Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations

Private plans that provide health coverage to people with Medicare or Medicaid, and in the new Marketplaces collectively serve more than 70 million Americans as of January 2015 – and the numbers are on the rise.¹  These plans – Medicare Advantage plans, Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations (MCOs) – operate under rules established by the federal government, many of which are designed to ensure that enrollees have access to coverage and the full scope of benefits and providers to which they are entitled. The rules for plans in each of the three markets differ, even though each market is overseen and regulated, to some degree, by the same federal agency, the Centers for Medicare and Medicaid Services (CMS). In addition, Medicaid MCOs and QHPs may be subject to more stringent consumer protection standards established and enforceable by the state in which they operate.   This report examines similarities and differences in federal consumer protection standards for Medicare Advantage plans, QHPs, and Medicaid MCOs. It focuses on rules established at the federal level, though some states have chosen to go above the federal minimums and impose additional requirements for QHPs and Medicaid MCOs.

These three insurance markets were created at different times, for different purposes and for different populations, and to some extent, the different set of rules in which plans operate reflect this diversity. While Medicare is a purely federal program, Medicaid is a joint federal/state program, and the Marketplaces are subject to minimum federal standards but can be administered by either states or the federal government, or the two in partnership. Medicare was designed to serve people ages 65 and older, and younger people with disabilities, without regard to income. Medicaid is a program for individuals with low-incomes and also is a major source of coverage for people with disabilities. The Marketplaces were created to provide insurance to non-elderly people without access to other sources of coverage. The consumer protections now in place for both Medicare Advantage and Medicaid MCOs have evolved over time, and in response to issues that have emerged over many years. The rules for Marketplace plans are relatively new, developed and implemented following enactment of the Affordable Care Act.

Our comparison of the federal consumer protections requirements for Medicare Advantage, QHPs and Medicaid MCOs finds some similarities across the three markets, as well as several notable differences that could have important implications for consumers (See Table ES-1). In some instances, the different set of rules across the three markets can be easily explained; for example, differences in allowable cost-sharing reflect different statutory requirements. However, the rationale for other differences – such as minimum coverage standards for prescription drugs, network adequacy standards, appeal rights when claims are denied, and the circumstances under which an enrollee may change plans mid-year – is less clear.

While beyond the scope of this paper, further work is needed to explore whether the different set of rules for plans that provide coverage to Medicare, Marketplace and Medicaid enrollees are in the best interest of consumers, plans, and the federal government. Many insurers operate in all three markets – so inconsistencies in applicable standards can add to administrative burden. In addition, individuals can and do move between these different sources of coverage, sometimes within the same calendar year, and may also be confused, if their rights and protections shift abruptly following an enrollment change. At the same time, it is important to not dilute existing consumer protections simply for the sake of achieving uniformity, particularly provisions needed to safeguard vulnerable populations. Analysis of the reasons for and impact of some of these differences could inform whether more consistency across programs would be helpful.

Delivering health insurance benefits through private plans, particularly capitated arrangements, can make costs more predictable for state and federal governments and increase care coordination for consumers. However, delivery of insurance benefits through private plans also can add complexity for consumers because each plan and market is unique, and can provide different benefits, require different cost-sharing for services, and often include and exclude different providers. Navigating health coverage delivered through private plans can be especially challenging for consumers with low incomes, low health literacy, cognitive impairments, expensive or chronic health conditions, and those who have a history of being uninsured. Building consumer protections into private health plans can help to ensure enrollees have access to coverage and the full scope of benefits to which they are entitled.

This issue brief examines the similarities and differences in consumer protections in three major sources of insurance coverage delivered through private plans: Medicare Advantage (MA), Qualified Health Plans (QHPs) offered through the Marketplaces, and Medicaid Managed Care Organizations (MCOs). These three insurance markets, to different extents, are overseen by the same agency within the federal government, the Centers for Medicare and Medicaid Services (CMS). Although there are similarities in the consumer protections provided by these various coverage schemes, there are also notable differences, and these differences may raise issues for consumers – particularly those who are enrolled in plans in two or more of the markets either consecutively or concurrently. For example, someone may be covered by a QHP offered through a Marketplace followed by a Medicare Advantage plan when they turn 65. It is likewise possible that individuals with low incomes may be in a QHP, Medicaid MCO, and Medicare Advantage plan within the span of several years due to age, fluctuations in income and/or disability status.

The three insurance markets on which this paper focuses were created for different purposes and for different populations, and their varied structures reflect this diversity. Medicare is a purely federal program, Medicaid is a joint federal/state program, and the Marketplaces are federal, state, or federal-state partnership. Medicare was designed to serve older adults and younger people with disabilities, without regard to income. The Marketplaces were created to provide insurance to people without access to other sources of coverage, and include premium tax credits and subsidies to make coverage more affordable for those with limited incomes. In contrast, Medicaid is a program for individuals with low-incomes and cost-sharing is correspondingly more restricted than in the other two programs. For purposes of this report, Medicaid is included when the comparison to the other two programs is relevant; in other words, when the difference is more than a reflection of the different program target populations or program design intent.

This paper reviews the federal rules that apply for Medicare Advantage plans, QHPs and Medicaid MCOs but assesses neither the degree to which these rules are enforced by state and federal governments, nor whether states apply more stringent requirements than the federal minimum standards for QHPs and Medicaid MCOs. It should be noted that some states have chosen to go above that federal minimum and have imposed additional requirements through their state-based Marketplaces as some states have similarly imposed additional requirements beyond the federal minimum for Medicaid MCOs. Further, a number of consumer protections for QHPs are currently either unimplemented or partially implemented.

Background on Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations

Medicare Advantage (MA) is built on the foundation of Medicare, a federal entitlement health coverage program with federal rules and oversight for people ages 65 and older and younger people with disabilities. The Medicare Advantage program, also known as Medicare Part C, is a voluntary coverage option available to Medicare beneficiaries as an alternative to the traditional fee-for-service Medicare program. Medicare Advantage plans must cover all services that are covered by Medicare Parts A and B, (and, if applicable, the Part D prescription drug benefit). Medicare Advantage plans can, and are often required to, provide benefits in addition to those covered by traditional Medicare.

