Medicaid Managed Care: Compliance Under New Program Rules, Waiver Initiatives and Future Changes as Yet Unknown

The past few years has brought much change to the Medicaid program, both under the previous and current administrations. In 2016, CMS made the first comprehensive revisions to the Medicaid managed care regulations in more than 12 years. This effort to modernize the Medicaid managed care rules impacted not only the 39 states that use managed care organizations to administer their Medicaid benefits, but also the Medicaid managed care entities, participating providers and other stakeholders. The Trump Administration is now using administrative action to make changes to the Medicaid program more broadly, some targeting fundamental aspects of the program through waiver approval. One newly proposed rule seeks to amend the process for state documentation of whether Medicaid payments in fee-for-service systems are adequate to assure beneficiary access to covered care and services. However, support for efforts to move Medicaid towards value-based payment remains an ongoing theme.

Increased use of value-based payments in Medicaid programs brings a corresponding focus on encounter data. Both federal and state governments are tying the submission of encounter data to federal payments. Further, the CMS may penalize Medicaid managed care plans for failing to maintain and submit such data.

Transparency efforts added through the Medicaid managed care final rule require managed care entities to have processes to (1) notify states of changes in a network provider’s circumstances that may affect the provider’s eligibility to participate in the Medicaid managed care entity’s network and (2) verify that services claimed to have been provided by network providers were in fact received by enrollees. Further, managed care organizations, prepaid inpatient health plans, and prepaid ambulatory health plans must have a mechanism for reporting receipt, and timely returning, of an overpayment.

Listen as the panel examines Medicaid managed care requirements and state level demands on participating managed care organizations. The panel will also discuss compliance with the law and potential changes to Medicaid managed care under the current administration.

1. Compliance with Medicaid managed care final rule
   1. Medical loss ratio
   2. Actuarial soundness
   3. Authorization of “pass-through” payments
   4. Provider screening and enrollment
   5. Provider integrity
2. State demands and new care management models
   1. Impact on MCOs
   2. Impact on providers
   3. Impact on patients
3. Potential changes to Medicaid managed care

The panel will review these and other high priority ssues:

• The final rule’s changes to MLR, network adequacy standards and rules for setting capitation rates
• Addressing compliance challenges under the Medicaid managed care regulations
• Changes implemented by the current administration and expectations for the future