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Thursday, May 28, 2015

New Medicaid Managed Care Proposed Rule Is Out

Andrea Callow

Associate Director of Medicaid Initiatives

On May 26, the Centers for Medicaid and Medicare Services (CMS) released a long-awaited proposed rule that seeks to modernize the regulatory framework governing Medicaid managed care plans. The proposed rule aims to increase efficiency in the managed care program for providers, enrollees, and health plans, while maintaining consumer protections. 

A steadily increasing number of Medicaid enrollees receive all or some of their care through private managed care plans. In fact, more than half of all Medicaid beneficiaries are currently enrolled in a managed care plan. And enrollment isn’t the only thing expanding in Medicaid managed care; the types of services offered through managed care are growing. More states are now choosing to provide Medicaid services that were traditionally only delivered through fee-for-service (like long-term services and support like adult day care and home health aide services) through managed care. 

Since the rule was last updated in 2002, the health care landscape has changed tremendously both within and outside the Medicaid program. The proposed rule aims to improve Medicaid managed care for enrollees and participating health plans by aligning rules on appeals, medical loss ratio requirements, and enrollment (among others areas) with Medicare Advantage and qualified health plans offered in the marketplace. Increased regulatory alignment can serve to ease enrollee transitions from one source of coverage to another and make oversight and compliance simpler for plans and the government. 

The rule, which will be published in the Federal Register on June 1, has a 60-day comment period (comments are due August 1 and can be submitted electronically through Families USA will review and comment on the proposed rule. 

Highlights for consumer advocates include: 

Provider network adequacy: The proposed rule would implement time and distance standards for primary and certain specialty care providers. This would limit how far a plan can require one of its enrollees to travel before agreeing to cover care from an out-of-network provider (considering it “in-network”). Families USA will draw on its extensive work in the private market when commenting on the rule’s network adequacy requirements. 

Care coordination: The proposed rule seeks to improve managed care plans’ care coordination role by setting new standards for treatment plans and health risk assessments. Plans would be required to coordinate and facilitate transitions between care settings (for example, from a hospital to a nursing home) and would be encouraged to ensure enrollees complete a health risk assessment within 90 days of enrollment. 

Enrollment: There are currently few minimum requirements related to plan enrollment processes. The proposed rule would establish a 14-day plan selection period to allow Medicaid eligible individuals time to evaluate plan options and would establish an independent options counselor to assist consumers in their choice. 

Quality: The rule proposes an updated regulatory structure to improve quality and support delivery system reform. This includes enhanced state and federal quality review, as well as a star quality rating system for enrollees, similar to that for Medicare Advantage.

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