The Affordable Care Act (ACA) expands access to individual health insurance coverage largely through private, non-employer based, individual health insurance offered through Marketplaces. Under the ACA all private insurance, including Qualified Health Plans (QHPs) offered through the Marketplaces, is subject to minimum federal standards, with flexibility reserved for states to apply stronger standards to plans they regulate. Income-based premium and cost-sharing subsidies are available through the Marketplaces to ensure coverage is affordable for those who have no other source of affordable coverage. Health insurance plans must be certified as QHPs by a Marketplace before they may be sold to consumers on that Marketplace. To be certified, QHPs must provide coverage for certain essential health benefits (EHB), follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meet other requirements. QHPs are divided into four different categories based on the percentage of health costs a plan is expected to pay (actuarial value): Bronze, Silver, Gold, and Platinum, all of which must cover EHB.² 

Medicaid is a major source of coverage for people with low incomes and people with disabilities. Medicaid is jointly financed by the federal government and the states and administered by the states with federal oversight.   Federal law requires states participating in Medicaid to cover certain mandatory benefits, and states can choose to cover additional optional benefits. States can choose to provide Medicaid benefits through managed care delivery systems, including managed fee-for-service (FFS) models, such as primary care case management, and capitated models, such as managed care organizations (MCOs), private health plans that contract with the state on a risk basis to deliver Medicaid services.³  An increasing number of Medicaid beneficiaries – now more than half – receive Medicaid coverage through managed care plans. (For more information about these three programs, see Appendix A.)

In Medicare, Medicaid, and now, Marketplace QHPs, consumers are guaranteed a base level of access to coverage and financial protection. They are likewise afforded other procedural safeguards. Across the range of consumer protections, including those pertaining to eligibility, enrollment, renewability, benefits, cost-sharing and other categories of consumer protections, there are many similarities between Medicare Advantage plans, QHPs and Medicaid MCOs, as well as some notable differences in such protections, which are highlighted below. While the comparison chart in Appendix C contains a more detailed comparison across a broader range of consumer protections, highlights are summarized below.

Covered Benefits

Medicare Advantage plans, QHPs and Medicaid MCOs are all required to provide a certain core set of benefits. All three markets require plans to cover a range of similar services, and have similar exclusions from coverage, but state Medicaid programs generally provide greater coverage of long-term services and supports than Medicare Advantage plans or QHPs.⁴  Medicare Advantage plans must provide all services covered under Parts A and B of Medicare except for hospice services (and in certain circumstances, must provide Part D prescription drug coverage). The Medicare Advantage plan benefit package is based on traditional Medicare Parts A, B and D (if applicable) which can have limitations in scope and duration of coverage in certain care settings (for example, Medicare limits coverage in a skilled nursing facility to up to 100 days in a benefit period).   Medicare Advantage plans do, however, have some flexibility to loosen, but not tighten, benefit restrictions relative to traditional Medicare’s structure (e.g., Medicare Advantage plans can choose to waive coverage limits that apply under traditional Medicare; for example, MA plans can waive the 3-day prior hospital stay requirement for skilled nursing facility coverage, or extend such coverage beyond 100 days per benefit period).

QHPs are required to cover 10 categories of essential health benefits (EHBs) enumerated in statute. Detail defining EHBs is based on a benchmark plan. The default state benchmark package is based on the most popular small group plan, though states can designate other benchmark options. Federal regulation provides limited detail defining benefits within categories, and states may provide more detailed regulation. Otherwise, insurers have flexibility to determine which EHB category applies to specific services covered under the benchmark plan; further, absent state limitations, insurers then have flexibility to substitute actuarially equivalent services within EHB categories. Under federal rules, insurers are not required to report to the Marketplace or to consumers when they adopt such substitutions.   As a result, coverage for some services under QHPs could vary significantly plan to plan. Examples of variations in current QHP offerings include limits on the number of home health visits, imaging services, speech therapy and organ transplantation. QHPs are also subject to a ‘nondiscrimination’ standard; benefit design and cost-sharing design cannot discriminate based on health status and other factors. To date, regulations to define the nondiscrimination standard in further detail have not been issued. For the 2016 plan year, CMS will require QHP insurers to attest that their plan design complies with the nondiscrimination standard. CMS guidance indicates it will monitor complaints data for 2016 QHP plans. Other oversight seems to be evolving; for example, CMS guidance indicates it will “consider” outlier analysis of QHP cost-sharing designs, such as whether drug treatments for given health conditions are assigned to the highest cost-sharing tier. No other compliance standards have been issued to date.

Unlike Medicare Advantage plans and Medicaid MCOs, the actual services in the ten EHB categories that QHPs must cover are not enumerated in statute or regulation. The statute requires the Secretary of Health and Human Services (HHS) to periodically review EHB standards, and HHS has indicated that it will monitor the benchmark/EHB system and may revisit the coverage requirements in 2016.

Federal law requires states participating in Medicaid to cover certain mandatory benefits, and states can choose to cover additional optional benefits. The underlying Medicaid program provides the primary public coverage of long-term services and supports, while only limited coverage for such benefits is provided through Medicare or Marketplace QHPs. States choose whether to deliver long-term care benefits through Medicaid MCOs.

Medicaid has the most comprehensive drug coverage requirements of plans in the three markets, and requires coverage of all FDA approved drugs (provided that the state opts to cover prescription drugs and to deliver that benefit through MCOs, which all currently do). Medicare drug plans are required to cover at least two drugs in each pharmacopeia class while QHPs need only cover one. Medicare plans are also required to provide enrollees with substantially all drugs in six protected classes of drugs while QHPs are not. Plans in all three markets may employ utilization management tools.   Medicare Advantage plans that offer drug coverage can develop their own formularies as long as protected classes and non-discrimination requirements are honored. Protected classes include cancer medications, anti-psychotics, anti-convulsants, anti-depressants, immunosuppressants, and anti-retroviral drugs. There are no similarly protected classes of drugs within QHPs but, similar to Medicare Advantage rules, benefit and cost-sharing design cannot be discriminatory. Medicare Advantage plans must also cover at least two drugs in each US pharmacopeia class, whereas QHPs must cover at least one drug per US pharmacopeia class or the same number of drugs in each class as the benchmark, whichever is greater. The protected classes are not relevant for Medicaid since Medicaid must cover all FDA approved prescription drugs for which the manufacturer has a rebate agreement, which in practice means virtually all FDA approved drugs are covered, although states can use utilization management tools, such as preferred drug lists. Starting in 2017, QHPs will be required to establish pharmacy and therapeutics (P&T) committees, similar to those required for Part D plans, to make drug coverage decisions based on scientific evidence. P&T committees will be required to review newly approved drugs and new uses for existing drugs within 90 days of market release and make coverage decisions within 180 days of market release.

