Regulators have clarified how Medicaid managed care organizations pay and report benefits to close gaps in social factors that determine consumer health needs have low income.
A growing number of state Medicaid and Children’s Health Insurance Programs are adopting coverage to improve people’s health, increase patient access, and reduce health care costs. . The Centers for Medicare and Medicaid Services, along with the Department of Health and Human Services, have authorized state Medicaid programs to provide at least food, housing, long-term assistance, and other alternative benefits. since 2016.
But most states contract with private insurers to run their Medicaid programs, and the companies have struggled with how to report benefit costs and reimburse them. community-based organization. Federal agencies hope to expand the states’ Medicaid-managed care plans and health insurance companies’ access to these benefits by clarifying the rules of through-payments New guidelines were issued on Wednesday.
CMS guidelines that allow Medicaid agencies to pay for non-medical services such as housing, nutrition, and transportation will reduce medical costs by preventing adverse health events. States must determine such services as appropriate and a cost-effective alternative to medical care. It requires that such alternative services, known as respite services, be included in the managed care contract and considered when determining payment to the private insurer.
Guidance instructs Medicaid agencies to bypass statutory exclusions for services CMS may pay for in mental health facilities by using alternative services as a means of payment. maths. The federal agency says this is the most common use for the alternative service delivery mechanism.
“Today’s announcement is the next step in CMS’s efforts to use every lever available to protect and expand coverage to all eligible individuals as we work with our partners. state to provide holistic care,” CMS Administrator Chiquita Brooks-LaSure said in a release.
Medicaid is paid for by state and federal governments, and states decide what services are covered and how they are administered. States usually pay insurance companies a certain amount to cover all the medical expenses each member is expected to pay each month, and the insurance companies manage the effect. Patient care results can pocket any savings achieved.
This guidance allows states and private Medicaid insurers to spend up to 5 cents per dollar in premiums on social determinants of health need, according to a letter from the Deputy Administrator and Director CMS Director Daniel Tsai sent to state Medicaid directors Wednesday.
Managed care organizations that spend at least 1.5% on respite benefits must report to federal regulators in advance how they determine the coverage that will result in savings. States must also report to federal regulators how coverage affects patient care and health care costs once it’s rolled out.
CMS will not approve any Medicaid replacement benefit claim that does not comply with these standards. State Medicaid programs with existing social determinants of health coverage must comply with the regulations by January 2024.
The guidance comes as many state Medicaid programs seek to initiate payment for services that address social determinants of members’ health. In California and North Carolina, Medicaid agencies have launched programs in 2022 that seek to reimburse non-medical services such as housing, nutrition, transportation, and peer support to beneficiaries with high demand. In these arrangements, managed care plans have struggled with how to pay community-based organizations for their services.
