How Providers Can Help Increase Transparency Into Policy Plans

While doctors and dentists are on this this earth to help us live long and healthy lives, that often does little to ease the anxiety that many feel when visiting their office. In fact, increased levels of stress almost always accompany a visit to either the doctor or dentist’s office, in addition to a corresponding elevated blood pressure reading. The process can be made easier and more settling, however, when these same doctors and dentists properly educate their patents about new processes and policies being incorporated into the insurance.

Much of the anxiety that occurs when needing to go the dentist or doctor revolves around cost. Many simply do not know how, or if, they will be able to pay for any medical procedures that become necessary. They cannot understand their insurance policy, and are unsure of where to even go for help. For this reason alone, a staggering number of Americans simply stay away from the Doctor or Dentist’s office altogether until it is often too late. There are, however, certain things that insurance providers can due to help increase transparency within their policy plans.

Transparency Made Easier Under the Affordable Care Act

One of the final rules implemented as a provision within the Affordable Care Act was a requirement that all health plans now should provide consumers with a uniform summary of coverage. This applies to those people currently enrolled in a place, as well as new applicants. This is a step in the right direction, as it now ensures that individual dental insurance is transparent and easy to understand. Benefits and provisions of coverage should be more clearly spelled out of individuals, and this will make it easier for them to determine what is and is not covered, and to what extent.

In this regard, providers can help to ease the stress and anxiety that many consumers feel over health and dental insurance related issue. In the past, it was felt that many individuals faced too many choices when dealing with insurance policies, and that they were not adequately informed as to how coverage actually works. One survey even found that people would prefer to go to the gym or even work on their taxes than take the time to read through earlier versions of health insurance policies.

The Transparency of Coverage Disclosures

Most insurance policies must now disclose any information that would enable consumers to better understand how their particular plan will reimburse the claims that are made for covered services, and whether or not a service would actually be covered under the existing policy. In essence, the following information must be disclosed in a transparent and easy to understand manner:

• Polices and Practices Related to the Payment of Claims
• Financial Disclosure to be Made on a Periodic Basis
• Data Enrollment Must be Disclosed
• Data Account For Those Who Unenroll Must Be Disclosed As Well
• Information on the number of claims that are denied in the end
• Information about rating practices
• Data related to cost-sharing and payments, particular in terms of out-of-network coverage that is available
• Data of the rights afforded to enrollees and participants under the terms of the policy

All of the information mentioned above is to be written in clear English that is geared specifically to the consumer, and should be designed for people who have limited proficiency in the language. This effectively makes it easier for individuals to understand their policy and what they should expect from the insurance provider.

While there will likely still be a great deal of anxiety associated with visits to the doctor or dentist, this will be lessened somewhat with the advent of these new policies. Knowing what is covered and how the benefits will be paid can go a long way towards not only lessening the financial burden on the individual, but also towards making the process much more streamlined and comfortable in the end.



About the author:

Greg Dastrup is a world traveler and professional writer with a passion for learning new languages. He’s spent most of his career consulting for businesses in North America. You can follow Greg here.

The Implications of the Mega-Reg on the Medicaid Managed Care Industry: 2016 & Beyond

2016 is a year of transformation for the healthcare ecosystem - over the past year we’ve seen the implementation of major ACA provisions, delivery system reforms, payment reforms, and states pursuing better value. There’s been a recent shift away from taking a budget-driven approach, and is now driven by the desire to improve quality and outcomes. The implications will be huge and will go beyond Medicaid. 

We’ve had a short Q/A with Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations, Association for Community Affiliated Plans (ACAP), who will also be chairing and presenting at the Medicaid Managed Care Congress in May. 

What upcoming major trends are you excited about? 

Medicaid is undeniably undergoing a great deal of change right now, and there are many advancing trends keeping all Medicaid policy analysts on our toes. One of the most exciting, from my perspective, is efforts by Medicaid health plans to impact social determinants of health and to integrate within the health plan help for people to get jobs, housing, nutritional support, even support as they leave the criminal justice system. A substantial number of ACAP member plans are doing important work in these areas, as described in a fact sheet we produced in 2014. Efforts by health plans to impact social determinants underscore that 
our collective goal is to improve the health and well-being of people covered in Medicaid.

