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

Executive Summary
  1. See Kaiser Family Foundation Medicare Health and Prescription Drug Plan Tracker for Medicare Advantage Enrollment, available at https://www.kff.org/data-collection/medicare-health-and-prescription-drug-plans/ Kaiser Family Foundation State Health Facts for Marketplace Enrollment, available at https://www.kff.org/other/state-indicator/state-marketplace-statistics-2015/ Kaiser Family Foundation Medicaid Managed Care Tracker for Medicaid Managed Care Enrollment, available at https://www.kff.org/medicaid/state-indicator/total-medicaid-mc-enrollment/

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Introduction
  1. 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.

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  2. 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.

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Comparison of Specific Areas of Consumer Protections
  1. 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://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.

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  2. “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.

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  3. See e.g., “Medical and Prescription Drug Deductibles for Plans Offered in Federally Facilitated and Partnership Marketplaces for 2015”, Kaiser Family Foundation https://www.kff.org/health-reform/fact-sheet/medical-and-prescription-drug-deductibles-for-plans-offered-in-federally-facilitated-and-partnership-marketplaces-for-2015/.

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  4. 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.

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  5. 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.

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  6. 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://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/.

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  7. 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.

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  8. 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.

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Appendices
  1. See, e.g., “Medicare Advantage Fact Sheet,” Kaiser Family Foundation, May 1, 2014, available at https://www.kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/.

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  2. See, e.g., “Summary of the Affordable Care Act,” Kaiser Family Foundation, April 25, 2013, available at https://www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/.

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  3. See http://aspe.hhs.gov/health/reports/2014/Targets/ib_Targets.pdf.

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  4. See, generally, “Medicaid Moving Forward,” Kaiser Commission on Medicaid and the Uninsured, June 17, 2014, available at https://www.kff.org/medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/.

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  5. “Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options,” Kaiser Commission on Medicaid and the Uninsured, January 1, 2012, available at https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-expenditures-by-federal-core/.

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  6. Unless states were granted a waiver by HHS to cover those not otherwise (categorically) eligible.

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  7. 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.

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  8. “The Federal Courts’ Role in Implementing the Affordable Care Act,” Kaiser Family Foundation, September 12, 2014, available at https://www.kff.org/health-reform/issue-brief/the-federal-courts-role-in-implementing-the-affordable-care-act/.

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  9. “Status of State Action on the Medicaid Expansion Decision,” Kaiser Commission on Medicaid and the Uninsured, as of Jan. 27, 2015, available at https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  10. “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://www.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/.

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  11. Id.

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  12. 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://www.kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/.

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  13. 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.

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  14. 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.

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