CMS Vows New Medicaid Managed Care Rules in 2015

A crackdown to ensure that Medicaid beneficiaries get accurate information about provider networks is coming in January, CMS officials vowed yesterday, according to published reports. New regulations for Medicaid managed care to be unveiled in early 2015 will ensure that consumers get timely access to care and better integration of services.

A crackdown to ensure that Medicaid beneficiaries get accurate information about provider networks is coming in January, CMS officials vowed yesterday, according to published reports.

New regulations for Medicaid managed care to be unveiled in early 2015 will ensure that consumers get timely access to care and better integration of services, following complaints and a September report from the HHS inspector general. Consumer protections, which were announced at a conference of the Medicaid Health Plans of America, will include:

  • Rules for states for how quickly patients should be able to get an appointment
  • Standards for network adequacy
  • Rules for setting rates
  • Stronger language for beneficiary protections
  • Standards to reduce disruption among Medicaid, Medicare Advantage, and insurance exchanges, as members transfer among the plans

The changes will stem from recent findings of the CMS Office of the Inspector General (OIG), which deployed common regulatory techniques used in states for years to ensure consumer access, such as cold-calling physician offices and trying to make an appointment. OIG staff found violations that included physicians listed in the networks who were not working in the practices. However, access issues are not limited to Medicare.

Mental health has also presented access issues. In New Jersey, an advocacy group earlier this month decried the lack of access to care in a survey of preferred provider organizations.

Transitions to Medicaid managed care have been marked by numerous problems, from lack of access to care to slow payment to disruptions in services for clients who had enjoyed longtime relationships with providers. Too often, critics have said, promises that managed care would bring better coordination have brought just the opposite, and instead the focus has been on trimming costs from cash-strapped state budgets.

Nonetheless, a recent survey by the Kaiser Family Foundation of state Medicaid officials found a majority of states plan to continue with expansions of Medicaid managed care in 2015, mostly to save money.

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