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The Need for Transparency in Medicaid Managed Care: Section 1115 Waiver Requirements as a Blueprint

Published online by Cambridge University Press:  02 April 2024

Nicole Doherty
Nicole Doherty*
Affiliation:
Boston University School of Law, Boston, MA, USA
*
Email: ndd@bu.edu
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Abstract

Medicaid plays a significant role in the health care space, providing insurance coverage to nearly one quarter of the U.S. population. In recent years, managed care organizations have taken on an increasingly prominent role in the Medicaid space, and in many instances have become the sole insurance option for Medicaid recipients. The scale and method of implementation for managed care programs has varied widely from state to state. This Note discusses the many methods by which a state can enact managed care within its Medicaid program, and summarizes the challenges with assessing the success of such programs. It proposes a uniform approach to managed care reporting requirements designed to increase transparency and accountability across state lines, and in turn ensure quality care for Medicaid managed care beneficiaries.

Keywords

Medicaid Managed CareSection 1115 waiverhealthcare regulationreporting requirements
Type
Notes
Information
American Journal of Law & Medicine , Volume 49 , Issue 4 , December 2023 , pp. 457 - 470
Copyright
© 2024 The Author(s)

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References

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4 Bowen Garrett et al., Effects of Medicaid Managed Care Programs on Health Services Access and Use, 38 Health Servs. Rsch. 575, 576 (2003).

5 42 U.S.C. § 1396n(a) (2018).

6 42 C.F.R. § 438.2 (2023).

7 §§ 438.2, 438.3.

8 42 U.S.C. § 1396u–2(1) (2020).

9 § 1396u-2(3).

10 Elizabeth Williams et al., Medicaid Financing: The Basics, KFF (Apr. 13, 2023), https://www.kff.org/medicaid/issue-brief/medicaid-financing-how-does-it-work-and-what-are-the-implications/ [https://perma.cc/8YAS-96GS].

11 Id.

12 Id.

13 Id.

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15 Social Security Act, 42 U.S.C. § 1396(n)(a) (2023).

16 § 1396(n)(b).

17 § 1315.

18 § 1396(u-2).

19 Medicaid and Children’s Health Institute Program (CHIP) Programs, 81 Fed. Reg. 27498, 27500-01 (May 6, 2016) (to be codified at 42 C.F.R. pts. 431-457) [hereinafter 2016 Rule].

20 Key Federal Program Accountability Requirements in Medicaid Managed Care, MACPAC, https://www.macpac.gov/subtopic/key-federal-program-accountability-requirements-in-medicaid-managed-care/ [https://perma.cc/SM69-YGM8] (last visited Aug. 2, 2023).

21 Id.

22 Id.

23 Id.

24 Id.

25 Garrett, supra note 4, at 575.

26 Andy Schneider & Allie Corcoran, Medicaid Managed Care in 2021: The Year that Was, Geo. U. Health Pol’y Inst. (Dec. 21, 2021), https://ccf.georgetown.edu/2021/12/21/Medicaid-managed-care-in-2021-the-year-that-was/ [https://perma.cc/UQ59-9XQN].

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28 Id.

29 42 C.F.R. § 438.4(a)-(b)(1) (2023).

30 Jeff C. Goldsmith et al., Medicaid Managed Care: Lots of Unanswered Questions (Part 2), Health Affs. (May 4, 2019), https://www.healthaffairs.org/do/10.1377/forefront.20180430.510086/full/ [https://perma.cc/VJ5E-K6HQ].

31 Medicaid Program, 85 Fed. Reg. 72754, 72767 (Nov. 13, 2020) (to be codified at 42 C.F.R. pts. 438, 457) [hereinafter 2020 Rule].

32 Id. at 72760.

33 Id. at 72765.

34 Daniela F. Montoya et al., Medicaid Managed Care’s Effects on Costs, Access, and Quality: An Update, 41 Ann. Rev. of Pub. Health 537, 543 (2020).

35 See id.

36 Christopher Smith et al., States Are Questioning Medicaid MCO Rx Benefits, Chain Drug Rev. (July 27, 2020) https://www.chaindrugreview.com/states-are-questioning-medicaid-mco-rx-benefits/.

37 Id.

38 Id.

39 Id.

40 Id.

41 Id.

42 Samantha G. Auty et al., Association of Medicaid Managed Care Drug Carve Outs with Hepatitis C Virus Prescription Use, 2 JAMA Health F. 1, 2 (2021).

43 Id.

44 Goldsmith et al., supra note 30.

45 Marguerite E. Burns, Medicaid Managed Care and Health Care Access for Adult Beneficiaries with Disabilities, 44 Health Servs. Rsch. 1521, 1523 (2009).

