12 Years in the Making – Rules Guiding Medicaid Managed Care are Getting a Makeover
At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago!
Discussions surrounding the update were focused on three main themes:
- Aligning Medicaid Managed Care with other public programs
- Payment and accountability
- Network adequacy
Aligning with other programs — This could take many different shapes and sizes. Certainly the well-established program guidelines of Medicare Advantage could become very prominent. In contrast, the newly evolving rules of the Exchange Marketplace could be drawn more into the spotlight. Being that Medicaid beneficiaries sometimes align with Medicare Advantage and sometimes with Exchanges, this is likely to draw a lot of comments from the industry when released in the coming months.
Regardless of how you think it should be done, the rationale to better align all of these programs makes good sense for both beneficiaries and the managed care plans that serve them. Beneficiaries can have common experiences; families with multiple program enrollments have an easier time navigating the system; and plans reduce unnecessary administrative burden to administer multiple programs.
Payment and accountability — Several hot button items are involved in this theme. All of these involve modernizing the regulation to the current day environment.
- Using data to think about issues related to rate setting and rate review
- Using program dollars wisely, as more is at stake as the program continues to evolve and grow
- Integration of long-term services and supports into the regulation
Network adequacy — The OIG recently released a report identifying significant variation between states as it relates to access to care, and how those standards are being checked on a regular basis. With the recent significant growth in Medicaid Managed Care enrollment, this becomes even more concerning. We can expect CMS to take a strong stance on access to care issues including network composition, availability of primary care and specialists, and provider directory issues. As a major beneficiary protection issue, we also expect this area to draw a lot of comments from the beneficiary community.
We are very anxious to see the draft regulation and the “give and take” it is going to provide to the industry. With 12 years worth of ideas baked into it, it should be a fun ride!
Resouces
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