Final Medicaid Managed Care Rules

CMS released a proposed overhaul of the regulations governing Medicaid and CHIP Managed Care last May and accepted comments through July. In addition to their sweeping impact, these rules are particularly meaningful as they are the first major changes to the rules governing Medicaid Managed Care since 2002.

As states agencies and others review the final regulations, we are sharing a summary of the proposed regulations that we first released last summer. The proposed regulations seek to modernize the rules in light of the expanded use and scope of managed care in Medicaid programs across the country. Among a few of the notable changes, the rules:

  • Seek to align Medicaid Managed Care with other coverage, particularly Medicare Advantage plans and Qualified Health Plans (QHPs);
  • Require states to adopt provider network adequacy standards for Medicaid Managed Care;
  • Amend appeals standards;
  • Require reporting of medical loss ratios by Medicaid Managed Care plans; states that have minimum MLRs must set that minimum at or above 85%;
  • Allow for consideration of short term stays in Institutions for Mental Diseases in setting capitation rates;
  • Set new standards for auto-assignment; and
  • Require adoption of Comprehensive Quality Strategies across all Medicaid programs.

For a comprehensive summary of the proposed regulations, click here. And, stay tuned for a summary of the final regulations. On April 25, 2016 the final regulations were released, and as mentioned above, we will be circulating more information soon. The final regulations can be found here.

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