CMS recently proposed regulations regarding Medicaid managed care.  The proposed rule, which was released on June 1, offers the fist major update to Medicaid and CHIP managed care regulations since 2002 – in many ways, this update and modernization of the regulations is overdue.  In general, the proposal takes a big step toward aligning Medicaid and CHIP managed care requirements with those already in place for qualified health plans (marketplace plans) and Medicare advantage plans.  The proposed regulations also:

  • Establish standards for plan network adequacy
  • Create new beneficiary protections, especially for vulnerable populations
  • Establish a medical loss ratio (MLR) for plans
  • Require greater transparency in capitation rate setting
  • Create a new framework for quality improvement
  • Change the way in which plans can pay for short-term stay in institutions for mental disease (IMDs)
  • Give states flexibility in designing and administering managed long term services and supports (LTSS)
  • Provide opportunities for states and plans to work together toward innovative payment and delivery reforms