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New Lewin Report Shows Need for National Medicaid Out-of-Network Claims Policy
Date:7/16/2009

care rendered to Medicaid enrollees. Federal legislation has successfully addressed this problem in the Medicare Advantage program and with Medicaid emergency care. Our study finds that it is important to fix this loophole for all remaining Medicaid out-of-network care as well."

"We need a solution that is fair, predictable, and encourages providers to contract with health plans," said Thomas Johnson, executive director of MHPA. "Contracting with providers is always the preferred scenario for Medicaid health plan members to realize the full benefits of care coordination. In the small subset of claims that are out-of-network, we support Lewin's recommendation to set payments at fee-for-service rates. A national policy setting all out-of-network payment at each state's underlying Medicaid fee-for-service rates would reduce cost for health plans, Medicaid and taxpayers. It would also align Medicaid policy with Medicare. A clear, consistent policy would advance the goals of our health plans, which is to provide broad access to providers that are culturally competent and convenient for their members in their communities," said Johnson.

Section 6085 of the Deficit Reduction Act of 2005 (Pub. L 109-171), also known as the "Rogers Amendment," set payment for emergency services provided by Medicaid health plan out-of-network providers at the Medicaid fee-for-service rates in each state. Lewin found the policy has generally been effective in establishing reasonable payments for out-of-network emergency services and in preventing disputes over payments.

Contact: Karen Seidman; karen@seidman-says.com; (202) 364-8134


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SOURCE Medicaid Health Plans of America
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