CMS Issues New Proposed Rule to Modernize Managed Care for Medicaid

June 4, 2015 | By

The Centers for Medicare and Medicaid Services (“CMS”) has issued a new proposed rule (the “Proposed Rule”) intended to “modernize Medicaid and the Children’s Health Insurance Program (CHIP) managed care regulations to update the programs’ rules and strengthen the delivery of quality care for beneficiaries.” As CMS continues it mission toward creating better care, smarter spending, and healthier people, the Proposed Rule will provide the first major update to Medicaid and CHIP managed care regulations in more than a decade.

CMS has utilized managed care as a cost-efficient health care delivery system while maintaining quality and access to care. Medicaid utilizes managed care through contractual agreements between state Medicaid agencies and plans that accept a pre-defined payment for the required services. Managed care has become the dominant delivery system for Medicaid, due mostly to its impact on the delivery of important health care services. As of 2011, more than half of all Medicaid beneficiaries in almost every state access at least some of their Medicaid benefits though managed care plans. In addition, the Affordable Care Act has further increased the number of individuals who are newly eligible for Medicaid.

As managed care continues to expand to more diverse roles, CMS has decided to update the Medicaid managed care regulations for the first time since 2002. The extensive Proposed Rule promotes administrative simplicity and highlights the importance of policy alignment between managed care regulations and Medicare Advantage, along with other health insurance programs.

CMS proposes to modernize the Medicaid managed care regulations in the following ways:

  • Improving beneficiary experience in enrollment, care coordination and ease of availability and accessibility of important services;
  • Encouraging state delivery system reform initiatives within managed care programs in order to improve health care outcomes;
  • Requiring a state wide quality strategy for the whole Medicaid program, with a focus on transparency and alignment with other heath care programs;
  • Aligning the CHIP managed care regulations with the Medicaid rules to ensure beneficiaries receive the same quality and access across the managed care spectrum; and
  • Implementing best practices identified in current long-term services and supports programs.

The Proposed Rule would improve beneficiary communications and access, provide new program integrity tools to increase transparency and support state efforts to deliver higher quality care in a cost-effective way. Overall, CMS intends to update Medicaid regulations and best practices to better align with the recent changes in the delivery of health care services in the managed care field and enhance overall beneficiary experience.

To read the Proposed Rule, click here.

To read the CMS Fact Sheet, click here.

For more information on Medicaid managed care, click here.

Anthony Knapp is a guest contributor to Health Law Gurus™. He received his J.D. from Widener University School of Law, where he was editor of the Health Law Colloquium. He previously clerked in the Philadelphia Court of Common Pleas and worked as a Navigator to facilitate consumer access to health insurance in Delaware.