Like Medicare Advantage plans, QHPs may use tiering and other utilization management tools. As noted above, benefit and cost-sharing design cannot be applied in a discriminatory manner for QHPs, though regulatory standards have not yet been issued. Recently a complaint to the HHS Office of Civil Rights was filed by patient advocates alleging that the assignment of HIV drugs to higher cost-sharing tiers under certain QHPs violates the nondiscrimination standard.⁵  Unlike Medicare Advantage plans, though, QHPs are not required to limit the application of utilization management to any classes of “protected” drugs for which plans must cover all or substantially all drugs in such classes.

For Medicaid, states elect whether to deliver prescription drugs through managed care. Medicaid programs may use utilization management and clinical effectiveness guidelines in drug coverage decisions. States may use a preferred drug list and impose quantity limits although there must be a prior authorization process for exceptions. This is a feature of state Medicaid programs rather than individual Medicaid MCOs just as protected classes in Medicare Advantage plans are a feature of the Medicare program rather than Medicare Advantage.

Cost-Sharing

Cost-sharing charged by Medicare Advantage plans is bound by actuarial equivalence with traditional Medicare – in other words, Medicare Advantage plans may impose cost-sharing that is different from that under Parts A and B, as long as total Medicare Advantage cost-sharing for Part A and B services does not exceed cost-sharing for those services in traditional Medicare.   Medicare Advantage plans must also apply actuarial equivalence to certain service categories; for example, in 2015 Medicare Advantage plans must apply actuarial equivalence to inpatient care, skilled nursing facility, home health, durable medical equipment and Part B drugs. In addition, plans’ cost-sharing for some services cannot exceed cost-sharing under Parts A and B: renal dialysis, chemotherapy and skilled nursing facility care.

QHPs must conform to actuarial value (AV) based upon the plan’s “metal level” but QHPs generally have significant leeway in how they structure deductibles and other cost-sharing (except in a few states, like California and New York, which require standardized cost-sharing designs). This leads to significant variation in cost-sharing across QHPs.   For example, for silver level QHPs in the federal Marketplace in 2015, just over half apply a comprehensive deductible for all services while 45 percent of silver plans have separate medical and drug deductibles. Among plans with separate deductibles, the average medical deductible is about $3,500, though some plans have medical deductibles as low as $0 or as high as $5,000.⁶ 

Medicare Advantage plans and Medicaid MCOs limit enrollees’ financial liability for out-of-network balancing billing, while QHPs are not required to include such protections. QHP cost-sharing protections are generally only applicable for in-network services. While QHPs are required to charge in-network cost-sharing for out-of-network emergency services, no balance billing protections are required for any out-of-network care in QHPs, including for emergency services. This means a provider may collect above and beyond the out-of-network cost-sharing amounts from enrollees if they so choose. By contrast, Medicare Advantage plans and Medicaid MCOs protect enrollees against balance billing by providers for emergency services used outside of the provider network.⁷   In general, a Medicare Advantage enrollee is protected from balance billing by non-contract providers and is limited to in-plan cost-sharing amounts for services that are covered by the plan. QHPs do not have comparable protections. Medicaid, including services offered through MCOs, offers comprehensive cost-sharing protections to enrollees, including billing protections that prevent a participating provider from refusing to provide a service due to non-payment of cost-sharing by beneficiaries with incomes at or below 100 percent of the Federal Poverty Level (FPL).

All three types of plans provide for caps on enrollees’ in-network out-of-pocket expenses. As noted above, since it is a program designed to serve individuals with low-incomes, Medicaid cost-sharing is more limited than the other two programs.   Medicare Advantage plans must establish a maximum out-of-pocket liability amount (MOOP) for all Part A and B services, established annually by CMS. In 2015, the mandatory MOOP is $6,700.⁸  There is a separate maximum out-of-pocket or “catastrophic” threshold limit for prescription drugs of $4,700 (for 2015), after which point cost-sharing is the greater of 5 percent or $2.55 for generic or preferred drugs and the greater of 5 percent or $6.35 for all other drugs. The Medicare Advantage MOOP is not indexed to inflation and has not changed in five years, while the cost-sharing threshold under Part D plans is declining annually as the “donut hole” is gradually phased out.

For QHPs, the out-of-pocket limit for 2015 is $6,600 for an individual plan and $13,200 for a family plan. This amount includes prescription drugs.   The maximum out-of-pocket limit under QHPs is adjusted each year and started at $6,350 for individuals and $12,700 for a family plan in 2014. For 2016, the maximum limit is $6,800 for individuals and $13,600 for families.

While both Medicare and QHPs provide low-income subsidies, subsidy eligibility for QHPs has higher income limits and does not impose an asset test. QHPs provide enrollees with incomes between 100 percent and 400 percent FPL ($11,770 – 47,080 in 2015) sliding scale premium tax credits which limit the amount they will pay in premiums to a set percentage of income. QHP enrollees with incomes from 100-250 percent FPL ($11,770 – 29,425 in 2015) are also eligible to receive cost-sharing subsides that lower out-of-pocket caps and deductibles.

In states that have expanded Medicaid under the ACA, adults with income up to 138% FPL ($16,242 per year for an individual in 2015) are eligible for Medicaid. Under federal law, Medicaid premiums and cost-sharing for covered services apply only to certain groups of beneficiaries and are limited in amount. Neither Marketplace financial assistance programs nor Medicaid in poverty-related (MAGI) categories, including newly eligible adults, impose an asset test.

Medicare Advantage enrollees may qualify for the same Medicare low-income programs as traditional Medicare beneficiaries. For people living below 135 percent FPL ($15,889 in 2015) with limited assets, the Medicare Savings Programs pay the Part B premium ($104.90 per month in 2015). For individuals with incomes below 150 percent FPL ($17,655 in 2015) and limited assets, the Part D low income subsidy (LIS) pays the monthly Part D prescription drug premium and lowers co-pays at the pharmacy.

