A little noticed provision of the Patient Protection and Affordable Care Act offers opportunities for Medicaid managed care.
A LITTLE NOTICED PROVISION of the Patient Protection and Affordable Care Act offers opportunities for Medicaid managed care. The Basic Health Program provision was put into the law to allow states the flexibility to cover the uninsured who might not qualify for Medicaid.
"It is completely voluntary at the state level," says Jeremy Palmer, principal and consulting actuary at Milliman, who has written a briefing paper on the Basic Health Program.
The new option permits states to create a health plan serving primarily uninsured people with incomes between 133% and 200% of the federal poverty level, people who would otherwise receive premium subsidies in the exchange. The plan must provide at least the same essential health benefits as plans in the exchanges, and there are limits on premiums and cost-sharing.
"The Basic Health Program offers states a degree of flexibility they don't have in conventional Medicaid, while still meeting certain core standards," says Mark Reynolds, CEO of Neighborhood Health Plan of Rhode Island, a not-for-profit HMO founded by the state's community health centers.
When a state decides to implement this option and designs its Basic Health Program so it follows the same pattern as its Medicaid program, that opens up a significant market opportunity for managed care Medicaid plans.
"Currently we serve 68% of the Medicaid managed-care lives in Rhode Island," says Reynolds. "We would expect to have a significant share of the population enrolled in the Basic Health Program."
If a state does not opt for the model, then people at 133% to 200% of the federal poverty level will obtain subsidized insurance through the health exchanges. In that case, because more insurers will be involved in the exchange, plans like Neighborhood Health Plan are likely to have a much lower share of that segment, Reynolds says.
Upended: Can PBM Transparency Succeed?
March 6th 2024Simmering tensions in the pharmacy benefit management (PBM) industry have turned into fault lines. The PBMs challenging the "big three" have formed a trade association. Purchaser coalitions want change. The head of the industry's trade group says inherent marketplace friction has spilled over into political friction.
Read More
In this episode of the "Meet the Board" podcast series, Briana Contreras, Managed Healthcare Executive editor, speaks with Ateev Mehrotra, a member of the MHE editorial advisory board and a professor of healthcare policy and medicine at Harvard Medical School. Mehtrotra is also a hospitalist at the Beth Israel Deaconess Medical Center in Boston. In the discussion, Contreras gets to know Mehrotra more on a personal level and picks his brain on some of his research interests including telehealth, alternative payment models and price transparency.
Listen
Inflation Reduction Act: Reforms to Patient Cost-Sharing
September 18th 2023Lower out-of-pocket costs for patients might put upward pressure on drug prices, as manufacturers face less price sensitivity, note Matthew Majewski and Rhett Johnson of Charles River Associates. But they also note that upward pressure on price is likely to be limited to the inflation rate as any additional price increase would need to be paid back to CMS in the form of inflation rebates.
Read More
Spending climbed by 2.7% in 2021. In 2020, it soared by 10.3%, fueled by federal government spending in response to the pandemic. The blizzard of calculations of 2021 healthcare spending by CMS’ actuaries also provides further evidence that utilization of healthcare services bounced back in 2021.
Read More