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Medicaid Managed Care

Medicaid Managed Care

As states struggle to address growing deficits, states have increasingly explored managed care models in Medicaid programs. Under a managed care model, Medicaid agencies contract with private health plans or other organizations to deliver and manage a recipients’ care. The plan/organization pays providers a capitated rate for services. 

While managing care from a medical benefits perspective is not of significant concern for our community, capitating clotting factor therapies can negatively impact the standard of care and treatment of those affected by bleeding disorders. Furthermore, it can have the exact opposite effect of managing health care costs for a Medicaid program. 

In the past, NHF, local chapters and associations, and our stakeholders, have been successful in working with states to “carve out” clotting factor from managed care programs. This means that clotting factor was still covered by Medicaid, but paid for under the traditional fee-for-service model. By doing so, states remained eligible to receive a refund on the reimbursement (“federal rebate”) from manufacturers.

However, the Affordable Care Act (ACA) now allows states to capture federal rebates for many drugs paid for through a managed care model. Thus, we may see states either: (1) eliminate existing carve outs; or (2) refuse to consider such carve outs in newly implemented managed care programs.  In doing so, states will continue to receive federal rebates and keep managed care organizations’ fees capitated, which could result in potentially insufficient rates to cover the significant cost of clotting factor.

NHF remains committed to working with local chapters and associations and our stakeholders to educate state Medicaid agencies about the potential impact capitation may have on our community.   

Learn about NHF’s position on capitation of clotting factor.