Ensuring Continuity of Care for Individuals Transitioning from Medicaid to Marketplace: Post-PHE Considerations for States

Jul, 20, 2022

Ensuring Continuity of Care for Individuals Transitioning from Medicaid to Marketplace: Post-PHE Considerations for States

Sabrina Corlette, Georgetown University’s Center on Health Insurance Reforms, and Jason Levitis, Urban Institute

Background

When the COVID-19 public health emergency (PHE) ends, an estimated five to six million people are projected to be disenrolled from Medicaid but eligible for subsidies on the Affordable Care Act Marketplaces. Many of those losing their Medicaid benefits will have health needs requiring uninterrupted care. Medicaid enrollees tend to have poorer health than the general population and are disproportionately likely to have diabetes, hypertension, asthma, mental illness or a substance use disorder. Even generally healthy people could be in the midst of a hospitalization, recovering from injury or trauma, or in the latter stages of pregnancy when their Medicaid benefits are terminated. Many, regardless of health status, will have longstanding relationships with a family doctor, OB/GYN, or pediatrician, or rely on continued access to a particular prescription.

Yet people who transition from Medicaid to the Marketplace will enroll in plans with different benefit designs, drug formularies, provider networks, and cost-sharing policies than their Medicaid coverage. Services they previously received for free could come with deductibles or other cost-sharing. Hospitals and doctors may suddenly become “out-of-network,” which for most Marketplace plans means their services are not covered at all. Patients may be required to re-submit paperwork to receive prior authorization for services that their previous plan had already approved. For state Medicaid agencies, Marketplace officials, and insurance regulators, helping people maintain continuity of insurance coverage is only part of the challenge. States will need to give equal attention to ensuring continuity of care.

Ensuring Continuity of Care: Options for States

The PHE has been extended to mid-October, meaning the resumption of Medicaid eligibility redeterminations is unlikely to begin before late 2022 or early 2023. This gives state officials some lead time to develop and implement policies and practices that can help ensure uninterrupted access to healthcare services for people who transition from Medicaid into the Marketplace. In some states, legislative or regulatory action may be required, but other policies or practices may be implemented through operational changes or done voluntarily by participating insurers. Some of the measures described here could also help ease transitions between Medicaid and employer-sponsored health insurance.

This is the second expert perspective in a series about maintaining continuity of coverage and care during the PHE unwinding. The first expert perspective noted that state Medicaid agencies can mitigate disruptions by identifying high risk enrollees and those in the middle of a course of treatment. Medicaid officials can sequence eligibility redeterminations to help as many individuals as possible to complete necessary treatment and to minimize the risk of a coverage gap. They can also provide enhanced outreach and assistance to help place higher risk individuals in a plan that meets their benefit, provider, and formulary needs. In this second expert perspective, we identify strategies for state-based Marketplaces (SBMs), in partnership with Medicaid agencies, departments of insurance (DOIs), consumer assisters, and participating insurers, to help maintain continuity of care. A third expert perspective will discuss strategies for the SBMs and their partners to help ensure continuity of coverage.

Communications and Consumer Assistance

Many individuals who have been enrolled for multiple years in Medicaid may be unfamiliar with important elements of commercial insurance plan design, such as the use of premiums, cost-sharing, and differences in benefits and provider networks. Many also may be unaware that they should review the provider directories or search tools of Marketplace plans before enrolling, to ensure that any providers upon whom they rely are in-network.

SBMs may want to review and update their educational materials to ensure they clearly explain the terms of coverage for a population transitioning from Medicaid benefits. SBMs can also work with their assister partners to ensure that they build health insurance literacy into their enrollment assistance for transitioning individuals.

There are other ways SBMs can provide support. For example, SBMs could use claims data provided by their Medicaid agency to “map” transitioning individuals to a Marketplace plan that includes the providers that they use regularly. The SBM could then send notices to these individuals that identify the plans in the service area that include those providers, with guidance on how to enroll.

Strategies to Improve Continuity of Care

Insurers who offer Marketplace plans will be important partners throughout the public health emergency unwinding. They may be incentivized to gain new enrollees, but may have less incentive to make operational changes necessary to maintain continuity of care for transitioning enrollees. States may wish to require Marketplace insurers to implement the continuity of care strategies identified below through legislation or using Marketplaces’ and DOI’s existing regulatory authority. Some insurers may be willing to undertake these measures voluntarily.

