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What to expect from the Medicaid managed care proposal

CMS will address beneficiary information, network adequacy

The federal government will soon propose new Medicaid managed care organization (MCO) rules for the first time since 2002. The Centers for Medicare & Medicaid (CMS) Services--which has been working on updating the regulations for more than a year--plans to address beneficiary information, provider network requirements and how plans spend money they receive from the program.

These new rules on long-term care are "a big deal," Jeff Myers, president and CEO of Medicaid Health Plans of America, which represents managed care plans, told the National Journal.

For starters, out of the 70 million Medicaid beneficiaries around the country, 40 million are covered in managed care plans, reported Healthcare Payer News. Additionally, a majority of the 40 million are in risk-based MCOs.

Due to the large MCO population, CMS most likely will focus on the issue of information access, noted a recent Kaiser Family Foundation report. KFF predicted that the new rule may require plan information to be made available electronically or posted online by MCOs and states. CMS may also mandate that plans report on accessibility measures with people with disabilities.

CMS most likely will tighten rules regarding network adequacy, which has been a growing concerning around the country, according to Healthcare Payer News. For instance, while all 33 states with MCOs have provider access standards, wait-times often exceed one month in more than 25 percent of providers accepting MCO plans, Meanwhile, provider directories continue to be inaccurate.

To address the issue, CMS may require both states and MCOs to make sure provider directories are corrected and updated in a timely fashion, KFF said. CMS may also require states and MCOs to monitor provider availability.

Even though MCOs occupy a gray area between quality care and cost savings, insurers for the most part support beneficiary protections, such as allowing them to switch plans if their provider leave the network, noted the National Journal.

For more:
- here's the National Journal article
- check out the Healthcare Payer News piece
- read the KFF brief

Related Articles:
CMS to tighten Medicaid managed care organization regulations
Managed care continues to spark debate
How states can craft the right Medicaid managed care contract