Editor's Note: This Manatt on Medicaid is the second in a series of updates focused on CMS's new Medicaid/CHIP managed care regulations. In the coming weeks, Manatt will be exploring key provisions of the regulations and highlighting their implications.

On April 25, 2016, the Centers for Medicare and Medicaid Services (CMS) released its final rule that significantly overhauls regulations governing Medicaid managed care.1 The final rule establishes new requirements for providing support to consumers both prior to and after managed care enrollment, and clarifies the existing requirements for enrolling and disenrolling Medicaid beneficiaries. The requirements formalize and standardize the consumer supports available to Medicaid managed care applicants and enrollees to promote unbiased plan selection decisions and help consumers more easily navigate and use their coverage.

Beneficiary Support System. Among the most significant changes to Medicaid managed care requirements, CMS requires states to establish a beneficiary support system that will assist consumers in making informed health plan enrollment choices, taking into account their healthcare needs.2 The beneficiary support system must be accessible by phone, in-person, and through the Internet, and provide choice counseling for all beneficiaries, assistance in understanding managed care, and targeted assistance with Long Term Services and Supports (LTSS). In a departure from the notice of proposed rulemaking, CMS did not finalize a requirement that the beneficiary support system functions include training for managed care entities and network providers on community-based resources and supports.3 Instead, CMS defers to states on training requirements, and encourages managed care plans to expand existing training curriculum to include topics on available community-based supports.

"Choice counseling entities"—defined in the final rule as entities providing information and services to assist beneficiaries in making enrollment decisions4—will be considered enrollment brokers and therefore must meet independence and conflict of interest standards, including not having a financial interest in any managed care plan which operates in the state where the entity is providing choice counseling. CMS makes clear in the preamble that managed care plans may not support any beneficiary support system activities. These new requirements create opportunities for enrollment brokers with Medicaid managed care expertise to expand or develop new business in markets that have underdeveloped beneficiary support capacity.

The final rule also establishes new federal funding for LTSS-specific beneficiary support system activities. These functions include providing:

  • An access point for complaints and concerns;
  • Education on (1) enrollees' grievance and appeals rights within the State fair hearing process; (2) enrollees' rights and responsibilities; and (3) additional resources outside the managed care entity;
  • Assistance in navigating the grievance and appeals process, including referrals to legal representation; and
  • Review and oversight of LTSS program data to provide guidance to the State Medicaid Agency on identification, remediation and resolution of systemic issues.

The requirement to provide the full range of LTSS-specific supports may be challenging to some states that have traditionally relied on an ad hoc network of community-based organizations and long-term care entities to provide more limited supports. States with established long-term managed care programs, especially those implementing demonstration programs that serve dually eligible populations, are already providing many of these LTSS-specific services and will be best positioned to meet these new requirements.

In response to concerns that the beneficiary support system will require significant administrative and financial resources, CMS encourages states to leverage existing services and clarifies that states are not required to build new beneficiary support systems if they already provide the required resources. CMS also clarifies that states are not limited to one beneficiary support system entity and may use multiple entities to provide different services. To further address states' financial concerns, the rule makes beneficiary support and enrollment broker services eligible for federal financial participation at the administrative match of 50 percent.

Most Medicaid managed care states already provide some degree of choice counseling and navigational assistance to beneficiaries. In planning to meet these requirements by their effective date of July 1, 2018, states will likely look to their existing beneficiary support networks—community-based organizations, application assisters, navigators and enrollment brokers—and assess whether they meet the independence and conflict of interest standards and fulfill the range of required choice counseling, beneficiary support and navigational assistance. States that need to augment their existing services will likely have to invest in new infrastructure and vendor relationships.

Enrollment Process: Choice Period and Plan Assignment. The final rule establishes new requirements for enrolling beneficiaries into managed care on voluntary and mandatory bases. To address varied enrollment processes across states, CMS establishes formalized standards that are designed to ensure beneficiaries can affirmatively exercise their right to choose a plan that best meets their healthcare needs. Looking to experiences in Medicare Advantage, dual eligible capitated financial alignment model demonstrations, and Qualified Health Plans, the final rule establishes guidelines for enrollment processes applicable to all Medicaid managed care entities.5

CMS declined to finalize a proposal that states enroll individuals into fee-for-service (FFS) for 14 days in order to make an active plan choice prior to managed care enrollment. CMS cited the high number of comments in opposition to this proposal noting, among other reasons, that: the 14-day FFS enrollment period was inconsistent with state Medicaid agencies' desire to effectuate managed care at the point of enrollment; the 90-day without cause disenrollment window serves as a choice period; and many states have an insufficient number of FFS providers available to accommodate the proposed 14-day window. In mandatory managed care programs, individuals may be enrolled in either the plan of their choice or a plan based on the state's default process (e.g., auto-assignment), without first being enrolled in FFS.

The final rule's standardized enrollment processes in both voluntary and mandatory managed care programs require states to ensure enrollees are provided a period of time to make an active plan choice. To support informed decision making, states must provide beneficiaries with an appropriate notice that provides clear information on how to contact the beneficiary support system, the length of the enrollment period, disenrollment rights, implications of exercising each enrollment option, the managed care plans available for selection, and the process for making the plan selection. This new notice requirement will likely be a challenge for many states that already struggle with providing clear, dynamic and user-friendly notices.

The final rule does not include significant changes with regard to plan assignment but establishes flexibility to use additional criteria when evaluating "existing provider-beneficiary relationships" when passively enrolling or defaulting individuals into managed care plans. States must ascertain the "existing-provider relationship"—where the provider was the main source of Medicaid services for the beneficiary during the previous year—through state records on plan enrollment or FFS experience, encounter data, or contacting beneficiaries. If states are not able to make a plan assignment based on the provider relationship criteria, they must distribute enrollment into plans equitably, though they may consider additional criteria in plan assignment, including enrollment preferences of family members, quality assurance and improvement performance, contract evaluation elements, and accessibility of provider offices for people with disabilities. States have historically experienced data challenges when evaluating existing provider-beneficiary relationships and will likely continue to struggle with implementing this requirement despite the new flexibility.

Conclusion. CMS's new requirements with regard to consumer support, enrollment and disenrollment reflect increasing efforts to improve transparency and consumer decision support in Medicaid managed care, consistent with similar efforts in QHP and Medicare Advantage. Over the coming years, states, managed care plans, consumer advocates and other stakeholders will be implementing Medicaid's new consumer support requirements, leveraging existing resources and building new capacity to provide enhanced, consumer-focused services in the nation's large and growing Medicaid managed care delivery system.