Experts on value-based healthcare outlined the federal government’s proposed rule changes to Medicaid managed care and how they signal improved alignment and quality of care for Medicaid-Medicare dual eligible special needs plans (D-SNPs) at the 2023 Illinois State of Reform Health Policy Conference earlier this month.
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“This proposed rule would advance CMS’s efforts to improve access to care, quality, and health outcomes, and better address health equity issues for Medicaid and Children’s Health Insurance Program (CHIP) managed care enrollees. The proposed rule would specifically address standards for timely access to care and states’ monitoring and enforcement efforts, reduce burden for some State directed payments and certain quality reporting requirements … and establish a quality rating system for Medicaid and CHIP managed care plans.”
— CMS and the US Department of Health and Human Services.
Illinois launched its Medicare-Medicaid Alignment Initiative (MMAI) in 2013 in an effort to streamline healthcare delivery and reduce costs for dual-eligible Illinoisians. In 2019, CMS strengthened its Medicare-Medicaid integration requirements.
Jennifer Maslowski, PhD, former health insurance specialist at CMS and a senior consultant at Health Management Associates (HMA), highlighted some of the compelling new regulations that impact MMAI.
“[CMS is] going to require [states] to submit an annual payment analysis that compares managed care plans’ payment rates for certain services as a proportion of Medicare’s payment rate for certain home and community-based services and the state’s Medicaid state plan payment rate.
It’s also going to require states to implement a remedial plan for any managed care plan that has an access issue and needs improvement.”
— Jennifer Maslowski, PhD, HMA
Another major change will be new regulations on state-directed payments, which include removing barriers to help states use automated processing to implement value-based payment agreements. Under the rule, CMS would require Illinois to submit state-directed payment evaluations if the cost for payment exceeds the 1.5% threshold for percentage of total capitation payment.
The rule change would also eliminate written prior approval for state-directed payments that are at the base Medicare payment rate.
In its 2022-2032 framework for health equity, CMS signaled it is prioritizing racial health equity and quality measurements in its reviews of state 1115 Medicaid 1115 waivers.
“[CMS is] really driving home, in the rule, [the importance of] really having performance measures and metrics versus just access metrics … Even in more established programs, access measures are needed, but ensuring that there are performance measures and metrics to go along with [access] as well.”
The changes will come as Gov. JB Pritzker’s administration prepares to submit its early childhood initiatives for CMS approval. The state-driven focus on early childhood will invest billions into building a full range of health and social services support through Medicaid managed care.
The panelists said the state is overall well-positioned to make the transition from Medicaid-Medicare plans (MMP) to fully integrated D-SNP plans.
Representatives from two of the state’s MMAI plans, Aetna and Meridian Health, shared insights into how their managed care organizations will track and incorporate quality and health metrics as part of its value-based performance measures.
Rushil Desai, CEO of Aetna Better Health of Illinois, said the organization was focused on simplifying healthcare access through system improvements.
“[Value-based contracting is] core to what we’re looking to build here at Aetna. It’s not a one-size-fit-all—it really varies by provider type. You’ve got to get beyond fee-for-service and really figure out how we start driving towards quality and ultimately outcomes.”
— Rushil Desai, CEO of Aetna Better Health of Illinois
Desai says payers have to be foundational to the work of the state’s transformation initiatives, a point that Centene Senior Vice President of Regulatory and Legislative Affairs Jeanette Badrov agrees with.
“Because integration and collaboration [with providers] is the key to a long, sustainable partnership.”
— Jeanette Badrov, Centene
Badrov says industry alignment with state and federal objectives around improving population health has yet to be achieved, but believes the provider rate increases that were approved this legislative session will be impactful in meeting those goals.
“Where I hear a lot from providers [is], ‘We don’t make enough money in Medicaid to be able to [take] risk-based payments.’ So that [rate] increase is really going to have a lot—to be able to get to that glide path towards risk with baseline data.”