How CMS proposes to align Medicaid managed care with private plans

Among the many provisions in the newly finalized rule for Medicaid managed care, the federal government seeks to align MMC regulations with ones that govern other privately managed plans.

This standardization makes sense, health policy expert Tim Jost writes in a post for Health Affairs Blog, as many large insurers offer MMC plans, Medicare Advantage plans and Affordable Care Act qualified health plans alike. In addition, many beneficiaries switch between Medicaid plans and QHPs.

 In a fact sheet about that particular facet of the finalized rule, the Centers for Medicare & Medicaid Services outlines areas in which it will align Medicaid managed care with both QHPs and Medicare Advantage. They are:

Medical loss ratio: The rule cements a controversial regulation that sets a target MLR of 85 percent for Medicaid managed care plans. The standards for calculating MLR are consistent with MA and private market plans, CMS says, "with some variation to account for the unique characteristics of the Medicaid and CHIP programs." For his part, Jost notes that MLRs function a bit differently in MMC plans than for those in the private sector, so when setting capitation rates, states must consider both whether MLRs are too high or too low.

Appeals process: The rule aligns definitions and timeframes for the resolution of appeals, streamlines levels of internal appeals and requires beneficiaries to use a managed care plan's internal process before proceeding to a state hearing with a complaint about an adverse benefit determination. This, CMS says, "allows health insurers to adopt more consistent protocols across product lines and markets."

Consumer information: The rule includes a host of consumer information requirements, including mandating that managed care plans include provider directories and drug formularies on their websites, as well as permitting states and MMC plans to communicate with beneficiaries via mail, email and website postings. Many of these requirements closely parallel those that govern private market plans, Jost notes.

Provider screening and enrollment: The rule requires that all providers in Medicaid, who order, refer or furnish services under the managed care program are appropriately screened and enrolled--but it doesn't require that providers in MMC networks also participate in the state's Medicaid fee-for-service program. The regulation, CMS says, will result in administration and cost efficiencies by eliminating duplicate screening processes.

To learn more:
- here's the fact sheet
- read Jost's post

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