Troubling Medicaid, SIM updates

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Friday’s Medicaid Council meeting focused on eligibility, renewal changes and implementation with a very helpful primer on the process. There is no clear answer to why Medicaid membership has dropped by 34,232 since October, but the transition to MAGI income rules and renewal delays to protect consumers from lapses in coverage are probably part of the answer. DSS expects the decline to continue for some time. But it may also be due to the slow but steady economic recovery. However we learned that because of delays in renewals, to allow time for complete processing and paperwork, some HUSKY members will be found to be over income and ineligible. While providers will be paid for services provided in the interim, consumers will be expected to repay the costs of their care during the time they were not eligible but did not know it. At a future meeting, the Council will further discuss the issue, and barring fraud, how to avoid punishing people who acted in good faith based on the information they received from the state.

We also received troubling news at the PCCM/PCMH meeting Friday afternoon about the timeline to design the payment system transformation of the entire Medicaid program. Unfortunately, this is exactly what advocates have been concerned about with SIM. To meet the SIM mini-grant timeline for shared savings in Medicaid, DSS must have an RFP for the large ACO-like provider networks that will accept financial risk by May 1st. Advocates were very concerned that this timeline is not responsible or realistic to ensure that Medicaid members are protected, or that we don’t repeat the disaster of HUSKY managed care organizations, and unravel recent progress in better quality, access to care, and cost stability. To engage any real interest from applicants, the RFP must include very specific qualifications, formulas for measuring savings and how they will be distributed, as well as attribution, quality benchmarks and underservice monitoring methodologies. Advocates are concerned that the design has already been decided behind closed doors. (We did learn that consumers will have a choice among providers. A decision that has already been made apparently, but a good one.) We were also disturbed to read again that for the quality benchmarks for granting savings payments to ACOs, DSS will “reach consensus with the (SIM) PMO regarding the core measure set.” We were assured (again) that this does not mean that inappropriate, weaker quality measures will be chosen for the unique Medicaid population. However, we were assured earlier that the state would take the necessary time to build the program responsibly. We also learned that quality measures being discussed for use for PCMH bonuses were now also expected to serve as the basis for the quality benchmarks for granting shared savings – a very very different purpose with very different incentives and impact.

It is important to note that, just two days before this meeting, the Governor proposed cutting funding for the “shovel-ready”, very promising, well-planned shared savings plan for the most fragile and costly Medicaid members. This plan, with great potential to both improve care coordination and access while holding down costs in the most expensive part of the program was worked out over the last three years by a diverse, transparent stakeholder group with varied expertise the state could not engage behind closed doors.