46 Id.

47 Id. at 1530-32.

48 Id. at 1533.

49 Garrett et al., supra note 4, at 590-91.

50 Lynda C. Burton et al., Health Outcomes and Medicaid Costs for Frail Older Individuals: A Case Study of a MCO Versus Fee-for-Service Care, 50 J. Am. Geriatric Soc’y 382, 382 (2002).

51 Id. at 387.

52 Amanda J. Abraham et al., Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care, 3 JAMA Health F. 1, 1 (2022).

53 Burton et al., supra note 50, at 382.

54 Allie Corcoran et al., Geo. U. Health Pol’y Inst., Transparency in Medicaid Managed Care: Findings from a 13-State Scan 17 (2021).

55 Id.

56 Id.

57 Id. at 1.

58 Id.

59 Id. at 2.

60 See Andy Schneider et al., Geo. U. Health Pol’y Inst. Transparency in Medicaid Managed Care for Children and Youth in Foster Care 2 (2021).

61 Ming Tai-Seale et al., Racial Disparities in Service Use among Medicaid Beneficiaries after Mandatory Enrollment in Managed Care: A Difference-in-Differences Approach, 38 Inquiry 49, 56 (2001).

62 Montoya et al., supra note 34, at 544.

63 Id. at 545.

64 Social Security Act §1915(b), 42 U.S.C. 1396n(b).

65 See Jeff C. Goldsmith et al., Medicaid Managed Care: Lots of Unanswered Questions (Part 1), Health Affs. (May 3, 2018), https://www.healthaffairs.org/do/10.1377/forefront.20180430.387981/full/ [https://perma.cc/AW9E-FVPR].

66 Liz Beaulieu, Not All MCOs Are Hot on Medicaid: Smaller and Nonprofit Organizations Exit, Consolidating Market, Hme News, (May 2019) https://www.hmenews.com/article/not-all-mcos-are-hot-medicaid [https://perma.cc/Y86J-NW4A].

67 Chad Terhune & Anna Gorman, Insurers Make Billions off Medicaid in California During Obamacare Expansion, L.A. Times (Nov. 5, 2017, 6:00 AM), https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html [https://perma.cc/9EUR-RDWE].

68 Andy Schneider & Ally Corcoran, Medicaid Managed Care Financial Results for 2021: A Big Year for the Big Five, Geo. U. Health Pol’y Inst. (Feb. 11, 2022), https://ccf.georgetown.edu/2022/02/11/Medicaid-managed-care-financial-results-for-2021-a-big-year-for-the-big-five/ [https://perma.cc/JQ83-NFKB].

69 Goldsmith, supra note 65.

70 Schneider & Corcoran, supra note 68.

71 Goldsmith, supra note 65.

72 2016 Rule, supra note 15, at 27498.

73 Kelly Hightower Hibbert et al., 2020 Medicaid Managed Care Rule Summary, Crowell (Feb. 16, 2021), https://www.cmhealthlaw.com/2021/02/2020-medicaid-managed-care-rule-summary/ [https://perma.cc/MF3P-TU9S].

74 2016 Rule, supra note 19, at 27501.

75 Id.

76 Id. at 27521, 27530, 27567.

77 Julia Paradise & MaryBeth Musumeci, CMS’ Final Rule on Medicaid Managed Care; A Summary of Major Provisions, KFF (Jun. 9, 2016), https://www.kff.org/Medicaid/issue-brief/cmss-final-rule-on-Medicaid-managed-care-a-summary-of-major-provisions/ [https://perma.cc/3S52-SAQP]; 42 C.F.R. § 438.74(a) (2023).

78 Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010); Jennifer Haberkorn, Medical Loss Ratios (Updated), Health Affs. (Nov. 17, 2010), https://www.healthaffairs.org/do/10.1377/hpb20101124.949788/ [https://perma.cc/46TZ-W4X7].

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80 2016 Rule, supra note 19, at 27524.

81 Id.

82 Id. at 27533.

83 Allan Baumgarten, LLC, Analyzing Medicaid Managed Care Organizations: State Practices for Contracting With Managed Care Organizations and Oversight of Contractors 16 (2020).

84 Id.

85 2016 Rule, supra note 19, at 27737.

86 Id. at 27860-61.

87 2020 Rule, supra note 31 at 72783.

88 2016 Rule, supra note 19, at 27653.

89 Id. at 27658.

90 Medicaid Managed Care Final Rule: Implications for Missouri, Mo. Found. for Health, https://mffh.org/wp-content/uploads/2016/08/Medicaid-Managed-Care-Final-Rule.pdf [https://perma.cc/R6R8-JZ5J] (last visited May 15, 2023).

91 2016 Rule, supra note 19, at 27626.

92 Id. at 27679.

93 Id. at 27686.

94 Id. at 27687; 42 C.F.R. § 438.334(a) (2020).

95 Elizabeth Hinton & MaryBeth Musumeci, CMS’s 2020 Final Medicaid Managed Care Rule: A Summary of Major Changes, KFF (June 30, 2017) https://www.kff.org/medicaid/issue-brief/cmss-2020-final-medicaid-managed-care-rule-a-summary-of-major-changes [https://perma.cc/ES6N-6522].

