State Affordable Insurance Exchanges are at the core of the coverage reform in the Affordable Care Act (ACA). The exchanges establish a marketplace in which individuals and small employers can compare and select among affordable, quality health insurance options. A key responsibility of exchanges is certification of qualified health plans (QHPs), based on criteria including network adequacy, marketing requirements, clinical quality measures, and consumer information. As state exchanges embark on the task of certifying QHPs, they would do well to look to their experience with Medicaid managed care.
In the past 20 years, states have learned an enormous amount from both their mistakes and their successes in purchasing Medicaid managed care services. Today, states vary in their managed care purchasing approaches, which range from highly regulated arrangements to free market models intended to drive value though competition. State exchanges are likely to have a similar range of strategies, and can learn from and perhaps in some cases adopt the purchasing levers and requirements used in managed care programs at both ends of the spectrum.
In this brief from the Center for Health Care Strategies, authors from Manatt Health Solutions examine Medicaid managed care contracts in six states. The brief notes opportunities for exchanges to “borrow” from and align QHP standards with Medicaid managed care requirements, as well as areas where managed care requirements may need to be modified for adoption in exchanges.
This brief is a product of the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation that is providing technical support to states to maximize coverage gains as they implement key provisions of the Affordable Care Act. The program is managed by the Woodrow Wilson School of Public and International Affairs at Princeton University.