February 13, 2019

Imagine Medicaid with Informed Consumer Choice

Patient getting in-person assistanceDo you remember when the ACA Marketplace opened in 2013, and the whole thing was so complicated that special roles like “navigators” and in-person counselors, aka IPCs, had to be created to help people enroll? Even though few assisters remain due to significant funding cuts from the federal government, people still need help with healthcare choices, especially in our Medicaid program.

Most people have access to expert help figuring out their healthcare choices. With an employer, you have an HR person or representative to help you sort through your healthcare choices. On the private market, you have brokers and agents. In Medicare, you have Senior Health Insurance Program counselors and brokers. Granted, all those systems have their shortfalls, but the common thread is that there is a person you can reach for help.

Not so for Medicaid recipients – the people likely to need it the most. They have a number to call, but no one to meet with (except maybe an untrained person who is trying to help), and limited information about the plans they’re choosing. Medicaid managed care involves making choices – and the choice is inherently confusing. Which plan offers high-quality services, your primary care physician, two specialists, particular medications, and hospitals near your home? It might be none. What’s the next best choice then?

But Illinois’ Medicaid program is moving in the right direction:

  • Improved information on quality is now available. The Department of Healthcare and Family Services recently rolled out a redesigned report card, which compares how each of our five statewide MCOs did under various metrics, ranging from how well doctors communicate to how many enrolled kids get their prescribed schedule of vaccinations.
  • Integrated Health Homes will help people navigate their benefits. Even though implementation has been delayed, this new form of care coordination is expected to help Medicaid members better understand and manage the full spectrum of their physical, behavioral, and social care needs.
  • A new set of requirements may do much to improve Medicaid managed care enrollment. The regulation, which Centers for Medicare & Medicaid Services rolled out in their major overhaul of Medicaid managed care regulations released in April 2016, is dubbed the “Mega-Reg” because of its size and scope. Among its many changes, it requires states to create and implement a “beneficiary support system” that includes choice counseling for Medicaid beneficiaries.

Choice counseling is a lot like what navigators and IPCs did for the ACA. For managed care, the counselors are supposed to assist consumers in making informed choices that are pertinent to their healthcare needs when enrolling or dis-enrolling. In Illinois, perhaps they could play an additional role by also helping consumers dealing with issues related to redeterminations, which have been a significant pain point for providers, who provide uncompensated services assisting former Medicaid beneficiaries in maintaining their benefits.

According to the “Mega Reg,” this support system must be accessible by phone, in person, and online. What does Illinois have currently? Well, it falls somewhat short of this vision. With the move to managed care, both intake of participating providers and enrollment of eligible beneficiaries is entrusted to vendor-run online and call-center operations. Maximus Digital Solutions was engaged to create the sign-up process and database for physicians and other providers that are participating in HealthChoice Illinois, as well as the process to enroll members. (Similarly, another vendor, GoHealth, was contracted to handle the state’s ACA Marketplace enrollment automation.)

HealthChoice Illinois’  public documents addressed consumer decision support but did not mention in-person assistance. “HFS offers a variety of avenues for an individual to receive education and enrollment assistance under its beneficiary support system,” says the quality strategy framework for 2016-18 “including an enrollment call center that provides education and enrollment assistance, a secure online enrollment portal, and the availability of education and enrollment materials in other formats or languages (auxiliary aids) when requested.”

In our experience with the early days of the Obamacare open enrollment, and working with first-time enrollees, in-person counselors and assisters made all the difference. In many cases, they were helping people who had never had an email address before – a first step to obtaining a Marketplace account.

The Mega Reg itself gives us some cause for a positive outlook. Although the initial compliance deadline of July 1, 2018, has already passed. The sweeping changes it dictated have only started to settle in. Federal rule makers anticipated that the support system requirement would be a new area for states and one drawing on administrative and financial resources. CMS has urged states to leverage their existing networks and partnerships that already provide similar services – community organizations, navigators, and IPCs. In recognition of the workload and cost ramifications, the rule makes choice support eligible for 50% federal match. Meanwhile, there is new legislation in Congress (H.R. 987) to restore ACA marketing and outreach funding, which the administration slashed by 90%.

We hope this rule will go a long way in providing Medicaid consumers what all other healthcare insurance customers already have – a little help understanding their options. While these changes may be a bit slow out of the gate, they hold the promise of a better, more transparent, more understandable Medicaid for its users – in Illinois, a quarter of the state’s population. The Mega Reg may also lay the groundwork for job creation, with the prospect of year-round work for brokers, navigators, and assisters – perhaps many of those who cut their teeth in the early days of ACA enrollment and have gained a deep understanding of how to explain a complex system to everyday people. It could be a strong step toward a healthcare access infrastructure where people are not only able to get care, but also to understand the system that provides it, and what it means for them.


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