The growth of managed care in State Medicaid programs has increased significantly since the passage of the Balanced Budget Amendment in 1997 authorized the routine use of managed care in Medicaid programs (as opposed to needing a waiver to implement managed care). Today, managed care serves approximately 65% of Medicaid beneficiaries, though that is expected to increase from the eligibility expansion under the Affordable Care Act.
Many State Medicaid programs use managed care as a way to serve expanded populations in a timely and cost-effective manner in two basic forms – risk-based programs and primary care case management programs. In addition, while Medicaid managed care traditionally has served children and families (the so-called TANF population), the trend today is to serve more complex Medicaid populations – such as children and adults with disabilities and chronic illnesses, persons with HIV/AIDS and dual eligible (i.e., individuals enrolled in both Medicaid and Medicare). By all expectations, the number of Medicaid beneficiaries enrolled in managed care plans will continue to grow in the years ahead.
Nationwide, nearly 12 million beneficiaries are enrolled in a Medicare plan – while most are covered by traditional Medicare, one in four are covered by manage care contracts. The Medicare Advantage (MA) program makes a range of private health plans available to beneficiaries including HMOs, PPOs and private fee-for-service (PFFS) plans. Collectively, all of these types of Medicare health plans are known as MA plans.
In addition, certain MA plans have the distinct feature of limiting enrollment to a particular population. A Special Needs Plan (SNP) is a type of MA plan that restricts enrollment to beneficiaries who are eligible for both Medicare and Medicaid (i.e., dual-eligibles – beneficiaries who reside in an institutional setting, or beneficiaries with multiple chronic conditions). SNPs tailor their programs to meet the unique needs of the populations they serve.
Our Health Law team has advised Medicare and Medicaid managed care entities nationwide on the rules under which they are required to operate. These rules affect the obligations of providers furnishing services to beneficiaries under MCO contracts as well as provide certain rights and protections for these providers. In particular, our attorneys have directed managed care organizations on state and federal requirements related to managed care, including the methodology for paying MCOs (including risk adjustment and actuarial soundness), assisted managed care entities with the application and bid process, and drafted downstream agreements between managed care entities and their vendors and providers.
Representative activities include:
- Bid protests under RFP processes
- State licensure and contractual requirements
- Participating provider agreements
- Business associate agreements
- HIPAA disclosures