2022 Outlook: Medicaid MCOs Brace for Return of Churn, Other Challenges

January 12, 2022

2022 Outlook: Medicaid MCOs Brace for Return of Churn, Other Challenges

2022 Outlook: Medicaid MCOs Brace for Return of Churn, Other Challenges

Reprinted with AIS Health permission from the January 6, 2022, issue of RADAR on Medicare Advantage

As a condition of receiving enhanced federal funds during the COVID-19 public health emergency (PHE), states were required to take certain steps to ensure continuous Medicaid and CHIP coverage for most enrollees, leading to a nearly 18% jump in Medicaid enrollment. But with the latest PHE extension set to expire on Jan. 16, states will no longer receive such funds and will therefore no longer be required to maintain continuous coverage, although CMS has given them 12 months after the month in which the PHE ends to complete eligibility redeterminations. As a result, supporting states’ reverification efforts and ensuring that eligible members stay on the rolls or have a viable landing spot will be critical to Medicaid managed care organizations this year, industry experts tell AIS Health, a division of MMIT.

“The biggest challenge for Medicaid MCOs in 2022 will be churn,” asserts Jerry Vitti, founder and CEO of Healthcare Financial, Inc., a firm that connects low-income, elderly, and disabled populations with Medicaid and other public benefit programs. “With redeterminations looming, we will see a ‘chaos and crisis’ situation when enrollees are cut off from crucial access to care. There are legitimate reasons why some enrollees get disenrolled — an income change, for example — however, there are administrative factors that can trigger the disenrollment of truly eligible enrollees, such as improperly recorded address changes and data problems and mismatches in a state’s electronic eligibility determination system.”

ACAP Lobbies for 12-Month Eligibility

The Association for Community Affiliated Plans (ACAP), which counts 78 safety-net plans among its members, has been actively promoting continuous coverage for all people covered by Medicaid after the PHE ends. The association supports a provision in the Build Back Better Act (BBBA), which passed the House but has been sidelined in the Senate, that would establish 12-month continuous eligibility for children covered by Medicaid and CHIP. The BBBA also seeks to mandate 12 months of coverage for postpartum mothers, which was extended as an option but not a requirement for states through the American Rescue Plan Act. But the legislation does not require 12-month continuous eligibility for all Medicaid enrollees, as called for in the Stabilize Medicaid and CHIP Coverage Act that was introduced in both the House and Senate in early 2021. According to ACAP, about two-thirds of states currently provide continuous eligibility to children in Medicaid and CHIP, but it is not applied consistently.

Previous research suggests that more than 1.5 million people in 2018 lost Medicaid and CHIP coverage, largely as a result of states’ complex redetermination processes, and people of color and those with less education experience greater income volatility that often leads to coverage disruptions.

“To ensure continuity of coverage for eligible members, I expect MCOs to build on the capacities that they already have in working with communities of color,” observes Vitti. “Knowing the diverse backgrounds of their members (as shown by the recent 2020 Census results), plans will continue what they are already doing well in terms of cultural competency — working with groups within those cultural communities to find hard-to-reach people to get them enrolled and stay enrolled.”

Meanwhile, plans are likely to make significant investments in identifying and addressing social determinants of health (SDOH) such as food insecurity as well as tackling behavioral health and substance use disorder, he predicts. “One of the most effective tools to do this is to have in-person case management; however, there are not nearly enough case managers to go around, so at the very least I hope states will give plans the funds to simply hire more case managers.” An example worth keeping an eye on is the California Advancing and Innovating Medi-Cal (CalAIM), a multiyear initiative that began on Jan. 1 to bring about delivery system, program and payment reform in California’s Medicaid program, points out Vitti. Key features of that initiative are enhanced case management and whole-person care, all within the context of innovating around SDOH.

Plans, States Should Invest More in SDOH

Given that states have additional cash from pandemic-relief legislation, Vitti is optimistic that they will spend those extra funds on “broadening the mission of Medicaid MCOs” in addressing SDOH. “Granted, MCOs with existing state contracts also did not spend as much as they had anticipated, but instead of having to return money to the state via a clawback, plans should be allowed to keep it so they can invest in innovative programs like those addressing SDOH,” Vitti tells AIS Health. “For MCOs bidding for new state contracts, I believe the states should be as flexible as possible with rates, program design, and funding.”

Another item to watch will be “how strongly CMS will look to add any type of health equity or SDOH requirements as part of MCO contracts,” weighs in Thomas L. Johnson, executive director of the Population Health Alliance, a population health management-focused trade association representing health systems, health plans, academia, and biopharma/technology companies. “Also, CMS is aware of the importance of telehealth, and whether they are going to do anything other than let the states regulate in that area is something to watch, and probably will be a focus of MCOs in the states.” At the same time, Johnson expects telehealth to be a focus of MCO investment.

Contact Johnson and Vitti via Joe Reblando at joe@joereblando.com.

By Lauren Flynn Kelly