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CMS Proposes New Medicaid Managed Care Regulations

The Centers for Medicare and Medicaid Services (CMS) proposed new regulations governing Medicaid and Children's Health Insurance Program (CHIP) managed care programs last week. The proposed regulations are intended to reduce administrative burdens while creating more flexibility for states to address local circumstances and populations. They are the product of a working group convened by CMS to respond to certain criticisms of the comprehensive Medicaid and CHIP managed care regulations adopted in 2016. The proposed regulations address managed care rate setting, network adequacy, communications with beneficiaries, fair hearings and appeals, network adequacy, and quality measurement and include the following provisions, among others:

  • Greater flexibility for states in developing and certifying managed care premiums.
  • Prohibiting states from retroactively adding or modifying risk-sharing mechanisms.
  • Regulatory authority for states that are shifting populations and services into mandatory managed care programs to implement a three-year transition period for existing fee-for-service payment arrangements to come into compliance with requirements related to pass-through payments.
  • More flexibility in network adequacy standards by replacing time and distance standards with other quantitative standards that can take into consideration alternative service delivery models, such as telehealth.
  • Elimination of the requirement that enrollees submit a written appeal after an oral appeal is submitted.
  • Changing the timeframe for requesting a fair hearing to no less than 90 calendar days and no greater than 120 calendar days.
  • Permitting quarterly, rather than monthly, updates to managed care plan paper provider directories, if the plan offers a mobile-enabled provider directory.
  • More flexibility in the timing of enrollee notices of provider terminations by allowing plans to send the notices by the later of 30 calendar days prior to the effective date of the termination or 15 calendar days after the receipt or issuance of a termination notice.
  • Allowing states greater ability to establish a state-customized Quality Rating System (QRS) for managed care plans while implementing a minimum set of federally-required measures.

A fact sheet on the regulations is available here. The proposed rule is available here. Comments on the proposed regulations are due on Jan. 14, 2019 and may be submitted here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124