Individuals who attain Medicare eligibility are no longer eligible for either Marketplace subsidies or expansion Medicaid and may face an increase in out-of-pocket costs as their insurance status, and therefore subsidy eligibility, changes. For example, a 64-year old individual with income at 200 percent FPL ($29,425 in 2015) and significant assets can access tax credits and cost-sharing subsidies to help defray the costs of QHP coverage in the Marketplace; however, no premium or cost-sharing assistance is available for the same individual through Medicare once they turn 65. Individuals with Medicaid and some with low incomes receiving Marketplace premium tax credit and cost-sharing subsides may encounter what is referred to as the Medicare “cliff” – meaning that depending upon their income and resources, they may see their out-of-pocket costs increase when they become eligible for Medicare because Medicaid for people over 65 and Medicare have more stringent eligibility requirements for cost-sharing assistance. (For more information, see Appendix B.)

Enrollment

The rules for Medicare Advantage plans, QHP, and Medicaid MCO enrollment and disenrollment partly reflect whether enrollment in managed care is mandatory, and whether an alternative source of coverage is available. Medicare Advantage enrollment, as an option for receiving Medicare services guaranteed through federal entitlement, is voluntary for Medicare beneficiaries.   Correspondingly, if a person chooses to dis-enroll from a Medicare Advantage plan, or is involuntarily dis-enrolled, the default is traditional Medicare coverage.   Since QHPs are not built on the foundation of a federal entitlement, if an individual is dis-enrolled from a QHP there is no default – they are left without coverage unless and until they can exercise enrollment rights and opportunities to gain new coverage. Medicaid also is a federal entitlement for those who meet eligibility requirements. States can choose to deliver Medicaid benefits through managed care and whether to make MCO enrollment voluntary or mandatory, except that CMS must approve the mandatory enrollment of certain populations.

Medicare Advantage and Marketplace rules generally restrict when during the year beneficiaries can enroll and dis-enroll from plans. Both markets provide for special enrollment periods (SEPs) triggered by certain events, while mandatory Medicaid managed care enrollees are allowed to change MCOs at least once per year after their initial enrollment and for “good cause” at any time. Special Enrollment Periods for QHPs emphasize the ability to enroll in coverage when someone loses other coverage, whereas Medicare Advantage SEPs work to allow individuals in to Medicare Advantage plans, out of Medicare Advantage and into traditional Medicare, or into another Medicare Advantage plan. As expected, differences in SEP rights between Medicare Advantage plans and QHPs partly reflect the fact that the “default” from a Medicare Advantage plan is traditional Medicare whereas there is no default for QHP enrollees. CMS sought to protect QHP plan sponsors against adverse risk selection and structured QHP SEPs accordingly. QHP SEPs are more broad than Medicare Advantage SEPs for life-changing events (e.g., marriage, since single v. family enrollment is a factor in QHP eligibility and enrollment, unlike Medicare Advantage) and exceptional circumstances preventing timely plan selection (e.g., serious medical condition and natural disaster; for more information about SEPs, see Appendix D).

One notable difference in SEPs between Medicare Advantage plans and QHPs concerns individuals enrolled in certain low-income programs.  Medicare Advantage plans allow an ongoing SEP right to change plans on a monthly basis for individuals enrolled in low-income programs: Medicaid, a Medicare Savings Program and/or the Part D low-income subsidy (LIS).   For Medicaid MCO enrollees, who by definition have low incomes, if states require MCO enrollment, there is an on-going SEP for the first 90 days after which time individuals are generally locked-in to their plan (for no more than 12 months). In the Marketplaces, in order to access an SEP based on a change in advance premium tax credit (APTC) or cost-sharing subsidy (CSR) eligibility, an individual must already be enrolled in a QHP. This SEP is for switching QHPs rather than enrolling in coverage for the first time.

Another notable difference in SEPs relates to changes in a managed care plan’s provider network. Starting in 2015, Medicare Advantage enrollees have a limited right to change plans based upon CMS’ finding of “significant” network provider terminations by their Medicare Advantage plans, but there is no corresponding requirement for QHPs (also see network adequacy section below). According to 2013 guidance, enrollees in Medicaid managed long-term services and supports waivers may dis-enroll from their MCO when the termination of a provider from their MLTSS network would result in disruption in their residential or employment support services.

Efficiency Standards

Medical Loss Ratio (MLR)

Medical loss ratio (MLR) refers to rules that limit the percentage of plan revenue that can be spent on administrative costs (claims administration, profit, etc.). Medicare Advantage plans must maintain an MLR of at least 85 percent/15 percent. Sanctions for failure to meet this standard can include rebates owed by the plan going back to the Medicare program, a prohibition on enrolling new members, and ultimately, termination of the plan’s contract with Medicare. Individual QHPs must maintain an MLR of at least 80 percent/20 percent with any rebates going back to the individual.   There is no federal MLR requirement in Medicaid, although states are permitted to include such a requirement in an MCO contract.

Provider Network Requirements: Adequacy, Enforcement, and Information

In the Medicare Advantage program, federal network adequacy standards and oversight are more developed than those for QHPs, while QHPs and Medicaid MCOs may be subject to more stringent state specific network adequacy requirements. Network adequacy generally refers to a plan’s ability to provide timely and adequate care to enrollees through a sufficient “network” of health care providers. Adequate plan provider networks are crucial to ensuring consumers have timely access to needed health care services. For Medicare Advantage plans, CMS has a mechanism for review of provider networks in all Medicare Advantage plans against minimum time/distance access standards and distribution of specialists. Actual review of such Medicare Advantage networks, however, occurs only when a plan is new to a service area, is expanding its service area, significantly changes its network, or if CMS receives many complaints about the network; in other words, there is no required annual review for plans renewing existing contracts with CMS. In the financial alignment demonstrations for dually eligible individuals, CMS will review the adequacy of plans’ networks annually beginning in 2015.

For QHPs, CMS implementation of network adequacy standards is evolving. In the first year, CMS required insurers to submit the “name” of the provider network (not the names of providers in the network) and attest to its adequacy. Since then, CMS has required QHPs to submit network directories, but agency review is ad hoc, focusing mainly on five provider types, and does not involve analysis against time/distance standards. CMS has suggested such review may take place in future years. CMS guidance also indicates the agency will analyze plan network data for the coming year with a focus on certain providers, which may include hospitals and primary care, mental health, oncology and dental providers. The ACA also requires QHPs and other private health plans to submit data to the Secretary on out-of-network claims and out-of-pocket expenses. These data could be used to develop measures of network adequacy; to-date, however, this provision of the ACA has not been implemented. Medicaid MCO network adequacy is left up to the states, within broad federal guidelines and with federal oversight, however plans must implement procedures to ensure that each enrollee has an ongoing source of primary care appropriate to individual needs, as well as identify people with special health care needs and ensure that they have direct access to specialists as appropriate.