96 Id.

97 Alexander Somodevilla, CMS Releases the New Medicaid Managed Care Final Rule, Foley Hoag LLP (Nov. 13, 2020), https://www.medicaidandthelaw.com/2020/11/13/cms-releases-the-new-medicaid-managed-care-final-rule/ [https://perma.cc/EL8S-YYQR].

98 See id.

99 2020 Rule, supra note 31, at 72754.

100 Id. at 72784.

101 Id. at 72802.

102 Id.

103 Id. at 72806.

104 Id. at 72781.

105 Elizabeth Hinton et al., State Delivery System and Payment Strategies Aimed at Improving Outcomes and Lowering Costs in Medicaid, KFF (Jan. 12, 2022), https://www.kff.org/Medicaid/issue-brief/state-delivery-system-and-payment-strategies-aimed-at-improving-outcomes-and-lowering-costs-in-Medicaid/ [https://perma.cc/FC57-CGU9].

106 See, e.g., 2020 Rule, supra note 27, at 72813.

107 Id.

108 Ctrs. for Medicaid & Chip Servs., Informational Bulletin on Medicaid and CHIP Managed Care Monitoring and Oversight Tools (2022).

109 Andy Schneider, Transparency in Medicaid Managed Care: Are the Times A-Changin’?, Geo. U. Pub. Health Institute (Jul 26., 2022), https://ccf.georgetown.edu/2022/07/26/transparency-in-Medicaid-managed-care-are-the-times-a-changin/ [https://perma.cc/5ABP-Y4GF].

110 MACPAC, supra note 20.

111 Corcoran et al., supra note 54, at 15.

112 Id.

113 Id. at 17.

114 42 U.S.C. § 1315(a)(1) (2012).

115 Id. at (e).

116 Section 1115 Research and Demonstration Waivers, MACPAC, https://www.macpac.gov/subtopic/section-1115-research-and-demonstration-waivers/ [https://perma.cc/556R-J28J] (last visited Jan. 20, 2023); 1115 Demonstration State Monitoring & Evaluation Resources: General Monitoring and Evaluation, Ctrs. for Medicare & Medicaid Servs., https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-demonstration-monitoring-evaluation/1115-demonstration-state-monitoring-evaluation-resources/index.html [https://perma.cc/AY6Y-9KLR] (last visited Oct. 10. 2023).

117 Section 1115 research and demonstration waivers, MACPAC (last visited Jan. 20, 2023), https://www.macpac.gov/subtopic/section-1115-research-and-demonstration-waivers/ [https://perma.cc/556R-J28J] (last visited Jan. 20, 2023); Ctrs. for Medicare & Medicaid Servs., Section 1115 Demonstrations: Developing the Evaluation Design (2020).

118 Ctrs. for Medicare & Medicaid Servs., Section 1115 Demonstrations: Developing the Evaluation Design (2020).

119 42 C.F.R. § 431.408-431.428 (2023).

120 § 431.420(d).

121 Ctrs. for Medicare & Medicaid Servs., Section 1115 Demonstrations: Developing the Evaluation Design (2020).

122 42 C.F.R. § 431.412(c)(2).

123 MACPAC, supra note 20.

124 Id.

125 Id.

126 Andy Schneider & Allie Corcoran, Medicaid Managed Care for Foster Care Children and Youth: A Natural Experiment with Little Transparency, Geo. U. Health Pol’y Inst. (Oct. 12, 2021), https://ccf.georgetown.edu/2021/10/12/Medicaid-managed-care-for-foster-care-children-and-youth-a-natural-experiment-with-little-transparency/ [https://perma.cc/8XKS-42KN].

127 The “Common Rule”, Nat’l Inst. Just. (Nov. 19, 2007), https://nij.ojp.gov/funding/common-rule [https://perma.cc/L9S5-F8BK].

128 Corcoran et al., supra note 54, at 4.

129 Id.

130 Id. at 17.

131 Andy Schneider, California’s Medicaid Managed Care Procurement: A Transparency Event, Geo. U. Health Pol’y Inst. (Oct. 18, 2022), https://ccf.georgetown.edu/2022/10/18/californias-Medicaid-managed-care-procurement-a-transparency-event/ [https://perma.cc/8DDP-DKCH].

132 Id.

133 Id.

134 See id.

135 Bernard J. Wolfson, Health Plan Shake-Up Could Disrupt Coverage for Low-Income Californians, KFF Health News (Sep. 27, 2022) https://khn.org/news/article/health-plan-shake-up-could-disrupt-coverage-for-low-income-californians/ [https://perma.cc/XR2Q-A3J2].

136 Corcoran et al., supra note 54, at 4.