Medicaid Managed Care: A Promising New Point of Accountability

In most states, a central challenge for Medicaid is holding managed care organizations (MCOs) accountable for their performance for enrollees, especially children and families. Medicaid MCOs are collectively responsible for the health of tens of millions (with an “m”) of Medicaid beneficiaries and the proper use of hundreds of billions (with a “b”) of federal and state dollars. All MCOs are accountable to the state Medicaid agencies with which they contract and the Centers for Medicare & Medicaid Services (CMS) that oversees the state agencies. Those MCOs that are publicly held are also accountable to their shareholders for their financial performance. Given the scale and complexity of most Medicaid MCOs, holding them accountable for performance for children and families requires more than under-resourced and over-matched state Medicaid agencies, especially in the midst of the unwinding of the PHE continuous enrollment requirement that begins on April 1.

Fortunately, there are other points of accountability. At the federal level, in addition to CMS, there is the Office of Inspector General (OIG) and Congressional oversight, not just through its own committees but also through its agencies, the Medicaid and CHIP Payment and Access Commission (MACPAC) and the Government Accountability Office (GAO).  At the state level, in addition to state Medicaid agencies and their External Quality Review Organization (EQRO) contractors, state insurance departments, state auditors, and state legislatures. Other points of accountability include beneficiaries (through Medical Care Advisory Committees), advocates, whistleblowers, foundations, and investigative reporters.  At both the federal and state levels, these points of accountability are far more effective when there is—wait for it—transparency.

Last week, Georgia investigative reporters for Kaiser Health News shed light on a promising new point of accountability: state child welfare agencies. As their name suggests, these agencies are responsible for the welfare of foster children and youth in their charge, including access to needed health care. Most of these children and youth receive assistance under Title IV-E of the Social Security Act, which automatically qualifies them for Medicaid, which in turn entitles them to critical EPSDT services. In many managed care states, foster children and youth are enrolled in MCOs. Nationally, a natural experiment of sorts is now underway, as some states enroll their foster children and youth in a single, statewide MCO focused only on that population, while others enroll them in MCOs that take all eligible children and adult beneficiaries.

Georgia is one of the states that contracts with a single, statewide MCO for health care for children and youth in foster care and other special child populations (the program is known as Georgia Families 360°). The KHN reporters cite a remarkable letter from the head of the state’s child welfare agency to her counterpart at the state Medicaid agency. The letter pulls no punches:

“Simply put, the State’s most vulnerable children cannot access the physical, mental, or behavioral health treatment they need – and deserve – in state custody or through post- adoptive care, and there is little accountability for Georgia Families 360° failures. As the State moves forward with future procurement activities, we must recognize and rectify burdensome administrative hurdles, ambiguous and outdated contract terms, generic coverage denials, coverage gaps, and lackluster data-sharing to better serve our most vulnerable youth. This contract should not be renewed.”

 The current contractor for Georgia Families 360 is Amerigroup. The state child welfare agency is particularly concerned about what it views as Amerigroup’s narrow definition for “medically necessary services,” which it says “is—on its face—more restrictive than state or federal standards” for EPSDT services. The letter makes clear that the agency is not waiting for the state procurement process (another potential point of accountability) to run its course in order to address the matter:

“Practically speaking, this narrow definition means that we often pay for treatment using state funds – essentially, double paying for care – while we wait on or appeal an adverse coverage decision. Acknowledging that we may never recoup those funds, we simply cannot allow a child to go without necessary treatment. To better advocate for our children, we recently hired three Medicaid attorneys to review these claims, dispute decisions, file appeals, secure reversals, and negotiate resolutions. This move is paying dividends. For example, Amerigroup recently denied ongoing psychiatric residential treatment for a suicidal teenager with severe mental and behavioral health issues. Our attorneys leveraged existing contract terms to appeal and demand the continuation of benefits pending the resolution of the dispute. Ultimately, Amerigroup decided to settle.”

Yes, you read that correctly. One state agency has hired lawyers to challenge service denials by the contractor of another state agency. And it’s working.

If you’ve seen one state Medicaid program, you’ve seen one state Medicaid program. The same applies to Medicaid MCOs. This particular dispute may be an outlier (or not); there’s not enough transparency to know. (There’s no reference to it on Amerigroup’s website or on that of its parent company, Elevance). But it illustrates how state child welfare agencies, advocating on behalf of the children under state supervision, can play a role in holding MCOs accountable for performance, and not just in states like Georgia that enroll all of their foster children and youth in a single statewide MCO.

But why stop at state child welfare agencies? There’s a role for state agencies with stewardship for other populations enrolled in Medicaid MCOs to ensure that those contractors are accountable for their performance. These include state maternal and child health agencies, state mental health agencies, and state developmental disabilities agencies.

From the MCO standpoint, this may seem like piling on. From where we at CCF sit, you can’t have too many people paying attention to how MCOs are performing for children and families—and when they see something, say something.

Andy Schneider is a Research Professor at the Georgetown University McCourt School of Public Policy.