MEDICAID MODERNIZATION—CMS
TAKES A STEP TOWARD MAKING
FEDERAL PROGRAM INTEGRATION
Tom James, MD
O
n May 26th, the Centers for Medicare and Medicaid Services (CMS)
took a step towards integration of
the two giant federal programs of Medicaid
and Medicare. The announcement of proposed rules on that date represented the first
major overhaul of the Medicaid program in
more than a decade. The stated goals of this
reform are to:
•
Support state efforts to provide high quality care for Medicaid
recipients.
•
Improve communication with and access to care for Medicaid
beneficiaries.
•
Provide new program integrity tools.
•
Implement best practices identified in existing long-term services and support (LTSS).
•
Better align Medicaid and CHIP managed care rules practices
with the federal exchanges (“Marketplaces”) and Medicare
Advantage.
This highly technical document proposed rule changes that primarily impact health plans and state governments. But there are
10
LOUISVILLE MEDICINE
elements which affect the practicing physician; these will be the
focus of this article.
As of 2014, 51 percent of physicians nationally accepted Medicaid. Of that group a majority of pediatricians, family physicians,
and obstetricians participated in Medicaid. Medical and surgical
specialists who did participate were in a minority. Under the Affordable Care Act, Medicaid has expanded in a large number of states,
including Kentucky. As a result, Medicaid is now the largest payer
of health care services, giving it as much or more clout compared
with Medicare. As administrative alignment of the requirements of
Medicaid, Medicare and CHIP programs becomes a reality, there will
be greater pressures for more physicians to participate in Medicaid.
The Medicaid and CHIP proposed rule changes further enhance
the alignment of government payment processes. It becomes important for the practicing physician to become aware of the key
elements relating to clinical practice:
•
Incentives and Risk Arrangements — By the end of 2015,
CMS estimates that 75 percent of Medicaid beneficiaries will
be in a managed Medicaid program just as virtually all are
in Kentucky and Pennsylvania. Since the managed Medicaid
organizations are capitated, CMS expects to