States may offer Medicaid benefits on a fee-for-service (FFS) basis, through managed care plans, or both. Under the FFS model, the state pays providers directly for each covered service received by a Medicaid beneficiary. Under managed care, the state pays a fee to a managed care plan for each person enrolled in the plan. In turn, the plan pays providers for all of the Medicaid services a beneficiary may require that are included in the plan’s
contract with the state. The majority of Medicaid enrollees, largely non-disabled children and adults under age 65, are in managed care plans, but just over half of Medicaid benefit spending is in managed care. The enrollment of
high-cost populations, such as people with disabilities, in managed care has been more limited than for lower-cost populations. In addition, coverage of certain high-cost services (e.g., nursing home and other long-term services and supports) may be excluded from managed care contracts, although such arrangements are growing in number. In general, states set provider payments under fee for service. Section 1902(a)(30)(A) of the Social Security Act
requires that such payments be consistent with efficiency, economy, and quality of care, and are sufficient to provide access equivalent to the general population. MACPAC has documented state-specific fee-for-service payment methods for a number of services. Medicaid FFS payment rates for physician services are often much lower than those paid by other payers, raising concerns that low fees affect physician participation in Medicaid, and thus access to care
(Decker 2012, Cunningham and May 2006). While other factors, such as administrative burden, are also known to affect physician participation, research has consistently shown an association between low payment rates (relative to other payers) and lower levels of physician participation. On average, Medicaid FFS physician payment rates are two-thirds of the rates Medicare pays, although this varies greatly by
state and service. (For an in-depth discussion of this issue, see Chapter 2 of MACPAC’s June 2013 report.) It is more difficult to compare Medicaid FFS payments to hospitals and nursing facilities due to the variation in how states pay these providers. MACPAC constructed a state-level payment index to compare states’ Medicaid FFS inpatient hospital payments both to other states and to Medicare. Overall, Medicaid payment is comparable or higher than Medicare once supplemental payments and provider contributions are taken into account. MACPAC has not undertaken a similar analysis for nursing facility payments. Managed CareIn 2019, 83 percent of all Medicaid beneficiaries were enrolled in some form of managed care (CMS 2021). States have incorporated managed care into their Medicaid programs for a number of reasons. Managed care provides states with some control and predictability over future costs. Compared with FFS, managed care can allow for greater accountability for outcomes and can better support systematic efforts to measure, report, and monitor performance, access, and quality. In addition managed care programs may provide an opportunity for improved care management and care coordination. Use of managed care varies widely by states, both in the arrangements used and the populations served. Medicaid programs use three types of managed care delivery systems:
States use a variety of methods to set rates for risk-based managed care plans but all must pay within an actuarially sound range. Many use an administrative process in which a specific rate is set by the state. Others use a competitive bidding or negotiation process. States may also use hybrid approaches, such as setting a range of rates and then asking plans to bid competitively within that range, or negotiating with plans based on the administered pricing or their competitive bids. At least 24 states use measures of health status to risk adjust their rates, rather than relying on demographic factors alone. Such techniques are meant to adjust rates to better reflect a plan’s mix of enrollees and their expected care needs and expenditures. Learn more from the following MACPAC resources:Key statistics Total Medicaid Benefit Spending by State and Category Additional background Timeline of Major Medicaid Payment Policy Developments Fact sheets Medicaid Inpatient Hospital Services Payment Policy Issue briefs Directed Payments in Medicaid Managed Care In-depth analysis and policy recommendations A Framework for Evaluating Medicaid Provider Payment Policy What is an optional uniform provision?The Illegal Occupation/Act Provision (an Optional Uniform Provision) allows the insurer to deny liability if the insured is injured while engaged in an illegal occupation or committing an illegal act.
Which provision is an optional uniform provision quizlet?Illegal Occupation/Act (an Optional Uniform Provision) allows the insurer the right to deny liability if the insured is injured while performing an illegal occupation or committing an illegal act.
Which of the following might be done to protect against adverse selection?Which of the following might be done to protect against adverse selection when underwriting group medical insurance? D. By requiring a minimum percentage of the group to enroll, the risk is spread by possibly getting those of better health to participate along with those of poorer health.
Which of the following best describes a conditional contract quizlet?Which of the following BEST describes a conditional insurance contract? A contract that requires certain conditions or acts by the insured individual This means that the insurer's promise to pay benefits depends on the occurrence of an event covered by the contract.
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