CMS' upcoming new managed care rule will affect plans serving 46 million Medicaid beneficiaries, according to a report from healthcare business advisory company Avalere Health.
The proposed rule, which was just reviewed by the Office of Management and Budget, will update federal regulations from 2002 governing Medicaid managed care organizations. Avalere expects that the rule "will aim to accommodate the evolution of managed care programs and address commonly identified weaknesses."
The company projects that the new Medicaid managed care regulations will cover the following, among other topics:
1. Medical Loss Ratio (MLR), including setting a minimum MLR for Medicaid managed care organizations.
2. Standards to evaluate healthcare access, as well as a focus on the accuracy of network information that beneficiaries receive.
3. Greater standardization of quality metrics across states and plans.
4. Federal oversight of rate setting and a more detailed, regimented process for ensuring actuarial soundness.
5. Continuity of care, including alignment of enrollment practices between Medicaid fee-for-service, Medicaid managed care organizations and exchange coverage.
6. Stronger public reporting and transparency requirements for Medicaid managed care organizations and states.
"Given the extent to which states have expanded their use of managed care, this regulation will have a significant impact," Caroline Pearson, senior vice president at Avalere, said in the report. Medicaid managed care organizations "do not just cover moms and kids anymore — states are now using these plans to cover beneficiaries with complex and chronic conditions, those in rural areas, and many new enrollees under the [Patient Protection and] Affordable Care Act."
By the end of 2015, Avalere estimates that 73 percent of Medicaid beneficiarieswill receive services through Medicaid managed care organizations.
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