Jul, 27, 2020

Ensuring Medicaid MCO Enrollees Receive Necessary Care During COVID-19

Michael Bailit and Jennifer N. Sayles, Bailit Health

It is clear that COVID-19 has significantly reduced health care utilization in the United States. Of great concern to states is that Medicaid beneficiaries safely access medically needed services. There are already worrisome indications that many beneficiaries are not receiving such care. For example, the Centers for Disease Control and Prevention (CDC) has reported a sharp decline in vaccinations.[i]

Over 55 million Medicaid beneficiaries nationwide are enrolled in comprehensive managed care plans.[ii] It is incumbent on states to take steps with their Medicaid plans to make sure needed services are delivered during the course of the pandemic. We specifically recommend the following three categories of state Medicaid program activities:

  1. Measurement of the impact of COVID-19 on Medicaid managed care organization (MCO) enrollees
  2. Assessment of what steps MCOs have taken to address member needs, including those of subpopulations, during the pandemic
  3. Performance requirements of MCOs for member outreach and engagement

While this perspective focuses on the state-MCO relationship, the content has equal application for states with contracted accountable care organization (ACO) relationships.

Measurement of Impact on MCO Enrollees

States should start by asking how COVID-19 has impacted each plan’s member population, as best as can be (imperfectly) determined through claim data. This might include asking MCOs to generate the following information:

  • Count and percentage of members with COVID-19 claim diagnosis, stratified by age, gender, race and ethnicity. 
  • Count and percentage of COVID-19 claims-diagnosed members that required hospitalization and intensive care unit (ICU) stay, stratified by age, gender, race, and ethnicity, and presence of co-morbidity. 
  • Count and percentage of members in skilled nursing facilities and in long-term care (LTC) facilities who have had a COVID-19 claims diagnosis, required hospitalization, or required an ICU stay. 
  • Total dollars and dollars per member per month (PMPM) for members with a COVID-19 claim diagnosis, stratified by age, gender and race and stratified by major service category.

Analyzing the impact of COVID-19 on MCO membership can inform both states and MCOs as to which populations may be disproportionately impacted and may benefit from additional outreach, case management, service coordination or transition-of-care support.  Also, an understanding of the impact of COVID-19 on members served in skilled nursing facilities and LTC facility settings can inform MCO and state efforts to ensure the appropriate management and safety of those members.

States should also ask how has delivery of medically necessary services been affected, with a focus on priority populations and services? States can ask MCOs to answer this question by generating the following data:

  • Healthcare Effectiveness Data and Information Set (HEDIS) or HEDIS-like administrative data-only utilization rates for the following measures, calendar year 2019 (CY19) year to date (YTD) versus CY20 YTD, stratified by age, gender and race, being certain to include telehealth codes when generating measurements. Suggested HEDIS measures (using HEDIS 2019 specifications) include the following:
    • Adults’ Access to Preventive/Ambulatory Health Services (also stratified by eligibility category)
    • Well-Child Visits in the First 15 Months of Life
    • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
    • Annual Dental Visit
    • Adolescent Well-Care Visits
    • Prenatal and Postpartum Care
    • Breast Cancer Screening
    • Follow-up after Hospitalization for Mental Illness – 7 Days
    • Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control
    • Comprehensive Diabetes Care: Eye Exam
  • Suggested non-HEDIS administrative data-only measures include the following:
    • Proportion of pharmacy days covered: diabetes and hypertension (at a minimum)
    • Outpatient mental health services for adults and for children (stratified)
    • Outpatient mental health services for adults with serious mental illness
    • Outpatient substance use services for persons with addictionsLong-term services and supports utilization by older adults and persons with disabilities

A third question to help assess what is happening to MCO members is to what extent is telehealth being employed as a substitution for in-person care?  MCOs can help states answer this question by providing the following data:

  • The following measures, CY19 by month and YTD vs. CY20 by month and YTD, stratified by age, gender and race:
    • Telehealth claim volume and total paid dollars
    • Telehealth claim volume and total paid dollars by provider type:
      • Primary care
      • Specialty medical care (excluding psychiatry and addiction medicine)
      • Outpatient behavioral health

Assessment of What Steps MCOs Have Taken to Address Member Needs During the Pandemic

States should ask their MCOs what they are doing to support their membership during the pandemic. A first, basic question is what are MCOs doing to facilitate COVID-19 testing?

States should require their MCOs to provide a narrative description of concrete steps to promote and facilitate COVID-19 testing, with periodic updates. These steps should include:

  • Supporting local health department community testing sites
  • Ensuring that the plan provider network is offering COVID-19 testing to members in outpatient settings (not only emergency department and acute care settings)
  • Ensuring members in SNF and in long-term care facility settings are being tested in accordance with state and local guidelines 
  • Coordination with the state and other MCOs on expanding testing access, including in disproportionately impacted communities

To the extent the plan is also paying for such tests, it should report the volume of COVID—19 tests per month and the PMPM expenditures paid by the MCO.

A second and critical question to ask of MCOs is what are MCOs doing to outreach to priority populations most adversely impact by COVID-19 to ensure they are receiving testing and medically necessary care and support services? Here again, states should require their MCOs to provide a narrative description of concrete steps, this time for member outreach and engagement in testing and care, with periodic updates.  These steps should include:

  • Identifying communities and members that are disproportionately impacted by COVID-19 and ensuring they have access to testing, ongoing medical and behavioral health care
  • Assessing members for social needs and linking them to social services for housing, food and income supports given the economic devastation many low-income individuals, families and communities are disproportionately experiencing in the epidemic

Performance Requirements of MCOs for Member Outreach and Engagement

While asking MCOs to describe how they are outreaching to members and engaging them in care during this national health emergency is important, it is not sufficient. We recommend states go further, and apply specific performance expectations.

Specifically, we recommend that states direct contracted MCOs to take defined actions, including up to three call or text outreach attempts with medical, behavioral health and social risk screens upon making contact, to ensure the delivery of necessary care to members who have not been receiving such care since the onset of COVID-19

Potential focus populations could include:

  • Children and adolescents, for well-care and dental care
  • Pregnant women
  • Adults with serious mental illness
  • Persons with substance use disorders
  • Persons identified as high-risk by the MCO
  • Persons with poorly managed chronic conditions including diabetes, hypertension, asthma, cardiac disease or COPD
  • Persons eligible for Medicaid due to disabling conditions aside from behavioral health
  • Persons eligible for long-term services and supports
  • Persons over age 65

This requirement should be complemented by required reporting and extensive follow-up discussion with MCOs.

Medicaid MCOs have an important and valuable role to play in the COVID-19 response, given the large number of low-income individuals, families and communities they serve who are disproportionate impacted by the pandemic. This expert perspective lays out several necessary steps that states should be taking now with their contracted MCOs to minimize the deleterious impact of COVID-19 on patient access to and receipt of necessary services.  States should reassess requirements over time, and make modifications as appropriate (e.g., remove reporting requirements that don’t produce valuable information).


[i] Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020.  Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, May 20, 2020.  https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm?s_cid=mm6919e2_w

[ii] 2018 Managed Care Enrollment Summary. https://data.medicaid.gov/Enrollment/2018-Managed-Care-Enrollment-Summary/gn4b-7d7q/data