Overlap Between Medicaid MCO’s, Marketplace Plans Could Smooth a Rough Edge of Health Reform

Margaret A. Murray and Jennifer Babcock, Association for Community Affiliated Plans

In late January, the Centers for Medicare & Medicaid Services (CMS) made public figures showing that more than three million people had enrolled in health plans offering coverage through Health Insurance Marketplaces in the last three months of 2013. Many have selected a Qualified Health Plan (QHP) that also participates in Medicaid.

We at the Association for Community Affiliated Plans have a special interest in the alignment between Medicaid and QHPs, as our 57 member plans all serve the Medicaid population—and as of this writing, sixteen offer QHPs through Marketplaces. We recently performed a study to see how many Qualified Health Plan issuers nationwide also offer a Medicaid managed care plan. (We are pleased that Joan Alker of the Georgetown University Health Policy Institute’s Center for Children and Families referenced this work in her February 10 blog about the “private option” for Medicaid expansions.) Of the 286 issuers participating in the Marketplaces, 117 also operate Medicaid plans in the same state. That’s about 4 in 10 plans. (Here’s the entire list.)

It’s unknown how many of the three million-plus people who enrolled have incomes close to the threshold for Medicaid eligibility, or have children who already receive health coverage through Medicaid and CHIP. But it’s fair to assume that it’s a substantial number. Previous studies have estimated 3 in 4 Marketplace-eligible parents will have at least one child who is eligible for CHIP or Medicaid. And another study estimates that 28 million people with incomes less than 200 percent of the Federal Poverty Level will experience income changes that would result in transitions in eligibility between Medicaid and the Marketplaces.

What this means is that a substantial number of people may face a unique set of complexities in navigating their health benefits: adults with incomes close to the Medicaid threshold may “churn” between Medicaid and subsidized Marketplace coverage, while families may experience “split eligibility,” where parents enroll in Marketplace plans while children are in a Medicaid or CHIP plan. To make matters even more complex, some families may experience both.

While navigating different coverage environments may be a daunting task, Marketplaces in 32 states and the nation’s capital offer at least one QHP which also operates a Medicaid plan. This overlap has promise for working families with low incomes or split eligibility for two reasons:

  • Medicaid plans participating in the Marketplaces will likely have significant overlap in their provider networks. Most ACAP Medicaid plans that decided to enter the Marketplace started building their Marketplace networks by going to providers with whom they already worked. Accordingly, families who move between the two coverage environments—or have family members in both—should be able to see similar sets of doctors.
  • Issuers that offer both a QHP and a Medicaid plan can offer consumers a single point of contact to help them navigate benefits. Having a single customer service line and a single Web site will significantly reduce complexity for families should questions about cost-sharing, benefits and other issues around navigation arise. Such plans may also have a strong incentive to retain their members should they shift eligibility, and may lead plans to help people stay covered.

As the health insurance landscape undergoes a tectonic shift, the market alignment between Marketplace and Medicaid plans seen to date is a relief to those of us concerned about continuity and cohesiveness of coverage. However, there are further opportunities for better market alignment: in 18 states, consumers do not have the option of choosing a QHP whose issuer also participates in the state’s Medicaid program.

And Marketplaces can do more to better inform consumer choice going forward by informing consumers which Marketplace plans also participate in Medicaid. This could be achieved by something as simple as an icon on the plan listing. This simple change—along with continued efforts to help lower-income consumers understand why it is important to know about both QHPs and Medicaid MCOs—might smooth out some of the rougher edges of health reform should their incomes decline—or better yet, rise.

The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.