powered by LeadingAge New York

CMS Releases Final Medicaid Managed Care “Mega Reg”

CMS has released a preview of the first comprehensive revision of the federal Medicaid managed care and Child Health Plus (CHIP) regulations in more than a decade. The final rule will be published officially on May 6th.

The regulations cover a broad range of issues including: managed care rate development and Medical Loss Ratio (MLR) standards; managed care enrollment and disenrollment; continuity of care upon managed care enrollment; network adequacy; stakeholder engagement in managed long term care programs; enrollee rights; grievances and appeals; continuation of services pending appeal and fair hearing; a new Medicaid managed care quality rating system; and program integrity. Summaries of selected portions of the final rule are available here.

To promote the alignment of requirements across different managed care products, and to ensure that capitation rates are actuarially sound, the final rule requires that Medicaid and CHIP managed care plans calculate and report an MLR beginning in 2017. The final rule's standards for calculating the Medicaid and CHIP MLR are generally consistent with the standards for Medicare Advantage plans. The final rule further requires that capitation rates be developed in a manner to allow managed care plans to achieve at least an 85 percent MLR. States may, but are not required to, elect a minimum MLR. If they do so, the MLR can be no lower than 85 percent.

General requirements specific to managed long term care programs (referred to as Managed Long Term Services and Supports (MLTSS) programs), under the final rule, include:

  • a framework for engaging stakeholders in the ongoing monitoring of MLTSS programs;
  • payment methodologies that seek to improve population health, beneficiaries’ experience of care, and community integration of benificiaries, while controlling costs;
  • an independent system of choice counseling, along with other supports to help individuals navigate the managed care system;
  • person-centered processes to ensure that beneficiaries’ medical and non-medical needs are met and that they have the quality of life and level of independence they desire;
  • standards for coordination and referral by the managed care plan to ensure that the beneficiaries' service plans are comprehensive;
  • standards for the adequacy of the networks, the qualifications and credentialing of providers, and the accessibility of providers to meet the needs of beneficiaries;
  • participation in efforts to prevent, detect, and report critical incidents that adversely impact beneficiary health and welfare; and
  • MLTSS-specific quality initiatives.

The final rule incorporates, as proposed, the previously-adopted home and community-based settings (HCBS) regulations into Medicaid managed care programs. CMS considered, but did not grant, stakeholder requests for an extended transition period to allow long-term care settings to come into compliance with the HCBS standards. Rather, it incorporated the transition period set forth in the HCBS settings rule into the managed care final rule.

A more detailed summary of the final rule will be made available in the near future. LeadingAge New York’s summary of the proposed rule is available here. Our comments on the proposed rule are available here.

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