Illinois health policy experts discuss Medicaid managed care and the future of eligible dual coverage – State of Reform

Value-based healthcare experts have outlined federal governments changes to the proposed rules for Medicaid managed care and how they report improved alignment and quality of care for dual Medicaid-Medicare eligible special needs plans (D-SNP) at the 2023 Illinois State Health Care Policy Reform Conference earlier this month.

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This proposed rule would advance CMS’s efforts to improve care access, quality, and health outcomes, and better address health equity issues for Medicaid and CHIP (Chip) managed care enrollees. The proposed rule would specifically address standards for timely access to care and states’ monitoring and enforcement efforts, reduce the burden on some direct payments from the state and some quality reporting requirements, and establish a quality assessment system for Medicaid and CHIP Managed Care Plans.

CMS and the US Department of Health and Human Services.

Illinois pitched its Medicare-Medicaid Alignment Initiative (MMAI) in 2013 in an effort to simplify health care delivery and reduce costs for dual-eligible Illinoisans. In 2019, CMS has strengthened its Medicare-Medicaid integration requirements.

Jennifer Maslowski, PhD, a former health insurance specialist at CMS and a senior consultant at Health Management Associates (HMA), highlighted some of the exciting new regulations impacting MMAI.

[CMS is] will require [states] present an annual payment analysis comparing managed care plan payment rates for selected services as a proportion of Medicare’s payment rate for selected home and community services and the state’s Medicaid plan payment rate.

It will also require states to implement a remediation plan for any managed care plan that has access issues and needs improvement.

Jennifer Maslowski, PhD, HMA

Another major change will be new state-direct payments regulations, which include removing barriers to help states use automated processing to implement value-based payment arrangements. Under the rule, CMS would require Illinois to submit state-direct payment assessments if the cost of the payment exceeds the 1.5% threshold for the percentage of the total capitation payment.

The rule change would also eliminate prior written approval for state-direct payments that are at the Medicare base payment rate.

In his 2022-2032 framework for health equityCMS has signaled that it is prioritizing racial health equity and quality measurements in its reviews of Medicaid 1115 state waivers.

[CMS is] really driving home, in the rule, [the importance of] really have performance measures and metrics rather than just access metrics Even in more established programs, access measures are needed, but making sure there are performance measures and metrics to follow [access] Also.


The changes will come as Governor JB Pritzkers’ administration prepares to introduce its own early childhood initiatives for CMS approval. THE state attention to early childhood will invest billions in building a full range of health and social services through Medicaid managed care.

Speakers said the state is overall well positioned to transition from Medicaid-Medicare (MMP) plans to fully integrated D-SNP plans.

Representatives from two of the state’s MMAI plans, Aetna and Meridian Health, shared insights into how their managed care organizations will monitor and incorporate health and quality metrics as part of its value-based performance measures.

Rushil Desai, CEO of Aetna Better Health of Illinois, said the organization has focused on simplifying access to health care through system improvements.

[Value-based contracting is] core of what we are trying to build here in Aetna. It’s not one size fits all, it really varies by provider type. You have to go beyond the fee for the service and really understand how to start driving towards quality and ultimately results.

Rushil Desai, CEO of Aetna Better Health of Illinois

Desai says payers must be critical to the work of state transformation initiatives, a point Jeanette Badrov, senior vice president for regulatory and legislative affairs at Centene, agrees.

Why integration and collaboration [with providers] is the key to a long and sustainable partnership.

Jeanette Badrov, Centene

Badrov says industry alignment with state and federal goals on improving population health has yet to be achieved, but believes the vendor rate increases passed in this legislative session will have an impact on achieving those goals.

Where I hear a lot from suppliers [is]We don’t make enough money with Medicaid to do that [take] risk-based payments. So that [rate] the increase will really have a lot that can hit that descent path to risk with baseline data.


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