Just as millions of Americans enroll in the expanded Medicaid health insurance program under the Affordable Care Act, the Obama administration is rolling out new rules that will measure quality and performance of private plans that provide such benefits.
Already, the federal government rates private health plans that contract with the Medicare program for seniors with a five-star system that has awarded bonus payments for high-performing plans, so the Centers for Medicare & Medicaid Services (CMS) announcement late Tuesday that quality ratings were coming to the Medicaid program for poor Americans seems a natural progression.
CMS said measures are expected to be similar to those used for Medicare plans, evaluating health outcomes and patient experience enrollees have with the private plans. Details have to be worked out with states that also have a role administering Medicaid, CMS said. The proposed new rules also face a public comment period.
More Americans than ever before are enrolling in private health plans that contract with state Medicaid programs for the poor. About three in five of all Medicaid beneficiaries access benefits through private health plans today compared to just 8% of Medicaid beneficiaries who were in private plans in 1992, CMS said.
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The more than 600 pages of regulations, linked here, would have each state that contracts with a health plan “establish a quality rating system to generate plan ratings.” Medicaid is funded jointly by the federal government and states, which have long had latitude in how they administer their programs.
The quality ratings have ramifications for some of the biggest names in health insurance like
The new rules say the ratings will be based on three components: “clinical quality management, member experience and plan efficiency.” The ratings should also be transparent and published on a state web site, the proposed rules say.
In a conference call with reporters Tuesday evening, the Obama administration was vague on whether the ratings would be just like the Medicare Advantage star rating system, which evaluated certain health outcomes and how quickly claims were processed or how attentive plans were to patient complaints. It depended on what “works best for Medicaid,” said Vikki Wachino, a CMS deputy administrator overseeing Medicaid and CHIP.
Insurers that contract with Medicaid programs are hoping the new regulations and quality measures take into account people who are eligible for Medicaid benefits tend to be sicker and have more health care needs. Thus, Medicaid health plans say the ratings should be different than star ratings used for Medicare Advantage plans.
“The current Medicare Advantage Star Ratings system doesn’t adequately take into consideration the unique and extensive needs of low-income beneficiaries and those dually eligible for both Medicare and Medicaid when making these assessments,” said Jeff Myers, CEO of Medicaid Health Plans of America. “By failing to properly weight the ratings for socioeconomic risk factors, higher occurrence of comorbidities, diminished health literacy, and overall health disparities in this population, the current system will cause a strain on health plans and providers that will ultimately affect those we’re all trying to help: the beneficiary.”
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