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Major Medicaid Managed Care Changes Follow Medicare Ones

Following major changes in Medicare Advantage (MA) and Part D, the Centers for Medicare and Medicaid Services (CMS) finalized a number of rules impacting Medicaid, but specificially managed care. With the vast majoirty of Medicaid beneficiaries in managed care, CMS is targeting numerous prorgams to the managed care programs in states. 

What are the major changes impacting Medicaid managed care?

Waiting times/access

  • Minimum appointment wait times standards are set, including 15 business days for routine primary care and obstetrics/gynecology and 10 business days for outpatient mental health and substance abuse.
  • An independent secret shopper program to validate wait times as well as provider directory accuracy is required.
  • States will need to implement a remedy plan for any managed care plan that needs improvement in meeting required access standards.

Rates, spending, and transparency

  • Medicaid managed care plans must share Medicaid rates and compare them to Medicare fee-for-service (FFS) ones.
  • There are numerous changes to how state-directed payments (usually to state-run or affiliated institutions) operate in the Medicaid managed care program.
  • The rule changes various calculations for the minimum medical loss ratio (MLR) requirement.
  • There are new clarifications and restrictions on the use of In Lieu of Service and Setting (ILOS) 
  • The rule aligns most state chidlren’s health (CHIP) policies with Medicaid.
  • Requires publication of Medicaid FFSand a comparison to Medicare FFS.
  • Requires publication of home and community-based care waiting lists.

Quality and satisfaction

  • Member satisfaction surveys must be conducted.
  • States need to maintain a single web page that is readily identifiable to the public, easy to use, and contains required information for public transparency.
  • Establishes each state to have a one-stop website for Medicaid and CHIP quality information.  The site also includes other plan information to facilitate decision-making.
  • Reforms Quality Strategy and External Quality Review (EQR) processes.
  • Further clarifies the requirements and minimum measures for a state Medicaid and CHIP quality rating system.
  • Outlines changes to the  Medicaid Advisory Committee and Beneficiary Advisory Council.

Nursing homes

The Biden administration finalized numerous changes impacting nursing homes, including minimum staffing requirements and directing that 80% of all payments from Medicaid (over a six-year period and with some flexibility) go to wages for aides and nurses. 

The problem with the rule is that rates just are not sufficient enough to meet these requirements and proposals Biden has made. Proposals to increase dollars have not yet passed.  The fear is that the moves in each case could force many nursing home providers to fold.

A new analysis from the Kaiser Family Foundation (KFF) finds that less than 20% of facilities meet the proposed minimum standards.

#medicaid #managedcare #nursinghomes #healthplans #providers

— Marc S. Ryan

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