Medicaid Managed Care: How States' Experience Can Inform Exchange Qualified Health Plan Standards

Prepared for the Center for Health Care Strategies

State Affordable Insurance Exchanges (exchanges) are at the core of the coverage reform in the Patient Protection and Affordable Care Act (ACA), establishing a marketplace in which individuals and small employers can compare and select among affordable, quality health insurance options. The ACA charges exchanges with certifying and making Qualified Health Plans (QHPs) available to consumers and small businesses within the parameters of proposed ACA implementation guidance released on July 15, 2011. As states begin to consider the standards to apply to QHPs, they would do well to look to their experience with Medicaid managed care (MMC).

The brief reviews relevant ACA provisions and the draft regulations, outlines the requirements of the federal MMC law and examines MMC contractual, statutory and regulatory requirements in six states—Arizona, Minnesota, New York, Tennessee, Washington and Wisconsin—where a significant percentage of Medicaid beneficiaries are enrolled in comprehensive risk-based plans. Manatt authors analyze the decisions these states have made with respect to (1) provider networks; (2) quality; (3) accreditation; (4) marketing; (5) information and data disclosure; and (6) plan selection and notes the opportunities for exchanges to "borrow" from and align QHP standards with MMC, as well as areas in which MMC requirements are ill suited for adoption in exchanges.



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