Tag: Managed Care Plans

Understanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments

Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Introduction

Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments in Medicaid managed care. This study, conducted by Samantha G. Auty, Jamie R. Daw, and Jacob Wallace, provides valuable insights into how these payments impact delivery costs and care quality.

Post Introduction

In this post, we’ll break down the key findings of the study, understand the implications of kick payments on Medicaid managed care, and discuss how these variations can affect maternal health outcomes across different states. Let’s get started by understanding the basics of Medicaid managed care and why kick payments are essential.

Detailed Story

What is Medicaid Managed Care?

Medicaid managed care (MMC) involves states contracting with private health insurers to provide Medicaid coverage. This model covers about 70% of pregnant Medicaid enrollees and finances approximately 41% of all births in the United States. Under MMC, insurers receive per-member-per-month capitated payments to cover a defined set of benefits. However, covering pregnant individuals poses a higher financial risk due to their increased healthcare needs, which often leads to states implementing one-time “kick payments” to MMC plans triggered by delivery events.

The Role and Variation of Kick Payments

Kick payments are designed to offset the higher costs associated with childbirth. The rates and use of these payments can significantly influence whether MMC plans are incentivized to attract or avoid pregnant enrollees. This study aimed to assess the prevalence and magnitude of these kick payments across different states and how they align with actual delivery costs.

Research Methodology

The researchers conducted a cross-sectional study, abstracting data from state documents and MMC contracts published between 2018 and 2020. They gathered information on whether states used kick payments, the services covered by these payments, and the specific rates.

Additionally, they compared these rates with average state Medicaid fee-for-service (FFS) payments for delivery hospitalizations in 2020 and the Medicaid-Medicare fee index.

Key Findings

The study revealed that out of the 38 states and the District of Columbia using comprehensive MMC, 33 states used maternity kick payments. These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland. Interestingly, the variation in kick payment rates did not correlate with the Medicaid payments to physicians or the actual delivery costs, indicating that in some states, kick payments might exceed delivery costs, while in others, they fall short.

These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland.

Expert Insights

To further explore the implications of these findings, let’s delve into some expert insights.

Potential Implications of Low Kick Payment Rates

When kick payment rates are set too low, MMC plans might attempt to limit services for pregnant enrollees or restrict access to maternity care providers. This can lead to disparities in care quality and access, particularly affecting Black and Indigenous women, who are disproportionately enrolled in Medicaid and face higher risks of maternal mortality and morbidity.

The Need for Aligned Incentives

Aligning kick payment rates with actual delivery costs and care quality is crucial. States need to design Medicaid payment policies that support maternal health and promote health equity. This requires continuous research to understand the effects of these payments on care access, quality, and outcomes.

In-Depth Analysis

The Study’s Limitations

While the study provides valuable insights, it has some limitations. It could not directly associate kick payment rates with MMC plan behavior or maternal health outcomes. Additionally, the comparison was made with Medicaid FFS payments rather than the prices MMC plans paid for delivery services, which were unavailable.

The Path Forward

Further research is essential to evaluate the impact of kick payments on maternal care access and outcomes. Policymakers need comprehensive data to design effective Medicaid payment strategies that ensure equitable and high-quality maternal care.

Practical Tips

For state policymakers and healthcare administrators:

  1. Regular Review of Kick Payment Rates: Ensure that kick payment rates are regularly reviewed and adjusted to reflect actual delivery costs and care quality needs.
  2. Focus on Health Equity: Design payment policies that address disparities in maternal health outcomes, particularly for vulnerable populations.
  3. Data-Driven Decision Making: Use comprehensive data to evaluate the impact of payment policies on maternal care access and outcomes.

FAQ Section

Q1: What are Medicaid managed care kick payments? A: Kick payments are one-time payments made to Medicaid managed care plans to offset the higher costs associated with childbirth.

Q2: Why do kick payment rates vary between states? A: The variation can be due to different state policies, healthcare costs, and the structure of Medicaid managed care contracts.

Q3: How can low kick payment rates affect maternity care? A: Low rates can lead to MMC plans limiting services for pregnant enrollees or restricting access to maternity care providers, affecting care quality and access.

Q4: What can states do to improve kick payment policies? A: States should regularly review and adjust kick payment rates, focus on health equity, and use data-driven approaches to design effective payment policies.