Secondly, I’m excited to learn about efforts by plans, states, and providers to look at improving quality of health at the population level. Again, these efforts offer a great opportunity to improve the health of the entire nation, given how expansive a coverage program Medicaid is. 

What do you think will be the major implications of the Mega-Reg? 

If finalized the way we at ACAP hope, the Mega Reg will erase any lingering questions about the crucial role MCOs play in Medicaid, leading the way to greater emphasis on the partnership between states and plans. I hope, for example, that CMS will require transparency between states and plans in general, and in particular with regard to the rate-setting process to ensure that all rates are set and approved in a timely and comprehensible manner. Also, I would like to see CMS move toward payment and coverage models that use MCOs to promote population health. Lastly, I would like to see movement toward standardized quality measurement that allows us to learn what Medicaid pays for, not just in MMC, but FFS as well.

Do you have any best practices of success stories you’d like to share? 

My colleagues at ACAP worked with a subset of ACAP plans last year on a substance use disorder collaborative, which resulted in this toolkit, which is available publicly for other health plans to use. This toolkit provides best practices for plans working with individuals impacted with SUD, including opioid addiction. It’s an example of how effectively and quickly Medicaid MCOs can respond to a significant population health problem. We are very proud of these plans’ efforts. 

For MMCC, what do you hope to learn more about? 

I am looking forward to hearing from the real experts about quality in Medicaid managed care and Medicaid. I am anxious to gain insights about how best to coordinate and standardize the myriad quality measurement and reporting efforts so that we can get on with the business of using results to improve care for people, and to improve Medicaid overall, and CHIP as well. While it’s fascinating to see the efforts many states are making to report on the adult and pediatric core measures sets (the CMS 2015 Annual Report on the Quality of Care for Adults in Medicaid and 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP were released in February of this year), I feel strongly that we all can do more to ensure that quality of care for Medicaid and CHIP enrollees is measured, reported, and improved.

Learn about the implications of the new regulations and beyond by joining the Medicaid Managed Care Congress (MMCC) in Baltimore, MD (May 18-20, 2016.) For more information about MMCC 2016 visit the website here.

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Four Major Managed Care Industry Concerns by Jennifer Babcock (ACAP)

The managed care landscape is evolving with the elections around the corner and the Mega-Reg stipulated to release. There is a lot going on in the industry. Read about the four major concerns of the industry by Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations, Association for Community Affiliated Plans (ACAP):


1.    ACAP’s member plans are very innovative and nimble Safety Net Health Plans that have demonstrated a clear dedication to their enrollees, their communities and to safety net providers. Some Safety Net Health Plans have participated in Medicaid in their states for decades. The move toward consolidation in the industry poses a threat to this commitment, so one of ACAP’s primary goals is to provide support for and create efficiencies for these plans.

2.   The continued lack of an Affordable Care Act Medicaid expansion in many states has produced a drastically inequitable coverage system with multiple negative impacts on people, providers, and states alike. I’m heartened, though, to see the efforts our members and many others are making in those states to encourage governors and state legislatures to expand.

3.   Despite progress, it is still so difficult for people to access all the services they need to thrive, including not only health services, but services addressing social determinants of health as well. Many ACAP health plan members have moved boldly into this area by providing linkages to housing, nutrition, and employment services. CMS has provided leadership in this area as well – one example is last year’s guidance related to how Medicaid programs can fund housing activities.

4.   The continued fragmentation of coverage and care complicates health care for families. Many of the families our plans serve are split between Medicaid, CHIP, Marketplace coverage, and Medicare. Certainly, plans can and do make the choice to operate in all of these programs to address overlap for families, but participation by plans in multiple programs is not a sure thing, and it is not an easy lift, particularly for Safety Net Health Plans. There aren’t always clear incentives for them to do so, which can mean that single families can have to manage two or more sources of coverage, networks, and so on. CMS’ efforts to align requirements across programs is appropriate and useful, although more work needs to be done in this area. Ultimately, enrollee families will benefit.



Hear more from Jennifer Babcock as she will be chairing and presenting at the Medicaid Managed Care Congress (MMCC) 2016, Baltimore, MD with the session "Dive Deep into the Implications of the Mega-Reg"

Download the brochure to see the most up-to-date agenda for the MMCC here.

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