to link Medicare and Medicaid payments to quality performance measures among healthcare providers. This can be clearly seen through the bundled payment programs established by the agency as well as its connection to strengthening accountable care organizations and aim to position 50 percent of Medicare reimbursement in alternative payment models by the end of 2018.

Much like the most recent CMS ruling, the push toward alternative reimbursement policies is making headway across the healthcare industry from payers to providers. Bundled payment models, accountable care organizations, and the focus on population health management will likely bring a decrease in healthcare spending as well as improved health outcomes throughout the patient community.