Medicaid Rule Imposes New Standards for Beneficiary Access

Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage.  However, as mentioned by GHG’s Sunmi Janicek, it would not be without challenges.  The compliance costs for Medicaid plans with the increase in diligence needed in identifying & documenting costs incurrent to improve quality could be high.  Additionally, the CMS proposed rule would impose new standards for beneficiary access and availability to the MCOs provider network.

As with our Medicare Advantage clients, GHG can assist plans by doing a deep dive into their MLR cost drivers, such as poor-performing providers within their participating network, while balancing the requirements for a robust, accessible provider network for beneficiaries.  Once we have identified the key cost drivers, we can work with plans to do the following:

• Develop forward looking budget assumptions for benefit premiums, project clinical utilization and provider reimbursement budgets
• Develop clinical & financial performance metrics designed to bring performance in line with expectations
• Develop strategies around how to best impact provider practice patterns, access, treatments, referrals and coordination of care
• Design network modifications based on clinical & financial performance
• Develop performance based payments for provider reimbursements benchmarked to clinical & financial outcomes metrics

Reaching these goals will require the formation of great partnerships between the plan and providers.  Plans will want to reach out to provider partners that share their same goals and incentives and secure strong leadership and physician champions to lead the charge.  We know the transformation will not be easy. The shift from fee-for-service to value based reimbursement, facing the social services, behavioral health needs of the population, and developing the analytical capabilities to support these changes are challenges that Medicaid managed care plans will face under the proposed rule.

GHG is here to help navigate you through the steps.

Please reach out if we can assist you with any of the following:

• MLR Analysis
• Provider Integration strategies
• Reimbursement strategies
• Risk Assumption strategies
• Network Adequacy compliance

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Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement.As states begin to increase oversight activities and implement more robust compliance and fraud waste and abuse practices, our expertise in compliance program development will be an asset to any organization. Contact us today >>