Although Medicare Advantage network adequacy standards and oversight are more developed than that for QHPs, including a specified ratio of certain types of providers, Medicare Advantage plans are not bound by the QHP requirement to contract with a threshold number of essential community providers serving predominantly low-income and medically underserved individuals. 

Notice, Appeals and Grievances

All three markets require appeals processes for plan enrollees when coverage of a service is denied or terminated. However, the protection afforded to the consumer for a service denial varies widely between the three markets, with the Medicaid program offering the strongest protections for beneficiaries as a result of the property interest beneficiaries have in Medicaid benefits and the due process rights conferred on them by the Constitution.

Medicaid MCOs have very detailed notice requirements and Medicare Advantage is required to provide standardized notices created by CMS while QHPs standards mirror those for plans governed by ERISA which are less robust. Medicaid MCOs must provide written notices in accessible language and format. The notice must include detailed information, including an explanation of the adverse action with reasoning, plan appeal and state fair hearing rights, circumstances under which expedited resolution is available and how to request it. The notice must also include detailed information on the right to have services continue pending the outcome of the appeal and the circumstances under which an enrollee may be required to pay for any care received while the appeal is pending. For QHPs, notices must include a description of the service denied, reason for the denial and information about appeal rights. For denials in states with a Consumer Assistance Program (CAP), the notice must also include contact information for the CAP. Rules concerning when notice must be provided follow the Employee Retirement Income Security Act (ERISA). Medicare Advantage plans are required to issue beneficiaries a standardized notice form for all denied services which includes information on why the service was denied and appeal rights, including expedited appeals and grievances.

Because Medicaid MCOs and Medicare Advantage are built on the foundation of federal entitlement programs, their appeals processes are more federally standardized than those in QHP. The Medicare five-step administrative appeals process is uniform across the country, whereas there is variation in levels/structures of QHP appeals between states. For example, most QHP enrollees will be bound by their states’ external review laws; that is, they will be subject to state law regarding when someone other than their plan must review a service denial. State law regarding external appeals and who may serve as an external appeal body varies somewhat, though state appeals laws must meet minimum standards under the ACA or they can be preempted. In particular, ACA minimum standards require that the external reviewer must be independent, not hired by the health plan. In 8 states where the external appeals law was preempted, however, health insurers can choose on a case by case basis to use one of two federal external appeals systems – one run by HHS, where the external reviewer is hired by the federal government, or one established by the Department of Labor (DOL) for all self-funded employer plans, where the plan hires its own external review organizations.¹¹  Similar to Medicare, Medicaid MCO baseline appeal rights, including plan appeals and state fair hearings, are in federal law, although states are permitted to make some choices within the federal framework (such as the number of days to request a hearing, or whether a beneficiary must exhaust internal plan appeals before requesting a hearing).

When a timely request is made by a beneficiary, Medicaid law requires MCO services to continue pending appeal whereas Medicare Advantage plans and QHPs are not required to do so. Medicare Advantage plans provide limited continued coverage when appealing discharges from hospital, skilled nursing facilities and home health coverage, and QHPs provide limited continued coverage pending the outcome of an internal plan level appeal.

The Medicare Advantage program has a more standardized, centralized complaint tracking system compared to QHPs and Medicaid managed care complaint tracking, which differs across states. There is a federal complaint tracking system in place for Medicare Advantage plans while grievances against QHPs are filed with plans, state departments of insurance or the Marketplace and vary from state to state – there are no federal reporting requirements or data collected.  However, it should be noted that the Secretary of Health and Human Services has the authority to require reporting by plans on claims denials and appeals, but this provision of the Affordable Care Act has not yet been implemented. The basic plan grievance process for Medicaid managed care is set out in federal law and like Medicare Advantage plan’s requirements about reporting to CMS, MCOs are required to report to the state on grievances received and disposed of.

Consumer Information, Assistance and Marketing

Consumer Information

Medicare Advantage plans, QHPs and Medicaid MCOs are all required to disclose certain information to enrollees; however, Medicare Advantage plans must generally provide a broader range of information. Medicare offers a uniform plan comparison tool that provides certain information about all plans allowing for an easier side-by-side comparison (Plan Finder), including premiums, cost-sharing, supplemental benefits and quality ratings. Notably, the comparison tool does not include all information individuals may want for comparing plans, such as provider networks. While there is no comparable electronic side-by-side comparison tool for QHPs at the federal level, some state Marketplaces offer them and the standardized Summary of Benefits and Coverage (SBC) that each individual QHP is required to publish does offer consumers a uniform vehicle for plan comparison. The SBC is required of all plans (including group health plans). Each SBC must present standardized information about covered benefits and cost-sharing, as well as benefit limits and exclusions. The documents are required by law to be consumer friendly and easy to use. The SBCs also must provide consumers with standardized coverage illustrations so consumers can compare coverage under different plans for like treatment scenarios (such as an uncomplicated pregnancy).   Such a standardized comparison document does not exist for Medicare Advantage; if Medicaid MCO enrollment is mandatory, the state must provide beneficiaries with a plan comparison chart.

Consumer Assistance

QHPs have dedicated consumer assistance entities, including those to assist with enrollment and appeals, written into law, although limited funding has kept the programs from fully developing. Under the ACA, statewide Consumer Assistance Programs (CAPs) are established to provide comprehensive assistance to all state residents in answering questions about their health plans, determining eligibility for coverage and subsidies, enrollment, and help filing appeals of denied claims. The CAPs are required to be advocates for consumers. In addition, by law, CAPs must collect and report data to the Secretary on the types of help consumers need and the problems they encounter, and the Secretary and other state and federal regulators are to use data to enhance oversight. Funding for CAPs is subject to an appropriation and Congress has not appropriated new funds since the ACA was enacted. In addition, the ACA requires that Marketplaces provide for other consumer assistance with enrollment and eligibility through Navigator programs. Navigators must be funded on an ongoing basis through Marketplace operational funds. Navigators are not required to help non-Marketplace consumers, nor are they required to help consumers with appeals or other post-enrollment problems and questions. Rather, the ACA requires Navigators to refer consumers to CAPs in these circumstances.

