CMS NEWS
FOR
IMMEDIATE RELEASE
November 8, 2018
Contact:
CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
CMS Proposes Changes to Streamline and
Strengthen Medicaid and CHIP Managed Care Regulations
Proposed Rule Continues Commitment to Promote Flexibility,
Strengthen Accountability, and Maintain and Enhance Program Integrity
in Medicaid and CHIP
Today,
the Centers for Medicare & Medicaid Services (CMS) is proposing
significant regulatory revisions to streamline the 2016 managed care
regulatory framework. The changes reflect a broader strategy to relieve
regulatory burdens; support state flexibility and local leadership; and
promote transparency, flexibility, and innovation in care delivery.
While the 2016 managed care final rule was a substantial and
comprehensive rewrite of the Medicaid and Children’s Health Insurance
Program (CHIP) regulatory structure, it included provisions that many
states and stakeholders identified as unnecessarily prescriptive and as
adding unnecessary costs and administrative burden to state Medicaid
programs without contributing to the improvement of health outcomes.
As
part of CMS’ broader efforts to reduce administrative burden, CMS
formed a working group with the National Association of Medicaid
Directors (NAMD) and state Medicaid Directors to create a framework to
review and prioritize areas of concern within the managed care
regulations. Together the working group reviewed and analyzed the
regulation to identify opportunities to achieve a better balance
between appropriate federal oversight and state flexibility, while also
maintaining critical beneficiary protections, ensuring fiscal
integrity, and promoting accountability for providing quality of care
for Medicaid beneficiaries.
“Today’s
action fulfills one of my earliest commitments to reset
and restore the federal-state relationship, while at the same time
modernizing the program to deliver better outcomes for the people we
serve,” said CMS Administrator Seema Verma. “I want to thank
the state workgroup and the CMS team for their diligent work in
analyzing these complex regulations and coming forward with a common
sense approach to right-size our regulatory oversight and let states
focus more on delivering quality health care to their beneficiaries.”
Managed
care is a system where states contract with private health plans to
administer Medicaid benefits. Over two thirds (68.1 percent) of all
Medicaid beneficiaries were enrolled in comprehensive managed care in
2016, up from 65.5 percent in 2015. As states continue to expand their
use of comprehensive managed care to deliver Medicaid services,
enrollment in comprehensive managed care reached 54.6 million
beneficiaries in 2016. The more states continue moving new populations into
managed care that have traditionally received their benefits through
Medicaid fee-for-service.
To
reduce state administrative burden and enhance the ability of states to
effectively manage s their Medicaid and CHIP programs, these key
proposed revisions to the 2016 final rule would include:
- Promoting Flexibility
- Providing states with
greater flexibility to develop and certify a rate range under
specific conditions and limitations, including that the rate
range be actuarially sound;
- Removing barriers that
made it difficult to transition new services and populations into
managed care because of existing fee-for-service payment
arrangements by providing states with a three year transition
period to come into compliance with requirements related to pass-through
payments;
- Providing states more
flexibility to set meaningful network adequacy standards using
quantitative standards that can take into account new service
delivery models like telehealth;
- Removing outdated and
overly prescriptive administrative requirements that govern how
plans communicate with beneficiaries to better align with
standards used across federal programs and enable the use of
modern means of electronic communication when appropriate.
- Strengthening Accountability
- Requiring CMS to hold ourselves
accountable to issue guidance to help states move more quickly
through the federal rate review process and to allow for
submission of less documentation in certain circumstances while
providing appropriate oversight to ensure patient protections and
fiscal integrity;
- Maintaining the
requirement for states to develop a Quality Rating System (QRS)
for health plans to facilitate beneficiary choice and promote
transparency, but with greater ability for states to tailor an
alternative QRS to their unique program while requiring a minimum
set of mandatory measures to align with the Medicaid and CHIP
Scorecard.
- Maintaining and Enhancing Program Integrity
- Maintaining the
current regulatory framework for program and fiscal integrity,
including provisions related to the actuarial soundness of rate
setting, provider screening and enrollment standards, and medical
loss ratio (MLR) standards;
- Strengthening federal
requirements to protect federal taxpayers from cost shifting by
prohibiting states from retroactively adding or modifying
risk-sharing mechanisms and ensuring that differences in
reimbursement rates are not linked to enhanced federal match.
Additionally,
states expressed their concerns with how the 2016 final rule’s
limitation of 15 days on lengths of stay for managed care beneficiaries
in an institution for mental disease (IMD) created difficult
administrative challenges for states. CMS is not proposing any changes
to this requirement at this time; however, it is asking for comment
from states for data that could support revisions to this policy.
Meanwhile, CMS continues to support state flexibility through section
1115 demonstrations, having approved a total of 15 waivers of the IMD
exclusion for states to treat patients with substance use disorder (SUD),
to expand access to treatment, and is exploring further options remove
barriers to important treatment options.
"Targeted
improvements to the managed care rule have been a top priority for
Medicaid Directors,” said Board President of NAMD, Judy Mohr Peterson.
“NAMD appreciates the partnership shown by CMS to explore these issues
and dialogue with the states, providing an opportunity to share
perspectives on how the managed care regulatory framework could be
improved. We look forward to reviewing CMS's proposed revisions and
submitting formal comments."
To
view a summary of the proposed changes, visit Medicaid.gov at https://www.medicaid.gov/medicaid/managed-care/guidance/index.html.
And to view the proposed rule, visit the Federal Register at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24626.pdf.
Comments on the proposed rule are due January 14, 2019.
###
Get CMS news at cms.gov/newsroom, sign up for CMS news
via email and follow CMS on Twitter
CMS Administrator @SeemaCMS, @CMSgov, and @CMSgovPress.
|