Source

State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Addressing Critical Health Needs: Partnership HealthPlan of California Strategic Response to the 2024 Population Needs Assessment

Business Brief: Addressing Critical Needs in Population Health

Partnership’s membership remained relatively stable in 2023. The member redetermination process, resulting from the winding down of the COVID-19 Public Health emergency, caused some small fluctuations. At the close of 2023, Partnership served approximately 660,800 members throughout 14 counties.

In 2024, Partnership will no longer contract with Kaiser Permanente, will fully operationalize its 10-county expansion, and the Medi-Cal redetermination process will continue.

Partnership’s membership is expected to continue to fluctuate as a result. The 2024 Population Needs Assessment draws from a broad range of data sources to identify member needs along with the overall community conditions where members live.

Executive Summary

The 2024 Population Needs Assessment (PNA) conducted by the Partnership HealthPlan of California highlights significant gaps in healthcare access, economic stability, neighborhood conditions, and social support across its 14-county service area. This brief outlines the critical needs identified and the strategic responses planned to address these issues, ensuring improved health outcomes and equity for all members.

Identified Needs and Strategic Responses

1. Healthcare Access and Quality

Identified Needs:

  • Provider Shortages: Insufficient access to primary care, dental, specialty care, mental/behavioral health, and substance use care providers.
  • Transportation Challenges: Particularly in rural areas, long distances and lack of transportation options hinder access to care.

Strategic Responses:

  • Provider Recruitment and Retention Initiatives:
    • Launching a Provider Recruitment Program to attract healthcare professionals to underserved areas with new incentives, including sign-on bonuses.
    • Implementing a Provider Retention Initiative (PRI) Pilot to incentivize primary care clinicians for long-term service, preserving institutional knowledge and clinical leadership.
    • Telehealth Expansion: Increasing the use of telemedicine to enhance access to behavioral health services, particularly in remote regions.
2. Economic Stability

Identified Needs:

  • High Poverty and Unemployment Rates: Prevalent in rural and frontier regions.
  • Severe Housing Problems: Overcrowding, high housing costs, and inadequate facilities affect many households.

Strategic Responses:

  • Leveraging State Funds:
    • Utilizing initiatives like CalAIM, Community Supports, and the Homeless and Housing Incentive Program (HHIP) to address housing instability.
    • Offering scholarships to local Community Health Worker (CHW) programs to create employment opportunities and enhance the healthcare workforce.
3. Neighborhood and Built Environment

Identified Needs:

  • Limited Access to Healthy Foods: Particularly in rural areas, contributing to poor nutrition and related health issues.
  • High Rates of Physical Inactivity: Linked to chronic health conditions in several counties.

Strategic Responses:

  • Food and Nutrition Programs:
    • Partnering with local agencies to improve access to healthy foods and provide nutrition education.
    • Conducting outreach to promote healthy eating habits and reduce food insecurity.
  • Physical Activity Promotion: Implementing community-based programs to encourage physical activity and healthy lifestyles.
4. Social and Community Support

Identified Needs:

  • High Rates of Adverse Childhood Experiences (ACEs): Leading to long-term negative health outcomes.
  • Substance Use and Smoking: High prevalence of tobacco use and substance abuse, including among adolescents.

Strategic Responses:

  • ACE Prevention and Support Programs: Developing initiatives in collaboration with schools and community organizations to address ACEs and provide support.
  • Substance Use Prevention Campaigns:
    • Conducting educational interventions to reduce tobacco use and prevent substance abuse among adolescents and adults.
    • Promoting smoke-free environments through community outreach and education.

Conclusion

The Partnership HealthPlan of California is committed to addressing the critical needs identified in the 2024 PNA through comprehensive and targeted initiatives. By enhancing healthcare access, addressing social determinants of health, improving neighborhood conditions, and strengthening community support, the organization aims to foster equitable health outcomes and ensure a higher quality of life for all its members.

PopulationNeedsAssessment2024-1Download

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Population Needs Assessment

Partnership conducts an annual Population Needs Assessment (PNA), which reviews and analyzes the overall environment, specific community needs, and factors influencing the health and well-being of Partnership’s member population.

To read the 2024 report, click on the following: Population Needs Assessment

Archived Population Needs Assessments

​Community Health Assessments and Community Health Improvement Plan

Partnership participates in the Community Health Assessments (CHA) (sometimes called a CHNA) and Community Health Improvement Plan (CHIP) processes conducted by the local health jurisdiction in each of our 24 counties. This collaboration enhances Partnership’s ability to identify needs and assets within our members’ communities, and strengthens our relationships with community partners.