The State Health Insurance Assistance Program (SHIP) provides a health insurance advisory service to assist Medicare beneficiaries with the receipt of services under Medicare, Medicaid and other health insurance programs. This includes help with enrollment and appeals. The SHIP program exists in all fifty states and is administered at the county level. Often, community non-profits, Offices for the Aging or long-term care ombudsmen serve as SHIPs although staff is primarily volunteer based. CMS is legislatively required to assess SHIP performance, and CMS uses data gathered by the SHIP National Performance Reporting (NPR) system.

Marketing

The Medicare Advantage program has well-developed marketing rules that plans and their contractors must follow. For example, Medicare marketing rules articulate when CMS must approve marketing materials, outline prohibited marketing practices (including marketing through unsolicited contacts), and provide for coordination with state regulators to address inappropriate marketing practices by plans and agents/brokers. While QHP marketing standards and oversight are left largely to individual states, the creation of designated Marketplaces as centralized, regulated forums to shop for and purchase insurance can serve to reduce the potential for marketing abuses sometimes seen in the individual, non-group market. To be offered on a Marketplace website, plans must submit to uniform rules about the content and display of information. Federal Marketplace regulations sets minimum standards for all Marketplaces (and are the sole standard in the Federally Facilitated Marketplace), while state-administered Marketplaces may require additional standards. Plans must also abide by federal non-discrimination rules in their marketing practices. Medicaid MCOs must get state approval of all marketing materials to ensure they do not mislead, confuse or defraud consumers and are accurate, whereas both Medicare Advantage and QHPs in most states are subject to “file and use” rules, meaning materials must be submitted to regulators but can be used after a designated time period if the regulator fails to respond.

Medicare Advantage plans, QHPs and Medicaid MCOs provide coverage for an increasing number of people and increasing shares of the insured population in the United States. Over the course of a lifetime, an individual may be covered in one, two, or all three of these insurance markets. Further, many of the same insurance companies or plan sponsors offer products in two or all three of these markets. While many consumer protections between the markets are similar, differences could both cloud consumers’ understanding of their rights in the different programs and fragment oversight by government entities and administration by plan sponsors.   Transitioning between types of coverage that have significantly different consumer protections raises issues of not only equity, but ease of administration, oversight and consumer understanding of how to use their insurance and exercise their rights. Whether these differences should be maintained warrants further review by policy makers, within the parameters of baseline protections, such as due process, that are constitutionally required for Medicaid.

There may be opportunities to both enhance and streamline oversight of plans across insurance type without sacrificing beneficiary protections since federal oversight can vary significantly across the programs. For example, as plans with oversight from both the federal government and the states, the federal government has set some standards for Medicaid managed care plans but has provided states considerable discretion – and often more discretion than it has provided to the Medicare Advantage plans. With Medicare Advantage plans, the federal government has gained considerable experience over the course of recent decades in regulating private Medicare plans, and has increased oversight and expanded consumer protections in reaction to plan behavior and market changes.

The Marketplaces are increasingly populated by the same plan sponsors offering private Medicare and Medicaid products. As a consequence, alignment of consumer protections might also ease administration by the plans offering products in two or all three markets. Likewise, closer alignment of consumer protections between these programs could potentially ease the transition of individuals from one program to another and enhance coordination when someone has more than one type of coverage. Additionally, aligned protections could foster better, more consistent understanding of program rules by consumers.

In addition to aforementioned positive aspects, there may be tradeoffs in strengthening consumer protections. For many of the consumer protections discussed, further enhancement and alignment would be low or no-cost. For example, more uniformity around enrollment periods and consumer information could be low-cost to plans, state and federal governments. However some changes, for example surrounding appeals or benefit design, could cost private plans, public programs, and potentially consumers more resources and money.

Alignment could be achieved in multiple ways, with different effects on plans, enrollees, and federal and state governments. One possibility is that an effort to align protections could cause dilution of consumer protections in favor of uniformity. Another possibility is that alignment could be based on the strongest protection in one single program, and other programs brought up to match that higher standard rather than relying on a lower floor, or a “race to the bottom.” The CMS financial alignment demonstrations for dual eligible beneficiaries offer an example of this “higher standard” uniformity, in that where there is a discrepancy in a protection between Medicare and Medicaid, the stronger protection is adopted. It should be noted that certain protections, such as due process for Medicaid beneficiaries, cannot be diluted because they arise from constitutionally protected property rights. Ultimately, better coordination across markets with an emphasis on consumer protections will help to improve health care for all participants.

Appendix A: Background on Medicare Advantage, Marketplace Qualified Health Plans and Medicaid Managed Care Organizations

Medicare Advantage (MA)

Medicare currently covers over 50 million individuals, almost a third of whom are enrolled in Medicare Advantage plans. The Medicare Advantage (MA) program, also known as Medicare Part C, is a voluntary coverage option available to Medicare beneficiaries as an alternative to the traditional fee-for-service Medicare program.¹²  Medicare Advantage coverage is offered through private insurance companies in the form of health plans, such HMOs and PPOs. An individual must affirmatively choose to enroll in a Medicare Advantage plan, and once enrolled they generally receive all their Medicare services through the plan. If a person chooses to dis-enroll from a Medicare Advantage plan, or is involuntarily dis-enrolled, they are by default enrolled into traditional Medicare coverage.

Medicare Advantage benefits, cost-sharing and other consumer protections are grounded in the federal rules governing traditional Medicare. Medicare Advantage plans must provide enrollees with coverage of all services that are covered by Medicare Parts A and B except hospice, (and, if applicable, the Part D prescription drug benefit). Medicare Advantage plans can, and are often required to, provide benefits in addition to those covered by traditional Medicare, such as vision and dental services or reduced cost-sharing.   The scope of benefits covered by Medicare Advantage generally has the same limitations as traditional Medicare (e.g., number of days covered in a skilled nursing facility); however, plans have leeway to loosen such restrictions. Medicare Advantage plans can also charge varying cost-sharing amounts, including deductibles and co-pays and, unlike traditional Medicare, provide caps on beneficiary out-of-pocket expenses. Cost-sharing in Medicare Advantage is limited by actuarial equivalency rules; in others words, in general, Medicare Advantage enrollees will not pay significantly more out-of-pocket than they would under traditional Medicare.

