With Coverage Comes Churn: Ensuring Continuity of Care Between Medicaid and the Exchanges

Guest blogger Veronica Guerra is a Program Associate at the Center for Health Care Strategies, Inc.
The problem of churn—individuals moving on and off or across insurance coverage due to income fluctuations—has long confounded state Medicaid agencies. As the Affordable Care Act (ACA) extends coverage to many more Americans through numerous vehicles, it will be important to ensure seamless continuity of care for people churning across various insurance options.
It is projected that within a six-month timeframe, more than 35 percent of all adults with family incomes below 200 percent of FPL will potentially experience a shift in eligibility from Medicaid to qualified health plans (QHPs) within the insurance exchange. Within a year, an estimated 50 percent will transition from obtaining their coverage through an exchange to the publicly funded state Medicaid program.
Take for example Oscar, 45, who receives minimum wage (190% FPL) from a landscaping job, lives with his elderly mother, and takes medications for high blood pressure and chronic depression. His work ebbs and flows seasonally – he is often unemployed for 4-5 months per year. In this scenario, with unstable income, he would switch from a QHP to Medicaid coverage. Without a coordinated transition, Oscar is at risk of missing regular physician appointments, not adhering to his anti-depressant and blood pressure medications, and facing exacerbated health problems. His worsening health status could result in problems finding employment.
For people like Oscar, states have the unprecedented opportunity to minimize coverage gaps. Well-designed coverage transitions can help ensure care continuity with current providers or health care systems. For individuals with chronic and special health care needs—e.g., those receiving ongoing services, pregnant women, and jail-involved individuals—it is even more critical to establish seamless coverage transitions.
Although there is not a “one size fits all model” for building a continuum of coverage, states can explore existing exchange models, such as the Massachusetts Health Connector, state Medicaid managed care organization (MCO) contracts, National Committee for Quality Assurance (NCQA) standards, and Medicare Part D for potential best practices.  A recent issue brief prepared by the Center for Health Care Strategies (CHCS) for the Robert Wood Johnson Foundation’s State Health Reform Assistance Network analyzes how states have historically dealt with individuals who shift between public subsidy programs. Following are existing models for coverage transitions drawn from the issue brief:
State Exchange Models: Massachusetts provides extensive contract language that guides MCO coverage transitions between Medicaid and the Health Connector program. Tennessee has proposed a policy that requires family members enrolled in different products (Medicaid vs. exchange) to receive coverage through a common carrier.
MCO Contracts: Several states require contracting MCOs to meet specific coverage transition requirements when transitioning a beneficiary from one MCO to another.  NCQA requires coverage transition standards for Medicaid and individual market MCOs seeking accreditation. A chart in the CHCS issue brief includes excerpts of sample contract language related to coverage transitions in existing programs.
Benefit Design: Medicare requires all Plan D sponsors to provide non-formulary medication coverage for individuals who are entering a plan or are transitioning between plans.
With the implementation of health reform in 2014, low- and middle- income families will face the prospect of traversing Medicaid and the exchange market with different health plans, cost sharing and benefit designs. Without coordinated transitions, people can experience potentially harmful gaps in coverage. The above models offer a starting point to help states provide continuous coverage and improved health outcomes, especially for people like Oscar who face multiple health conditions.
For more information on coverage transitions see a presentation on coverage transition models recently presented by CHCS and Robin Callahan, Deputy Medicaid Director in Massachusetts.
What is your state doing to ensure continuity of care as people transition between coverage programs? Are you using any of the strategies identified above? Let us know in the comments below or on the benefit continuity discussion page.