may be activated by the Medicaid client when contracts with the
MCO are renewed. For example, a requested four percent annual
increase by the Medicaid MCO may be offered by the Department
of Medicaid as a two percent Quality assurance withhold to meet
minimal quality standards, and a two percent withhold to fund a
health care provider performance bonus. Federal regulation continues to assure that mandatory enrollment in a Medicaid MCO
requires that there are at least two MCO options available in that
state to the Medicaid enrollee.
In June of 2015, new changes were made in the Medicaid managed
care rules. The Centers for Medicare and Medicaid Services (CMS)
announced that Medicare standards will be applied to state Medicaid contracts with MCOs. This may represent an effort by CMS
to further organize the delivery of health care and to require that
Medicaid coverage arrangements integrate with private coverage. In
many ways, this reaction from CMS seems related to the 46 million
new expansion enrollees expected from the ACA. CMS may have
a great concern that there will be a rapid expansion of patients
to private plans. CMS may also have information suggesting that
some Medicaid MCOs are reported to have inadequate networks of
providers, and, therefore, states will vary greatly in access to health
care for the newly enrolled Medicaid recipients.
Medicaid has no published national standards for quality rating.
Medicare has a 5-Star rating system to evaluate and rate private
health care plans. In 2016, ACA health exchanges should begin
publishing their annual quality ratings as well. It is suspected that
Medicaid MCO quality ratings will be similar. Health care issues
rated will include clinical quality, access, patient satisfaction, plan
management and affordability. The CMS standard of 85 percent
medical loss ratio, or revenue going to the actual costs of patient
health care, is an average and will likely be maintained for now.
All state Medicaid Departments will rapidly want to increase this
ratio based upon the total amount of Medicaid money not going
to direct patient health care. The companies that medically manage
FFS Medicaid, without the financial risk of the health care provided,
are presently working at much smaller margins.
The Medicaid MCO of the future will be judged by its reported
metrics and rated by how well its staff actually provides health care.
These ratings will be based upon how well its members stay healthy,
and upon how well they manage chronic illness. The members’
experience and satisfaction will be measured. How much the plan’s
performance has improved over time will be measured by members’
complaints and the resulting changes in the health care plan. The
health plan’s service to consumers will be measured upon how well
it manages their appeals. This Medicare 5-star rating system was
originally developed to rate nursing facilities. It did not provide
for, but should now also include, a rating of