(Bloomberg) — In the first major overhaul in more than a decade, the United States has proposed new rules for private health insurers who run Medicaid plans covering millions of poor people and children.
The proposed rules, issued Tuesday, call for plans to report what portion of the money they collect to care for patients actually gets spent on benefits. They would attempt to broaden access to doctors and hospitals by having states set standards on access to care. The rules would also create a performance-based ratings system for plans.
Big health insurers like Aetna Inc., Humana Inc., Anthem Inc., and UnitedHealth Group Inc. offer the Medicaid plans, as do specialized firms such as Molina Healthcare Inc., Centene Corp., WellCare Health Plans Inc. and Health Net Inc.
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The last major update to rules overseeing Medicaid managed care plans was in 2003. Since then, Medicaid and a related program for children, called CHIP, have expanded, in large part because of 2010's Patient Protection and Affordable Care Act.
Medicaid is the federal-state program for the poor. While states run the program, it is funded and overseen in part by the federal government.
Medicaid and CHIP now cover more than 70 million people in the country. The Affordable Care Act expanded eligibility and the program has added 12.6 million enrollees since the start of last year, according to the research group RAND Corp.
Managed care
Private plans in 39 states cover more than half of all Medicaid beneficiaries, according to the Kaiser Family Foundation. In return for a promise of lower costs and better- managed care, states typically pay private insurers a fixed sum for each Medicaid member.
California has the largest number of people enrolled in managed-Medicaid plans, followed by New York and then Florida, according to Avalere Health.
States were allowed to opt out of expanding their Medicaid programs in a 2012 Supreme Court decision on the Affordable Care Act, and 21 have since decided not to increase eligibility. Under the Affordable Care Act, the United States pays the full cost of expansion through 2016 and 90 percent thereafter.
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