CMSA Today - Issue 1, 2014 - (Page 28)

Medicaid and Case Management Innovation as Necessity The future of Medicaid and case management By Eric Auslander and Garry Carneal, JD, MA W ith over 30 million people receiving insurance coverage through Medicaid or the Children's Health Insurance Program (CHIP), and 10 million plus expected to join in the next few years, Medicaid is set to become an even larger part of the case management industry and, in a broader sense, the health care delivery system. The main driver of Medicaid's growth is the Affordable Care Act (ACA), which drastically expands the program's reach, as part of its primary goal is to expand health coverage to uninsured Americans. The ACA provides two main outlets to accomplish this goal: public insurance exchanges and increased Medicaid eligibility. Americans who can afford to purchase health insurance may buy a private plan on a government-run exchange, often with subsidies from the federal government. For those whose income is too low to afford even subsidized coverage, Medicaid has been expanded to accommodate them. PREACA IMPLEMENTATION Prior to the ACA, states set their own Medicaid eligibility levels, although some offered significantly more generous eligibility rules than others. As the ACA was initially written, all states would have to raise Medicaid eligibility levels to 138 percent of the federal poverty line beginning in 2014, forcing many states to drastically increase their Medicaid rolls. In exchange, the federal government would pay for 100 percent of the newly eligible population for the first three years, and then slowly introduce a costsharing system that would eventually reach a 90/10 federal/state cost share by 2020. Following a lengthy legal challenge to the ACA, the U.S. Supreme Court largely upheld the law in 2012, but decided that states could not be forced to raise their eligibility levels. States could choose whether or not to participate in this new Medicaid expansion. Since that decision, 28 CMSA TODAY 25 states and the District of Columbia have decided to expand their programs, while 25 have declined to do so. The Congressional Budget Office anticipates that, as a result, Medicaid will add an additional 12 million enrollees by 2020. time. People who have been unable to receive preventive care or those who have gone without care for chronic illnesses will be seeing primary care physicians and specialists, perhaps for the first time. This is, of course, a positive development in improving the health of those who have been unable to easily access the existing health care system. However, it is a challenge for the system itself, which will encounter a massive influx of high-need patients. Case managers will be required to help new patients navigate the unknown and often complex world of internal medicine. MEDICAID EXPANSION The expansion of Medicaid has important implications for case managers nationwide. Because case management is a covered benefit under Medicaid programs, the additional 12 million beneficiaries will have access to these benefits. To understand case management's unique impact on Medicaid, it is important to examine who will be receiving new benefits as a result of the ACA. Because Medicaid and CHIP eligibility was skewed heavily toward covering children before the ACA, many newly eligible recipients will be adults, largely without dependent children. They will also be low income; 138 percent of the federal poverty line is less than $27,000 for a family of three who, in many cases, have not had health insurance before. Understanding this population is key to understanding the daunting future challenges and incredible opportunities case managers will have beginning next year. For many newly eligible Americans, 2014 will be an opportunity to gain meaningful access to health care services for the first Issue 1 * 2014 * DIGITAL LOOMING PRIMARY CARE SHORTAGE While Medicaid recipients will have access to health care services, it may be difficult for them to find doctors and other providers for care. The doctor shortage that has plagued the medical community for years is exacerbated by aging baby boomers and more Americans with access to care through the ACA. While the shortage will affect the entire population to varying degrees, the problem will be particularly acute for Medicaid beneficiaries since reimbursement to providers has traditionally been lower for Medicaid patients than for patients with Medicare or private insurance. The ACA does provide a "primary care bump," mandating that providers be paid at least as much for Medicaid as for Medicare in 2013 and 2014. This provision was an attempt to ensure physicians would take on Medicaid patients. While this is a step in the right direction, the payment parity provision ends at the end of 2014, making this a temporary solution. Access to care

Table of Contents for the Digital Edition of CMSA Today - Issue 1, 2014

President’s Letter
CMSA Corporate Partners
Association News
The Opportunity to Lead Change
An Integrated Approach
Health Care Reform in the Military
Innovation as Necessity
Opioid Abuse Crisis
Index of Advertisers

CMSA Today - Issue 1, 2014