Below you will find CHAs and CHIPs for each Partnership county in addition to how Partnership participated with the county.

Butte County

Partnership staff participated in a review of the key findings and top 6 health needs identified in the CHA. Butte County released their CHA in December 2023. Click here to view the report.

Modoc County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Modoc County released their CHNA in January 2024. Click here to view the report.

Napa County

Partnership staff participated in a review of county concerns, and discussed a tentative goal with the county. Napa County released their CHA in December 2023. Click here to view the report.

Shasta County

Partnership staff participated in a review of the key findings and priority areas identified in the CHIP process. Partnership and Shasta County co-developed a SMART goal focusing on increasing child well visits, aligned with DCHS’s Bold Goals 50×2025 initiative. Shasta County released their CHIP in June 2024. Click here to view the report.

Sonoma County

Partnership staff participated in a review of the county’s approach to their assessment and improvement plan, discussed the county’s 4 priority areas, and gathered ideas for a tentative shared goal with the county. Sonoma County released their combined CHA/CHIP report in December 2023. Click here to view the report.

Yuba County

Partnership staff participated in a review of CHIP health priority areas, and a discussion around how Partnership can help the county going forward. Yuba County released their CHIP in December 2023. Click here to view the report.

Strategies for Success: Navigating California’s CalAIM Program

by Ali Modaressi, California Health Report

Photo by nathaphat/iStock

California’s ambitious journey to reshape health care through the multiyear Medi-Cal reform effort known as California Advancing and Innovating Medi-Cal (CalAIM) represents a profound leap forward. The effort will introduce a variety of new programs and benefits over five years, aimed at improving care for the millions of Californians enrolled in Medi-Cal, the state’s safety-net health insurance program.

Two years into the program, there is anecdotal evidence that providers are already starting to see improvements in the patients they serve. However, providers are experiencing many challenges in adapting to the new whole-person and coordinated care approach, including resource capacity and redundant processes. The problem is compounded by the fast pace at which the state and health plans drive the program. Achieving successful implementation requires creative thinking and coordination of available resources. 

As someone with more than 30 years of experience in health care information technology, and a member of a stakeholder advisory group for the California Health and Human Services Data Exchange Framework, here are the strategies I believe can make CalAIM a success.  

  • Seamless, purposeful data integration

CalAIM’s vision of more coordinated care across clinical, mental and social services, relies heavily on data integration and interoperability. This involves seamlessly sharing patient data among health care providers, payers and social service organizations. Achieving this level of data integration has been a formidable challenge. Health care organizations operate disparate data systems, each with their own workflow, formats, standards and protocols.

The Data Exchange Framework (DxF), which most of the state’s health care organizations are required to fully implement by January 2024, will support successful care coordination and sharing of patient information among stakeholders involved in CalAIM. 

State-funded grants are available to help facilitate this transformation. The Center for Data Insights and Innovation has allocated up to $47 million for organizations that have signed an agreement to adopt the DxF and share data. In addition, the CalAIM Incentive Payment Program from the Department of Healthcare Services provides  the funds dedicated specifically to helping CalAIM participants deploy the technology to meet key targets in their implementation and delivery of transformative programs and services. 

  • Build capacity to address skill gaps

Funds are also available for technical assistance. The state has appointed PATH TA Marketplace Vendors to allow providers, community-based organizations, counties and others to obtain assistance with implementing Enhanced Care Management (ECM) and Community Supports, two foundational initiatives of the CalAIM program. The program helps eligible organizations build data capacity, redesign workflow, strengthen services that address the social drivers of health, engage in CalAIM through Medi-Cal Managed Care plans, promote health equity, and enter cross-sector partnerships. 

  • Prepare the workforce for a data-driven future

Health care reform inevitably brings change. This requires comprehensive change management strategies that include communications, stakeholder engagement, and education and training for health care and social service professionals. The workforce will need to learn new technology and paradigms associated with CalAIM’s implementation. Future health and social service workers will require training on electronic health records, health information organization exchanges, and other health IT systems and how to use them effectively. 

  • Consider innovative solutions for care delivery challenges

The CalAIM transformation requires addressing workforce shortages, particularly in rural and underserved areas. Establishing comprehensive training programs and incentives for health care professionals in underserved regions can help address these shortages. Automating administrative tasks will reduce redundant processes and make resources available for patient care. Telehealth initiatives can also bridge gaps in access to care. In addition to IT training, cultural sensitivity training is critical to ensure the delivery of quality and compassionate care for our most vulnerable populations. 

