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Comprehensive Summary of Federal Medicaid Managed Care "Mega" Rule Now Available

A comprehensive summary of the new federal Medicaid managed care regulations, prepared by our attorneys at Hinman Straub, is available here. The memorandum includes, among other items, a summary of provisions governing:

  • managed care plan rate development;
  • calculation and reporting of medical loss ratios;
  • enrollment and marketing;
  • contracts between managed care plans and states, including provisions requiring that home and community-based services be delivered in compliance with the home and community-based settings rule;
  • program integrity;
  • appeals and grievances, including the reinstatement of the internal appeal exhaustion requirement prior to a fair hearing and new timeframes for notices, requesting appeals and fair hearings, and resolution of appeals;
  • care coordination, including the requirement that plans ensure that all providers share an enrollee health record;
  • network adequacy;
  • quality assurance and performance improvement, including special requirements related to transitions of care and critical incidents for managed care plans covering long term services and supports; and
  • dissemination of information to members and potential members, including new standards that reflect the use of the internet and email.

The complete text of the final rule is available here. LeadingAge New York's highlights of the provisions affecting long term care providers and plans are available here. The Centers for Medicare and Medicaid Services has provided summaries of selected provisions here.

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