Promoting Continuity Across Medicaid and Exchanges: How Can the Safety Net Help?

The Medicaid expansion and the availability of subsidies in the health insurance exchange are the first steps in giving millions of lower-income Americans access to health coverage. However,estimates show that nearly half of adults eligible for Medicaid or exchange subsidies—28 million people—would experience income changes within one year that could cause a shift in eligibility between Medicaid and the exchange. Safety net providers—community health centers, public hospitals, local health departments, and others—may help people continue their care as they cross back and forth between Medicaid and the exchange. These providers, who are already an important source of primary care for Medicaid enrollees and many of the uninsured who will become newly eligible in 2014, could also be a continuous source of care to the newly insured under health care reform.
As part of a national cooperative agreement with the Health Resources and Services Administration, NASHP is examining the potential role of safety net providers in serving as a link between Medicaid and the new health insurance exchanges.
NASHP recently sent out a few questions to state Medicaid directors and exchange directors or planning leads to find out how states are engaging safety net providers in their Medicaid expansion and health insurance exchange implementation work.
Although many states are early in their planning processes, a number of them had preliminary thoughts to share about the role and involvement of safety net providers in health reform, including:

• Health Reform Implementation Planning: Several states are having discussions within Medicaid or exchange agencies, or between them, on the role of safety net providers in health care reform implementation. States are also including safety net providers in the formal planning process. Some states have these providers represented on exchange boards, while others have included safety net providers in planning discussions.

• Financing: Federally Qualified Health Centers (FQHCs) are reimbursed by Medicaid using the Prospective Payment System (PPS)—a standardized per-visit payment rate based on a center’s average reasonable costs from 1999 and 2000, adjusted each year for inflation. States contemplating or establishing state-run health insurance exchanges are considering the implications of how qualified health plans (QHPs) will reimburse these unique providers, as well as other safety net financing issues.

• Outreach and Enrollment: A number of states currently use safety net providers for outreach and enrollment in Medicaid and the Children’s Health Insurance Program (CHIP), as enrollment facilitators or presumptive eligibility entities. These states believe there will be continued roles in the future for safety net providers in the exchange, especially as Navigators, who will help people identify, choose, and enroll in health coverage.

• Continuity of Care: Many states also report that Medicaid and CHIP programs already require plans to contract with FQHCs. In order to promote continuity of care, some states are considering requiring QHPs to use the same providers in their networks as Medicaid and CHIP do, or having Medicaid managed care organizations offer their plans in the exchange. These practices will allow safety net providers to serve people covered by Medicaid or exchange plans, and during periods of uninsurance.

How is your state working with safety net providers on health reform implementation? Are you working with them on general implementation planning, financing issues, outreach and enrollment, or on strategies to support continuity of care? As we continue our work, we will explore these issues and share our learning. Please share your thoughts below.