Medicare Advantage plans are regulated by the federal Centers for Medicare and Medicaid Services (CMS), which also administers other parts of the Medicare program. States are largely preempted from regulating Medicare Advantage plans. The Medicare Advantage program, and its predecessor Medicare+Choice, has had decades of experience operating within the Medicare program. Similarly, CMS has an established track-record of regulatory oversight of Medicare Advantage plans which continues to evolve in response to changes in the market and plan behavior.

Marketplace Qualified Health Plans (QHPs)

In an effort to expand access to health insurance coverage, the Affordable Care Act (ACA) created exchanges, or Marketplaces, through which individuals can shop for insurance coverage effective January 2014.¹³  States have the option to build and administer a fully state-based Marketplace, enter into a state-federal partnership Marketplace, or default to a federally-facilitated Marketplace (FFM) administered solely by the federal government. This brief focuses on rules governing the federally facilitated Marketplace. As of January 2015, 11.4 million people had enrolled in private insurance through the Marketplaces.¹⁴ 

Health insurance plans must be certified as Qualified Health Plans (QHPs) by a Marketplace before they may be sold to consumers. To be certified, QHPs must cover certain essential health benefits (EHB), follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meet other requirements.   QHPs are divided into 4 different categories based on actuarial value: Bronze, Silver, Gold, and Platinum, all of which must cover essential health benefits (EHBs).

Oversight of QHPs is shared by the federal and state governments.   States perform primary enforcement of federally mandated insurance market reforms that govern QHPs.   If a state cannot or will not perform such functions, however, CMS may step in. Currently, oversight and enforcement capacity at the federal level is limited – both for group health plans (DOL and Internal Revenue Service (IRS); HHS for public employer plans) – and for QHPs in federally operated Marketplaces. Note that most private coverage continues to be provided outside the Marketplace, through employer-sponsored group health plans, which are subject to federal regulation and for which most state regulation is preempted by ERISA.

Medicaid Managed Care Organizations (MCOs)

As the nation’s primary public health insurance program for people with low incomes, as of January 2015 Medicaid covers over 68 million Americans over the course of a calendar year.   It is a major source of coverage for people with low incomes and people with disabilities. Medicaid is jointly financed by the federal government and the states and administered by the states with federal oversight.¹⁵  Federal law requires states participating in Medicaid to cover certain mandatory benefits, and states can choose to cover additional optional benefits.¹⁶ 

Before passage of the ACA, federal Medicaid matching funds were available only for specified categories of people with low-incomes: children, pregnant women, parents, people with disabilities, and seniors.¹⁷  States that choose to participate in the Medicaid program must cover people in these groups with income up to federal minimum thresholds, and states have the option to expand coverage to individuals at higher incomes.

The ACA expanded Medicaid to nearly all adults under age 65 with income at or below 138 percent FPL or $16,242 per year (2015) for a single person, with no asset test, effective January 1, 2014.¹⁸  However, the 2012 Supreme Court ruling in NFIB v. Sebelius effectively made implementation of the Medicaid expansion a state choice.¹⁹  To date, 29 states, including DC, have implemented the ACA’s Medicaid expansion.²⁰ 

States can choose to provide Medicaid benefits through managed care, including managed FFS models, such as primary care case management, and private capitated managed care organizations (MCOs) that contract with the state on a risk basis to deliver Medicaid services. This brief focuses on consumer protections specific to enrollees in Medicaid MCOs. States have the option to make Medicaid managed care enrollment voluntary or mandatory for beneficiaries. However, states are required to seek CMS approval to require managed care enrollment for children with special needs, beneficiaries dually eligible for Medicare and Medicaid, and certain Native Americans. As of July 2014, 39 states including DC had comprehensive risk-based contracts with Medicaid MCOs.²¹  Among these states, 16 reported that over 75 percent of their Medicaid beneficiaries were enrolled in MCOs, and 34 states indicated that they made specific policy changes to increase their number of MCO enrollees, such as expanding voluntary or mandatory enrollment to additional coverage groups, in FY 2014 or planned to do so in FY 2015.²²  Over half of Medicaid beneficiaries nationally – mostly, children and parents – are enrolled in comprehensive MCOs; this share is growing as states expand managed care to include higher-need Medicaid populations, such as people with disabilities²³  and dual eligible beneficiaries, as well as newly eligible Medicaid expansion adults.

Appendix B: Low-Income Assistance and the Medicare “Cliff”

There are substantial differences in income and asset thresholds at which low-income assistance is available to Medicare beneficiaries and those seeking QHP coverage in the Marketplaces. For Medicare beneficiaries, including Medicare Advantage enrollees, assistance with Part A and B deductibles, coinsurance and copayments is available only to individuals with incomes up to 100 percent of the Federal Poverty Level (FPL) ($11,770 in 2015) and who meet certain asset tests. Assistance with paying the Part B premium is available to individuals with incomes up to 135 percent of FPL ($15,889 in 2015), with limited assets, and Part D premium and cost-sharing assistance is available, on a sliding scale, for individuals up to 150 percent of FPL ($17,655 in 2015) and limited assets. Assistance with Medicare Advantage premiums is limited to individuals dually eligible for Medicare and Medicaid, and only at state discretion.²⁴ 

By contrast, in Marketplaces, people with incomes between 100 percent and 400 percent FPL who have no other offer of affordable minimum essential coverage, including Medicaid, can access tax credits to defray premium costs for QHPs; there is no asset test for Marketplace tax credits. Additionally, cost-sharing subsidies are available for individuals between 100 percent and 250 percent of FPL. However, for individuals over 200 percent FPL these subsides lower the out-of-pocket cap on expenses (from $6,600 to $5,200 in 2014) but typically make only modest adjustments to other cost-sharing features, such as annual deductibles.  The Affordable Care Act made Medicaid available to more people. Now, in states that implement the Medicaid expansion, individuals with incomes up to 138 percent FPL may qualify. There is no asset test under the new financial methodology that applies to the newly eligible population as well as to other poverty-related coverage groups. Medicaid provides comprehensive coverage with very low out-of-pocket costs.

