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Medicaid Managed Care

Medicare-Medicaid dual eligibles are often talked about as a single type of patient. They have significant levels of disability and chronic disease, and account for a disproportionately large spending in both Medicare and Medicaid budgets. But dual eligibles are a diverse group. A few recent studies into health spending on dual...
Risk adjustment is a key mechanism to ensuring appropriate payments for Medicare Advantage plans, Medicare Part D drug plans, and Medicaid health plans.  Since health plans vary in their mix of healthy and sick enrollees, risk adjustment modifies premium payments to better reflect the projected costs of members served and...
Though most commonly associated with Medicare, Accountable Care Organizations are now making their way into state Medicaid programs. Providers, of course, are an essential part of the ACO model. But many providers don’t yet have the resources to coordinate care, analyze cost and usage data, and adapt to value-based...
Even as Accountable Care Organizations and other payment reform models become more common, there is still not much comprehensive information about which models providers participate in most often, and what exactly to do to make those arrangements work well. It is also important for providers to understand the best practices...
Billy Millwee, former Texas Medicaid director, recently published an excellent piece with insight into that state’s experience with quality-based payment reform. Health care payors, both private and public, are looking more and more to tie payment with outcomes. Millwee’s article is a thoughtful and thorough assessment of Texas Medicaid's...
Special Needs Plans (SNP) are part of the Medicare Advantage program and were created by the Medicare Modernization Act of 2003 (MMA). There are three types of SNPs, each intended to provide coordinated care for Medicare beneficiaries that meet specific criteria. Institutional SNPs (I-SNP) serve beneficiaries who, for 90 days...
Much of the story about rising health costs and spending has to do with relatively small groups of people with expensive health needs. For example, the Centers for Medicare and Medicaid Services (CMS) estimates Medicare beneficiaries with two or more chronic conditions accounted for 93 percent of Medicare spending...
The Centers for Medicare and Medicaid Services (CMS) has answered some questions about how Arkansas’s creative plan to expand Medicaid under the Affordable Care Act (ACA). The plan, which Gov. Mike Beebe put forward, would use federal Medicaid expansion money to give premium subsidies for Medicaid beneficiaries to enroll...
What's the impact on patient care, particularly prescription drug utilization, as Medicaid beneficiaries move from fee-for-service to Medicaid health plans?  This year, state Medicaid programs will spend over $22.1 billion on pharmacy benefits. This will grow to about $50 billion by 2020, according the CMS actuaries. Nearly half of Medicaid prescriptions...
Some states have expressed interest in using premium assistance to expand Medicaid eligibility under the Affordable Care Act (ACA).  Instead of serving the new ACA Medicaid expansion population through the Medicaid delivery system (through Medicaid health plans or Medicaid fee-for-service, depending on the state), the new enrollees would be...

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