Creating seamless coverage transitions between Medicaid and the exchanges
State Health Reform Assistance Network issue brief
McMahon, Shannon M.
Robert Wood Johnson Foundation.
State Health Access Data Assistance Center, University of Minnesota.
State Health Reform Assistance Network.
[Princeton, N.J.] : Robert Wood Johnson Foundation, 
Continuity of Patient Care
Contracts -- legislation & jurisprudence
Economic Competition -- legislation & jurisprudence
Health Care Reform -- legislation & jurisprudence
Health Plan Implementation -- legislation & jurisprudence
Insurance Coverage -- legislation & jurisprudence
Insurance, Health -- legislation & jurisprudence
Medicaid -- legislation & jurisprudence
Contracts -- economics
Economic Competition -- economics
Health Care Reform -- economics
Health Plan Implementation -- economics
Insurance Coverage -- economics
Insurance Coverage -- trends
Insurance, Health -- economics
Insurance, Health -- trends
Managed Care Programs
Medicaid -- economics
Medicaid -- trends
IN BRIEF. Under health reform, Medicaid will expand in 2014 to cover an additional 16 to 20 million beneficiaries. This population will include a significant percentage of childless adults with urgent and complex health care needs, who are likely to shift between subsidy programs over time. This brief draws from current programs that have dealt with this challenge successfully, with the hope that their experience will help guide seamless coverage transitions between Medicaid managed care organizations and qualified health plans in the exchanges. A companion chart includes excerpts of sample contract language related to coverage transitions in existing programs. The 2014 expansion of Medicaid under the Affordable Care Act (ACA) will cover 16 to 20 million new beneficiaries, most of whom will be childless adults with incomes below 138 percent of the federal poverty level (FPL). Many of these individuals are likely to have complex health care needs and pent-up demand for care. Due to fluctuations in income, this population is also likely to "churn" between existing Medicaid programs, the new Medicaid expansion, subsidized exchange qualified health plans (QHPs), and possibly state-run basic health plans, creating a heightened need for seamless coverage transitions across state health care programs. While the Affordable Care Act (ACA) offers numerous opportunities to stabilize coverage for beneficiaries as their incomes rise and fall, the path is far less clear for creating continuous care. This brief examines how seamless coverage transitions can be supported through policies designed to provide continuous care for individuals moving between health insurance products, plans, and providers. It reviews lessons from: (1) existing exchange programs in Massachusetts; (2) transition coverage policies within Tennessee's proposed exchange model; and (3) current transition practices between Medicaid managed care organizations (MCOs) and other programs. These models offer insights to aid states in developing coverage linkages between current public programs, programs for the future Medicaid expansion population, and options provided by proposed insurance exchanges. A companion chart summarizes existing coverage transition practices from various sources, including: (1) state Medicaid managed care contracts; (2) the National Committee for Quality Assurance (NCQA); and (3) Medicare Part D. Sample contractual language related to coverage transitions is also provided. This preliminary review is not intended to be exhaustive; rather, it is meant to raise considerations for states as they develop coverage approaches between Medicaid and a state or federal exchange.
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
NLM Unique ID:
101586569 (See catalog record)