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Transitions and Continuity of Care: A Discussion of Marketplace, Medicaid, and CHIP Issuers' Decisions and Strategies
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Transitions and Continuity of Care: A Discussion of Marketplace, Medicaid, and CHIP Issuers' Decisions and Strategies

Published: Nov 03, 2014
Publisher: Ann Arbor, MI: Mathematica Policy Research
Health Medicaid and CHIP Research & Evaluation Policy Analysis

Authors

Cara Orfield

Michael Barna

Lauren Hula

Key Findings

Key Findings:

  • Existing commercial, Medicaid, and Children’s Health Insurance Program (CHIP) issuers chose to offer coverage through the Marketplace because their organizations perceived it to be an exciting business opportunity. Most issuers interviewed decided to participate early on, sometimes before knowing details about how their states would implement their Marketplaces (such as whether they would opt out of the Medicaid expansion, or the type of Marketplace to be offered).
  • Provider network development is a concern mainly for Marketplace plans: all of the issuers interviewed that offer Medicaid and CHIP coverage reported that their networks had been established for many years and that, at this point, active provider recruitment was quite limited. Issuers with products across programs recognized that offering overlapping networks has many benefits, and that their approach to contracting with providers—whether offering participation in all product networks to all providers or undertaking selective contracting with them—affected the degree of overlap across those networks.
  • Continuity-of-care laws are important policy mechanisms that help ensure smooth transitions for individuals with serious medical needs; issuers reported that they were in compliance with these laws. California is the only state in our study currently considering bridge plan legislation, and issuers were uncertain about this approach.
  • Marketplace issuers gained insight into consumer behavior and decision-making processes during the first open enrollment period, but some drew different conclusions about the importance of price and provider choice. All of them entered the first open enrollment period thinking that “price was king”—some issuers found this assumption was validated, whereas others were surprised at the number of consumers who appeared to make their selection based on brand, quality, or other factors.

This report is the second in a two-part study aimed at learning more about how easily individuals can maintain their primary care physicians as they transition across programs. In this report, we explore in more depth the reasons behind issuer decisions on program participation and provider network design, how they respond to and perceive the federal and state regulatory framework in which they operate, and major lessons learned during the first open enrollment period. Existing commercial, Medicaid, and Children’s Health Insurance Program (CHIP) issuers chose to offer coverage through the Marketplace because their organizations perceived it to be an exciting business opportunity. Issuers with products across programs recognized that offering overlapping networks has many benefits, and that their approach to contracting with providers—whether offering participation in all product networks to all providers or undertaking selective contracting with them—affected the degree of overlap across those networks. Policy mechanisms have been enacted to help ease transitions, including continuity-of-care laws and bridge plan legislation.

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