Ohio is on the brink of making historic changes to its Medicaid program. For the first time since 2012, the Department of Medicaid is renegotiating its contracts with private insurance companies that are tasked with administering most of the state’s health care program for low-income residents. If these changes are fully implemented then vulnerable Ohioans, particularly children with complex conditions, will have better access to services they need.
These companies, known as managed care plans, have a difficult task. Unlike traditional Medicaid, where the state pays a fee for every service that is delivered, managed care organizations are paid a flat rate for each person enrolled in their plans and must pay for all their members’ health care regardless of the cost of that care.
Managed care is a popular way for states to administer their Medicaid program because it makes the state’s Medicaid budget more predictable while also giving plans an incentive to take an active role in making sure their members remain as healthy as possible — investing in preventive care or coordinating access to services saves the plan money by avoiding more costly hospitalizations or other complications.
However, a chronic problem with managed care plans is their tendency to, intentionally or not, put up barriers to accessing necessary services rather than investing meaningfully in promoting preventive services or care coordination for individuals with complex needs. Ohio is no exception.
Legal aid attorneys throughout the state have fought uphill battles against managed care plans for years to obtain necessary services for their clients.
Consider Adison’s case. Adison is a 16-year-old boy who was born with a rare muscular disorder that severely impairs nearly all his motor functions and requires him to use a specialized wheelchair. As Adison grew during his teenage years, he needed a powerchair that he could control with his head and that also had the ability to adjust his position and perform various other functions. Without one he would have been bed-ridden, in pain, and unable to move.
His physical therapist and legal aid attorneys from Advocates for Basic Legal Equality fought for nearly a year to overturn his plan’s refusal to cover the chair, despite ample medical evidence. At no point did the plan ever meet with Adison’s family or contact them in any way. Adison’s physical therapist let him borrow her practice’s demonstration chair while they worked to overturn the decision, which the Department of Medicaid eventually did.
Adison’s case makes you wonder how many other children are going without needed services and equipment because they are not lucky enough to have a team of professionals willing to spend a year fighting for them.
The new contract makes several changes that, if fully implemented and enforced, ought to make it less likely that special-needs children like Adison will have such a difficult experience. The Ohio Poverty Law Center issued a report, “A Bright Future for Ohio’s Medicaid Managed Care Program,” that highlights four key changes that will improve access to care.
First, plans must implement changes that simplify the grievance and appeals systems and make the process for challenging decisions a more meaningful process. Furthermore, plans will have to collect and report data on their appeals and analyze it for systemic problems in how they are approving or denying services.
Second, plans must hire a senior level administrator whose sole job is to ensure all children receive the services they need, from early childhood screenings to specialized services for children such as Adison. A special emphasis will be placed on providing services in schools, where children are easiest to reach.
Third, a top priority in the new contract is to make the system more individual-focused. The contract includes 20 pages of requirements regarding “care coordination,” which is a fundamental part of the managed care philosophy—proactively working with members to ensure their needs are met before they escalate into more serious conditions.
In practice, plans have struggled to provide meaningful care coordination and like in Adison’s case, other service providers end up informally playing that role. The new contract’s requirements are designed to ensure that plans implement “a high performing care coordination program that…reflects the guiding principles to optimize the health of the individual members and populations it serves…[and offers] the full spectrum of care coordination activities, ranging from short-term assistance to meet care gaps to longer-term, intensive, and holistic care management for members with the most intense needs.”
Finally, plans will be required to make meaningful investments in the communities they serve. Plans must invest 5% of their annual profits in “Community Reinvestment Plans” to support population health strategies that are not typically paid for by Medicaid.
As any legal aid attorney will tell you, people living in poverty are oftentimes navigating a dizzying array of non-medical issues that have an impact on their health such as trauma, inadequate housing, lack of transportation, domestic and community violence, and job insecurity. These types of issues that impact overall health are commonly called “social determinants of health.” The community reinvestment plans will bring millions of dollars into communities to help address these social determinants of health and lead to both a healthier population and less expensive Medicaid program.
For these reasons and more, during this time of unprecedented crisis, anyone with an interest in the wellbeing of Ohio’s economy and the wellbeing of its residents should be encouraged by the future of Ohio’s Medicaid program. We hope the state budget will have adequate resources to fully implement and enforce these changes so the state can reap the benefits of a healthier Ohio.