CMS has published a proposed rule that would update Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations to more closely align with Medicare Advantage (MA) and private health plan standards and to strengthen quality safeguards. The proposed rule, which represents the first major revisions to Medicaid and CHIP managed care standards in more than a decade, is intended to reflect the changing landscape for health care delivery as states have expanded the use of managed care in new geographic areas and broader populations, including seniors and persons with disabilities and those needing long-term services and supports (LTSS). Among other things, the 200-page rule would:

  • Conform Medicaid and CHIP marketing, appeals/grievances, and medical loss ratio standards to other health coverage program rules.
  • Revise the Medicaid managed care rate-setting framework to clarify standards for actuarially-sound capitation rates to ensure that Medicaid rates are developed in a transparent and consistent manner across Medicaid managed care programs.
  • Strengthen beneficiary protections, including provisions related to beneficiary enrollment and disenrollment, covered services, coordination and continuity of care, electronic exchange of health information; and standards for managed LTSS.
  • Create network adequacy standards for medical services and LTSS.
  • Strengthen quality measurement and improvement standards to promote transparency and consumer engagement.
  • Clarify current standards regarding choice of managed care entities.

The proposed rule was published on June 1, 2015, and comments will be accepted until July 27, 2015.