Provider access – continuity of care. The federal government and 39 states have enacted “continuity of care” laws that require insurers to cover services from an out-of-network provider as if they are “in network” for enrollees in the middle of treatment, terminally ill, or in the last trimester of pregnancy. These continuity of care protections are most often triggered when a provider is terminated from an enrollee’s network. But in 13 states, insurers must also provide the protection when an enrollee is switching from Medicaid to a new health plan.

State insurance regulators could assess their existing continuity of care laws and determine whether the protections could be expanded to ensure that people who are disenrolled from Medicaid and in the middle of treatment or have other significant healthcare needs can maintain access to their critical treating provider. The state may also want to consider amending their continuity of care rules to extend beyond the traditional 90 days, and to a broader set of services, at least for the transitioning population.
Many state continuity-of-care protections are contingent on the provider accepting the new plan’s in-network reimbursement rate. States may wish to make the protection automatic, and to prohibit balance billing. However, for most providers, it is likely that the Marketplace plan’s reimbursement rate will be the same or higher than their payment for treating a Medicaid enrollee.

Provider access – network capacity. Some Marketplace health plans come with narrow provider networks. When such a plan is also the lowest-cost option in a given area, the plan could receive more enrollment than its network has the capacity to serve, at least in the short-term.

State DOIs and Marketplaces could ensure they have requirements in place for participating insurers to report in advance their estimates for their maximum enrollment capacity, and identify a threshold at which that capacity could become strained. Should a plan exceed that threshold, Marketplaces may need to temporarily suppress enrollment in that plan.
Consumer assisters should be trained to advise clients when and how to report any challenges they face obtaining medical appointments, such as a lack of providers accepting new patients or excessive appointment wait times.
DOIs and Marketplaces will need to monitor consumer complaints and be prepared to respond quickly. For example, plans could be required to allow enrollees to obtain out-of-network care for needed services at in-network cost-sharing rates if in-network providers are unavailable.
Marketplaces could offer individuals who find themselves in a plan with an inadequate network a special enrollment opportunity to switch to a new plan.

Reducing paperwork barriers to care. Many transitioning individuals will have received from their Medicaid plan or program approvals for services that require prior authorization, including approval to obtain certain non-preferred prescription drugs not covered on the Marketplace plan’s formulary. Some will have also satisfied their Medicaid plan or program’s step therapy requirements but may face similar step therapy requirements in a Marketplace plan.

States could require Marketplace plans to honor the decisions of an enrollee’s prior Medicaid coverage, so that these individuals have uninterrupted access to necessary care.

Reducing cost-sharing barriers. The Centers for Medicare and Medicaid Services has advised that Medicaid agencies initiate eligibility determinations for no more than one-ninth of their total caseload each month, in order to establish a sustainable renewal schedule. This means that eligibility redeterminations will likely occur throughout the unwinding period, requiring many people to switch to a Marketplace plan outside of the annual open enrollment period. Many of these individuals will be enrolling in Marketplace plans with annual deductibles that can range from over $1,400 for a Gold plan to over $6,000 for a Bronze plan (for those who do not qualify for cost-sharing subsidies). These deductibles are generally not prorated for part-year coverage, regardless of when someone enrolls. Thus, if someone transitions to a Marketplace plan late in the year, like November, they could face a $6,000 deductible for just two months of coverage, and then face the full deductible again at the beginning of the following year. Such deductible costs could make it infeasible to continue ongoing services.

States could require Marketplace plans to pro-rate deductibles and plan maximum out-of-pocket caps according to the month in which an individual enrolls.

Conclusion

Federal and state officials are rightly focused on keeping as many people in coverage as possible once the PHE ends. But it is just as important that those who are most at risk—people for whom an interruption of services or treatment can be literally a life or death matter—transition into coverage that meets their needs. States can and should consider policies to ensure that those making the shift from Medicaid to the Marketplaces have uninterrupted access to the healthcare services they need. At a minimum, many of these policies could be adopted temporarily, or Marketplace insurers encouraged to implement them voluntarily.

The authors thank Tara Straw and Joel Ario, Manatt Health, for reviewing and offering insightful feedback on this expert perspective.