Innovative approaches to Medicaid expansion within the Medicaid managed care delivery system

Much attention has been paid to innovative approaches to coverage of the Medicaid expansion population that leverage the private commercial insurance market for coverage through “premium assistance” programs.  However, other states have turned to the Medicaid managed care delivery system as the vehicle for implementing innovative coverage designs for the newly eligible population.  As outlined below, these states have received 1115 Medicaid Demonstration waivers to gain flexibility in the coverage offered to this population via managed care plans.

Indiana

The expansion population in Indiana is covered via the state’s Healthy Indiana Plan (HIP), which primarily utilizes a Medicaid managed care delivery system (there is an alternative option for voluntary premium assistance for qualified employer-sponsored insurance).  HIP has two levels (Plus and Basic) of managed care coverage:

  • Those who make monthly contributions of up to 2% of household income to POWER (Personal Wellness and Responsibility) accounts, which are similar to Health Savings Accounts (HSAs), are enrolled in HIP Plus plans with cost-sharing limited to non-emergency use of the emergency department; and HIP Plus plans also have dental and vision benefits.
  • Those at or below 100% Federal poverty level (FPL) who do not make monthly POWER account contributions are enrolled in HIP Basic plans with cost-sharing aligned with the state plan and more limited benefits.

Persons between 101% and 138% FPL who do not make monthly POWER account contributions are excluded from coverage.  The state also contributes toward POWER accounts, with all funds in the accounts being used to pay the managed care plan deductible.  Total beneficiary out-of-pocket spending is capped at 5% of household income and individuals can receive contributions from employers or other third parties to decrease their monthly contribution requirement.

The Demonstration waiver in Indiana also allows for individuals’ choice of providers to be limited to the plan provider networks with an exception for family planning providers.  Retroactive coverage is also waived, as was non-emergency medical transport temporarily. Via separate waiver authority, the state has received approval to charge higher cost-sharing for non-emergency use of the emergency department.

Iowa

While initially structured as a Marketplace premium assistance Demonstration in part, Iowa’s coverage of the Medicaid expansion was revamped due to a lack of choice on the Marketplace.  Coverage is now provided for the entire expansion population via private Medicaid managed care plans. Under the amended waiver, premiums are charged to those with incomes greater than 50% FPL ($5 for those with household incomes up to 100% FPL and $10 for those with household incomes between 100% and 138% FPL).  Premiums start in the individual’s second year of enrollment and there is an exception for those who completed healthy behaviors (i.e., a wellness exam and health risk assessment) in the prior year.  No cost-sharing is charged except for co-payments for non-emergency use of the emergency department.

The state also received a waiver of its obligation to provide non-emergency medical transport.

Michigan

Michigan’s entire Medicaid expansion population is initially covered through private Medicaid managed care plans and Prepaid Inpatient Health Plans (PIHPs) for behavioral health services (beginning on April 1, 2018, enrollees with incomes above 100% FPL will have the option of transitioning to premium assistance for Marketplace Qualified Health Plans).  Under Healthy Michigan, all enrollees have co-payments for services via retrospective quarterly payments via MI Health Accounts.  Those enrollees with incomes between 100% and 138% FPL are also subject to monthly premiums of 2% of income.  Total beneficiary out-of-pocket spending is capped at 5% of household income and all enrollee out-of-pocket requirements can be reduced for those who achieve healthy behaviors. Once the Marketplace Option goes into effect, enrollees above 100% FPL will have to complete healthy behaviors to remain in the Healthy Michigan managed care plans.

The state also received permission via the waiver to limit operation of the Demonstration to specific parts of the state.  The state was also allowed to limit freedom of choice – in certain areas of the state, managed care can be provided through only one plan and, in all coverage, enrollees can be limited to choice of providers within the plan provider networks, except for family planning providers.

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