Saturday, August 30, 2014
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The Future of Medicaid: Seamless Coordination With Private Insurance

What does the future hold for traditional Medicaid? Some believe that, in the future, traditional Medicaid and commercial insurance will converge so that patients who move from Medicaid to commercial insurance will see no disruption in coverage, service, or the provider networks from which they receive medical treatment. While full convergence may still be a long way off, there are strategies that policy makers can begin to implement now on the pathway to a healthy Pennsylvania.

The Future of Medicaid: Seamless Coordination With Private Insurance

What does the future hold for traditional Medicaid?  Some believe that, in the future, traditional Medicaid and commercial insurance will converge so that patients who move from Medicaid to commercial insurance will see no disruption in coverage, service, or the provider networks from which they receive medical treatment. While full convergence may still be a long way off, there are strategies that policy makers can begin to implement now on the pathway to a healthy Pennsylvania.

First, it is important to minimize coverage gaps.  Pennsylvania should opt to continue Medicaid eligibility until the end of each month to allow beneficiaries to maintain coverage until they are covered under a commercial health plan (known as a qualified health plan) at the beginning of the following month. This provides individuals experiencing an increase in income with a smooth transition to commercial insurance enrollment at the end of their Medicaid coverage period.

Another strategy is to ensure continuity of care and of providers for traditional Medicaid recipients.  For example, Pennsylvania could require insurers that offer both qualified health plans and traditional Medicaid to use the same provider networks in each.  It could also require insurers to honor the current treatment plans of patients.

Pennsylvania could also create bridge plans for those transitioning between traditional Medicaid and the health insurance marketplace.  For example, Medicaid managed care organizations (MCOs) could be certified as qualified health plans to assist patients whose coverage is changing.  This would allow patients to stay with the same provider network, which again promotes continuity of care. 

More coverage

Requiring insurers both to become Medicaid MCOs and to participate in the federal marketplace, as proposed in the Governor’s Healthy PA proposal, is another strategy to ensure that Medicaid-eligible and other low-income individuals stay within the same provider network as they transition between Medicaid and commercial plans. 

The convergence of Medicaid and commercial coverage will create opportunities to improve care management and continuity of care.  Medicaid needs to become a smart purchaser of health care services and improving care management will help. 

While Governor Corbett’s Healthy PA proposal to use a private option to insure those newly eligible for Medicaid under health reform has been met with various reactions ranging from enthusiasm to opposition, it does represent the beginning of a convergence of Medicaid and commercial insurance. 

In pursuing federal permission to implement Governor Corbett’s Medicaid plan, Pennsylvania should make sure that it is on a strong pathway to convergence where the patient’s health needs are addressed in a seamless manner between Medicaid and commercial health plans. Policy makers could then turn their attention to strategies for those covered under traditional Medicaid, so that they, too, can fully benefit from continuity of coverage and care management.


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The Field Clinic reports and analyzes health care laws, government policies, and political trends that are transforming the care we receive and the way we pay for it. Read more about our panel of bloggers here.

This blog is produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente. Portions of this blog may also be found on Inquirer.com and in the Inquirer's Sunday Health Section.

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