Individuals who attain Medicare eligibility are no longer eligible for Marketplace subsidies, and they may see their eligibility for Medicaid change. Individuals transitioning to Medicare from Medicaid, and to a lesser extent those under 200 percent FPL enrolled in a QHP with subsides may encounter what is referred to as the Medicare “cliff” – meaning that depending upon their income and resources, they may see their out-of-pocket costs increase when they become eligible for Medicare because of more stringent eligibility requirements for cost-sharing assistance imposed by Medicare low-income programs and Medicaid. For example, Medicaid for seniors (over 65) has a federal income eligibility limit of 100 percent FPL and imposes an asset test in most states (unless states cover seniors at higher incomes or without regard to assets through a waiver). Likewise, Medicare has more stringent eligibility requirements for cost-sharing assistance.²⁵ 

Appendix C: Detailed Table Comparing Consumer Protections for Medicare Advantage, Marketplace Qualified Health Plans, and Medicaid Managed Care Organizations

Appendix C (.pdf)

Appendix D: Comparison of Special Enrollment Period (SEP) Rights

Appendix D (.pdf)

1. See Kaiser Family Foundation Medicare Health and Prescription Drug Plan Tracker for Medicare Advantage Enrollment, available at https://modern.kff.org/data-collection/medicare-health-and-prescription-drug-plans/ Kaiser Family Foundation State Health Facts for Marketplace Enrollment, available at https://modern.kff.org/other/state-indicator/state-marketplace-statistics-2015/ Kaiser Family Foundation Medicaid Managed Care Tracker for Medicaid Managed Care Enrollment, available at https://modern.kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment/ ↩︎
2. A fifth category of “Catastrophic” plans is only available to certain consumers. These plans have somewhat higher cost-sharing, and premium subsidies are not available for Catastrophic QHPs. ↩︎
3. The statute also permits other capitated models (Prepaid Inpatient Healthcare Plans (PIHPs) and Pre-paid Ambulatory Health Care Plans (PAHPs)), which have less than a comprehensive risk contract than is required for MCOs. PIHPs include inpatient services, while PAHPs do not. ↩︎
4. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Oct. 2014), available at https://modern.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/. ↩︎
5. “NHeLP and The AIDS Institute Complaint to HHS Re HIV/AIDS Discrimination by Florida Insurers,” National Health Law Program and The AIDS Institute, May 29, 2014, available at http://www.healthlaw.org/publications/browse-all-publications/HHS-HIV-Complaint#.VE-BRhZHWkJ. For more information, see Florida Insurance Commissioner Reaches Agreement with Insurer to Protect People with HIV/AIDS available at http://www.hivdent.org/_USPublicPolicy_/2014/USPP_FICR112014.html. ↩︎
6. See e.g., “Medical and Prescription Drug Deductibles for Plans Offered in Federally Facilitated and Partnership Marketplaces for 2015”, Kaiser Family Foundation https://modern.kff.org/health-reform/fact-sheet/medical-and-prescription-drug-deductibles-for-plans-offered-in-federally-facilitated-and-partnership-marketplaces-for-2015/. ↩︎
7. For example, for MA enrollee protections concerning balance billing and emergency services, see 42 C.F.R. §422.113(b).   See 42 C.F.R. §422.214 concerning what non-contract providers can collect in payment; also see Medicare Managed Care Manual, Ch. 4, §§180 – 190.2, and Ch. 6, §100. ↩︎
8. This maximum out-of-pocket amount is for in-network services covered by Medicare Advantage preferred provider plans (PPOs); such plans have higher limits for out-of-network care. ↩︎
9. Per CMS guidance, not statute or regulation. CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs at 10 (May 2013), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf. At this time, it has not been fully incorporated in state home and community based services waivers. See, e.g., https://modern.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/. ↩︎
10. Current regulations can be read to allow MCOs to provide aid pending appeal only to the end of the current authorization period, rather than during the entire pendency of the appeal, which is problematic for individuals with on-going care needs receiving long-term services and supports. ↩︎
11. 45 C.F.R. § 147.136. Also see “Guidance on External Review for Group Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage, and Guidance for States on State External Review Processes,” DOL, June 22, 2011, available at http://www.dol.gov/ebsa/newsroom/tr11-02.html. ↩︎
12. See, e.g., “Medicare Advantage Fact Sheet,” Kaiser Family Foundation, May 1, 2014, available at https://modern.kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/. ↩︎
13. See, e.g., “Summary of the Affordable Care Act,” Kaiser Family Foundation, April 25, 2013, available at https://modern.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/. ↩︎
14. See http://aspe.hhs.gov/health/reports/2014/Targets/ib_Targets.pdf. ↩︎
15. See, generally, “Medicaid Moving Forward,” Kaiser Commission on Medicaid and the Uninsured, June 17, 2014, available at https://modern.kff.org/medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/. ↩︎
16. “Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options,” Kaiser Commission on Medicaid and the Uninsured, January 1, 2012, available at https://modern.kff.org/medicaid/issue-brief/medicaid-enrollment-and-expenditures-by-federal-core/. ↩︎
17. Unless states were granted a waiver by HHS to cover those not otherwise (categorically) eligible. ↩︎
18. The ACA expanded Medicaid to 133% FPL. However, in calculating eligibility based on the new Modified Adjusted Gross Income financial methodology, an income disregard of 5% FPL is added, making the expansion effectively up to 138% FPL. ↩︎
19. “The Federal Courts’ Role in Implementing the Affordable Care Act,” Kaiser Family Foundation, September 12, 2014, available at https://modern.kff.org/health-reform/issue-brief/the-federal-courts-role-in-implementing-the-affordable-care-act/. ↩︎
20. “Status of State Action on the Medicaid Expansion Decision,” Kaiser Commission on Medicaid and the Uninsured, as of Jan. 27, 2015, available at https://modern.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. ↩︎
21. “Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015,” Kaiser Commission on Medicaid and the Uninsured, October 14, 2014, available at https://modern.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/. ↩︎
22. Id. ↩︎
23. See, generally, “People with Disabilities and Medicaid Managed Care: Key Issues to Consider,” Kaiser Commission on Medicaid and the Uninsured, February 1, 2012, available at https://modern.kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/. ↩︎
24. See, e.g., CMS’ MMCO – CMCS Informational Bulletin entitled “Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs),” January 6, 2012, available at: www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-01-06-12.pdf. ↩︎
25. See, e.g., Leo Cuello, “Health Advocate: Understanding the Medicare Coverage Cliff,” National Health Law Program, June 17, 2014, available at http://www.healthlaw.org/publications/browse-all-publications/Health-Advocate-June-2014#.VAukQ2Nl-XQ. ↩︎