Resource: Kaiser Family Foundation Summarizes Proposed Changes to Managed Care RuleShare this page
As written by the Kaiser Family Foundation:
“Managed care is the predominant Medicaid delivery system in most states, with over two-thirds of beneficiaries enrolled in comprehensive risk-based managed care organizations as of July 2016, and millions of others covered by limited-benefit risk-based plans or primary care case management programs. On November 14, 2018, the Centers for Medicare and Medicaid Services (CMS) proposed revisions to the Medicaid managed care regulations with public comments due by January 14, 2019. CMS previously finalized a major revision to these regulations in 2016. The November 2018 proposed rule is not a wholesale revision of the 2016 final rule but proposes changes in the following key areas:
Network adequacy. The proposed rule would remove the requirement that states use time and distance standards to ensure provider network adequacy and instead let states choose any quantitative standard.
Beneficiary protections. The proposed rule would relax requirements for accessibility of written materials for people with disabilities and those with limited English proficiency; modify some provider directory requirements; and change the timeframe within which plans must tell enrollees that a provider is leaving the network. It also would let states shorten the timeframe for enrollees to request a state fair hearing and eliminate the requirement to submit a written appeal after an oral appeal.
Quality oversight. The proposed rule would revise the requirement that a state’s alternative managed care quality rating system (QRS) yield information substantially comparable to the CMS-developed QRS; clarify that health plan encounter data must include allowed and paid amounts; broaden the definition of disability when addressing health disparities under states’ managed care quality strategies; and require states to annually post online which health plans are exempt from external quality review.
Rates and payment. The proposed rule would allow states to set capitation rate cell ranges instead of a single rate per cell. It also would expressly prohibit states from varying capitation rates based on the amount of federal financial participation for covered populations or any other way that increases federal costs and from retroactively adding or modifying risk-sharing mechanisms after the start of a rating period. The proposed rule would recognize two minimum fee schedules for directed payment arrangements from health plans to providers; allow states to direct the amount or frequency of plan expenditures; codify sub-regulatory guidance for multi-year approvals of value-based purchasing models; and allow states to make new supplemental provider pass-through payments for a time-limited period when transitioning populations or services from fee-for-service to managed care.”
The link above also gives access to the more in-depth issue brief and a side by side chart of the current rule and proposed changes.