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CMS to tighten Medicaid managed care organization regulations

Proposed rules to address program quality, MCO medical loss ratio

Forthcoming rules from the Centers for Medicare & Medicaid Services (CMS) should strike a better balance between the services offered by Medicaid managed care organizations and the operating profits of the private insurers that offer MCO services, Kaiser Health News reported.

Medicaid managed care occupies a gray area between quality care and cost savings, FierceHealthPayer previously reported. MCOs make more money if they provide less care, and healthcare reform emphasizes wellness management over care volume, but access to necessary care can be limited as a result.

The CMS rules, due later this spring, will represent the biggest overhaul of Medicaid managed care in a decade, the article said. In addition to addressing program quality and integrity, the rule should provide requirements for better plan transparency as well as protection of member rights during the enrollment, appeal and grievance processes, the Kaiser Family Foundation wrote in a recent report.

Those rules intend to help beneficiaries such as Lynda Douglas, who has spent years battling TennCare, Tennessee's Medicaid MCO, as well as United Healthcare and BlueCross, to secure adequate care for her adopted, disabled children, KHN reported. Denials of coverage for daytime nurses and a seizure control pump, for example, came as the TennCare MCOs made hundreds of millions in profits annually, KHN said.

Industry officials expect the CMS rules to impose medical loss ratios on MCOs in a similar manner that the Affordable Care Act imposed them on payers at large, according to KHN. However, they caution CMS against writing rigid federal regulations, noting that state insurance commissioners will better understand the needs of their specific Medicaid population.

For more:
- here's the Kaiser Health News article
- read the Kaiser Family Foundation brief

Related Articles:
Report: Medicaid enrollees experience limited access to care
Managed care continues to spark debate
GAO: Medicaid managed care needs better watchdogs
Insurers show greater compliance with medical loss ratio