Medicaid managed care just got a dramatic update that will align it more closely to the Affordable Care Act (ACA) Marketplaces and Medicare Advantage over the next several years. In Medicaid managed care, the state pays managed care plans to provide and manage the benefits that enrollees receive (whereas services for standard Medicaid enrollees are paid directly by the state). Over 55 million people (77 percent of all Medicaid enrollees) are in Medicaid managed care – that’s no small potatoes!

Overall, we are pleased about the final rules, which establish new federal standards and consumer protections that states can build upon. We also saw some big shifts in the approach and delivery of managed care, such as an emphasis on quality and performance improvement, stakeholder engagement, oversight, and requirements for all managed long-term services and supports (LTSS) to be person-centered by providing the opportunity to live and work in the setting that consumers choose. Advocates have a critical opportunity over the next few years to participate in developing these standards, monitor implementation and urge their states to add more consumer supports and protections where needed. Let’s unpack some key sections of the rule:

  • Network adequacy: states must come up with their own time and distance standards with respect to eight different provider types.
  • Provider directory: managed care plans must include at least five provider types (physicians, hospitals, pharmacies, behavioral health and LTSS), their spoken languages, availability of language assistance services and physical accessibility of the provider’s facility. Provider directories must be updated monthly.
  • Quality Rating Strategy (QRS): States will publicize quality ratings of their Medicaid managed care plans. Although the QRS won’t be released for federal public comment until 2018 at the earliest – and not implemented until 2021 – advocates can take time figuring out what quality measures matter most to consumers.
  • Non-discrimination: CMS added several non-discrimination protections for several categories, including sex, sexual orientation, gender identity, health status and disability.
  • Beneficiary support system: States must provide a beneficiary support system to managed care consumers that includes specific services geared toward enrollees in long-term services and supports (LTSS).

In a few areas, CMS improved the regulation based on feedback from advocates like you!

  • Behavioral health provider network adequacy standards must be separated into adult and child providers – an important distinction as adults and children have different health care needs.
  • The state quality strategy will include a focus on reducing health disparities based on demographic factors, including age, race, ethnicity, sex, primary language and disability status. We see this as a huge win for consumers, especially as states are shifting more Medicaid enrollees onto managed care and expanding it to new and vulnerable populations
  • We are pleased that CMS dropped its proposal to allow using the Medicare Advantage Five-Star Rating system for plans serving only dually eligible consumers. The Medicare Advantage Five-Star Rating system was not designed to account for people who are dually eligible and have more complex health needs or need LTSS.

Although the rules are final, there are still many opportunities to weigh in now that the baton has been passed from CMS to states. We encourage advocates to visit our fact sheet for a more detailed analysis and ways to get involved. We look forward to working with you in doing so!