Medicare, Medicaid, and the Delivery System
Uptake of Medicaid managed care plans in California compared to the national uptake
The state of California has been providing quality Medicare and Medicaid plans for its citizens. In the state of California and all other states in the United States, Medicare managed care plans provide insurance covers for the aged citizens (65 years and above), physically disabled persons and persons with complete renal failure (Crosson, 2009). The Medicare managed plans offered in the state of California include Health Maintenance Organizations (HMOs), Preferred Provider organizations (PPOs) and Medical Savings Account (MSA). On the other hand, Medicaid provides insurance covers to poor citizens (Crosson, 2009). The eligibility of persons for the Medicaid program is spelled out by the federal provisions which set guidelines for assessing the financial abilities of citizens. The federal guidelines spell out the assessments citizens need to pass so that they can be declared poor and eligible for Medicaid managed care plans. In the state of California, Medi-Cal is charged with the responsibility of administering Medicaid to the citizens.
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Currently, there are about 8.5 million people under Medicaid in the state of California. Most of these beneficiaries are children, youth and women. Other beneficiaries include disabled persons, expectant women, and infants born to poor families. However, the number of poor citizens under Medicaid is expected to go up with the implementation of new health overhaul plans proposed by the current political regime in the United States. The health overhaul plans are expected to add some 1 million citizens into Medicaid plans in California. In the United States, approximately 60% of healthcare policyholders are enrolled in Managed Care Plans. The state of California is leading in providing Medicaid managed care plans for its citizens. The number of enrollees in these plans is higher than the national figures. The high rate of enrolment has been attributed to the sound management of healthcare affairs in the state.
Medicaid managed care plans offered in California
There are two Medicaid managed care plans offered to citizens in California. The first is a Primary Care Case Management (PCCM) plan. The PCCM plan involves a primary care clinician who coordinates and monitors the services offered to Medicaid beneficiaries. If a beneficiary requires specialist care, then the primary care clinician organizes on how the beneficiary will be attended by a medical specialist. However, when beneficiaries need other healthcare services they usually pay fee-for-service. There is no financial risk attached to the clinicians for coordinating and monitoring the healthcare services offered to Medicaid beneficiaries. The primary care clinicians are entitled to a small monthly fee for their services. The PCCM plan is quite flexible, and it has accommodated many beneficiaries in the state of California.
The second Medicaid managed care plan is the Risk-Based Managed Care Organization (MCO). This plan takes care of all or part of the risks that could be encountered while offering healthcare services to the plan’s beneficiaries. The contractual arrangement involves payments of monthly fees to MCO per enrollee. However, the MCO plan might be limited to some services; for example, they can cater for mental or primary care services only. The MCO plan in the state of California takes about 30% of all enrollees for Medicaid managed care plans.
Payments for MCO and PCCM Medicaid managed care plans
Medicaid managed care plans follow vendor-based designs. Usually, the federal government pays a set amount of the cost incurred by citizens in accessing healthcare while the remaining percentage is paid by the individual state. All over the United States, states pay for Medicaid directly to healthcare providers or through other arrangements, such as through Health Maintenance Organizations (HMOs) and Preferred Provider Networks (PPOs). The federal government has given states the freedom to decide on the payment methods and rates for healthcare services rendered to their citizens. However, states act within the federal limits and restrictions (Guterman, Davis, Stremikis, & Drake, 2010). The participating healthcare providers are required to fulfill set requirements for them to be allowed to offer healthcare services to Medicaid managed care plan beneficiaries (Guterman et al., 2010). The state of California imposes deductibles, co-insurance, and co-payments on some Medicaid managed care beneficiaries.
However, some beneficiaries are excluded from cost-sharing. These are expectant women, children (under 18 years), and hospitalized patients who make most of their institutional healthcare costs from their income. Moreover, Medicaid beneficiaries are not expected to pay co-payments in emergency cases. Medicaid providers are required to accept Medicaid payment rates as stipulated in the contractual arrangement. State of California pays 75% of the total cost of Medicaid healthcare costs incurred by enrolled patients. The remaining 25% is paid by the federal government. There are plans contained in the Protection and Health Care Act (2010) that will lead to an increase of the contribution by the national government to 100% from 2014, but go down up to the year 2020 (Guterman, Davis, Schoenbaum & Shih, 2009). Waivers that are found in Medicaid managed care plans offer flexibility to both beneficiaries and providers. There has been a rapid increase in the number of Medicaid beneficiaries, thus enabling many poor citizens to afford healthcare services.
Crosson, F. J. (2009). Medicare: the place to start delivery system reform. Health Affairs, 28(2), 232-234.
Guterman, S., Davis, K., Schoenbaum, S., & Shih, A. (2009). Using Medicare payment policy to transform the health system: a framework for improving performance. Health Affairs, 28(2), 238-250.
Guterman, S., Davis, K., Stremikis, K., & Drake, H. (2010). Innovation in Medicare and Medicaid will be central to health reform’s success. Health Affairs, 29(6), 1188-1193.