  • Get involved to advocate, share and recognize efficiencies 

At the recent State of Reform Southern California Policy event, community-based organization representatives shared that new processes and more resources are needed to effectively deliver Enhanced Care Management for children and young people. Sharing key challenges and potential solutions creates new opportunities for dialogue and cross-training and can influence future resource allocation and policy. This reduces excessive burdens on community-based organizations and the risk of duplicating services. 

Considering that 50 percent of the state’s births are in Medi-Cal, it is critical to ensure the successful implementation of the CalAIM program for healthy and thriving communities across California. As with any transformational process, there are many factors involved in achieving successful implementation of CalAIM. These include ensuring frontline organizations responsible for delivering and coordinating care have enough resources, knowledge and preparation to move us closer to the vision of equitable health care for all Californians.

Ali Modaressi is CEO of the Los Angeles Network for Enhanced Services, a qualified health information organization in Los Angeles, and serves on the California Health and Human Services Data Exchange Framework Stakeholder Advisory Group. 

This article first appeared on California Health Report and is republished here under a Creative Commons license.

Florida Law Reminder for Early Prescription Refills (Managed Care Plans)

​Tallahassee, Fla. – Following Governor DeSantis’ Executive Orders 21-150 and 21-151 in response to Tropical Storm Elsa, the Florida Office of Insurance Regulation (OIR) issued the following notice to all health insurers, managed care organizations and other health entities licensed by OIR.

Florida Law Reminder for Early Prescription RefillsTuesday,

July 6, 2021

Contact Info:

​(850) 413-2515
press@floir.com

  
​Tallahassee, Fla. – Following Governor DeSantis’ Executive Orders 21-150 and 21-151 in response to Tropical Storm Elsa, the Florida Office of Insurance Regulation (OIR) issued the following notice to all health insurers, managed care organizations and other health entities licensed by OIR.

To: All Health Insurers, Managed Care Organizations, and Other Health Entities Authorized to do Business in Florida RE: Tropical Storm Elsa – Notice of Florida Law for Early Prescription Refills 

This notice is a reminder that all health insurers, managed care organizations, and other health entities must comply with must comply with the provisions of section 252.358, Florida Statutes, which allows for early prescription refills in the event that the Governor issues an Executive Order declaring a State of Emergency or when a county Emergency Operations Center (EOC) is activated.This statute has now been triggered due to Tropical Storm Elsa for Alachua, Charlotte, Citrus, Collier, Columbia, Dixie, Franklin, Gilchrist, Hamilton, Hernando, Hillsborough, Jefferson, Lafayette, Lake, Lee, Levy, Madison, Manatee, Marion, Monroe, Pasco, Pinellas, Sarasota, Sumter, Suwanee, Taylor, and Wakulla counties. This mandate remains in effect until the Governor’s Executive Orders are rescinded or expires.

Declaration of Emergency by Governor DeSantisThe Governor’s Executive Orders 21-150, and 21-151 are available here. In accordance with section 252.358, Florida Statutes, Emergency-preparedness prescription medication refills:

  • All health insurers, managed care organizations, and other entities that are licensed by the Office of Insurance Regulation and provide prescription medication coverage as part of a policy or contract shall waive time restrictions on prescription medication refills, which include suspension of electronic “refill too soon” edits to pharmacies, to enable insureds or subscribers to refill prescriptions in advance, if there are authorized refills remaining, and shall authorize payment to pharmacies for at least a 30-day supply of any prescription medication, regardless of the date upon which the prescription had most recently been filled by a pharmacist, when the following conditions occur:
  • (1) The person seeking the prescription medication refill resides in a county that:
    • (a) Is under a hurricane warning issued by the National Weather Service;
    • (b) Is declared to be under a state of emergency in an executive order issued by the Governor; or
    • (c) Has activated its emergency operations center and its emergency management plan.

  • (2) The prescription medication refill is requested within 30 days after the origination date of the conditions stated in this section or until such conditions are terminated by the issuing authority or no longer exist. The time period for the waiver of prescription medication refills may be extended in 15- or 30-day increments by emergency orders issued by the Office of Insurance Regulation.

This section does not excuse or exempt an insured or subscriber from compliance with all other terms of the policy or contract providing prescription medication coverage.

PLEASE BE GOVERNED ACCORDINGLY.