Managed care plans need protection from 'carve-outs' to ensure services across the continuum, group tells senators

Share this content:

State “carve-outs” and lack of transparency in rate-setting threaten the ability of managed care plans to support services across the whole continuum, the Medicaid Health Plans of America stated in a recent letter to leaders of the Senate Finance Committee.

In September, the committee members requested comments on Medicaid managed care best practices. The trade association representing Medicaid health plans sent its Nov. 14 letter in response.

One major area of concern is that states are not always transparent in how they set rates for managed care plans, which could affect people needing long-term services and supports, according to the MHPA letter. If states share “actuarial memoranda” with MCOs for review, then the managed care entities can “suggest … the use of appropriate proxy data or risk-sharing arrangements, especially with populations newer to managed care.” One such population is people needing long-term care.

Other organizations also have submitted comments calling for greater transparency, including the Association for Community Affiliated Plans, Bloomberg BNA reported Monday.

The MPHA also is advocating for fewer “carve outs.” By excluding services such as behavioral health from managed care coverage, states prevent MCOs from being able to support “fully integrated” health systems, the association stated.

The LTSS population benefits in particular from greater coordination and management across different settings. One example comes from Arizona, where a managed care plan worked with LTSS enrollees to set and achieve care goals, which ranged from learning to knit to moving from a facility to a community setting, according to the comment.

Click here to access the complete document.