CMS released a proposed overhaul of the regulations governing Medicaid and CHIP Managed Care last May and accepted comments through July. In addition to their sweeping impact, these rules are particularly meaningful as they are the first major changes to the rules governing Medicaid Managed Care since 2002.
As states agencies and others review the final regulations, we are sharing a summary of the proposed regulations that we first released last summer. The proposed regulations seek to modernize the rules in light of the expanded use and scope of managed care in Medicaid programs across the country. Among a few of the notable changes, the rules:
- Seek to align Medicaid Managed Care with other coverage, particularly Medicare Advantage plans and Qualified Health Plans (QHPs);
- Require states to adopt provider network adequacy standards for Medicaid Managed Care;
- Amend appeals standards;
- Require reporting of medical loss ratios by Medicaid Managed Care plans; states that have minimum MLRs must set that minimum at or above 85%;
- Allow for consideration of short term stays in Institutions for Mental Diseases in setting capitation rates;
- Set new standards for auto-assignment; and
- Require adoption of Comprehensive Quality Strategies across all Medicaid programs.
For a comprehensive summary of the proposed regulations, click here. And, stay tuned for a summary of the final regulations. On April 25, 2016 the final regulations were released, and as mentioned above, we will be circulating more information soon. The final regulations can be found here.
Lisa Kaplan Howe (J.D.) is a Senior Advisor who has spent her career working in health law and policy. At PCG, she focuses on statutory and regulatory analysis and strategic advising, particularly related to health care policy. Lisa has provided subject matter expertise to support state health care reform efforts, including policy development and regulatory support for health insurance Marketplaces and state insurance plan management efforts, Medicaid expansion and Medicaid Waivers (including DSRIP Waivers) and State Innovation Waivers. Lisa led PCG’s work with the New Hampshire Insurance Department relative the state’s Section 1115 Medicaid Waiver to provide coverage to newly-eligible adults through the Marketplace and continues to support the states’ Marketplace plan management work. In those roles, Lisa has served as the chief advisor and policy expert related to Medicaid and private insurance law to the New Hampshire Insurance Department, helping to identify, analyze and lead strategic consideration of federal opportunities and requirements. Lisa is also part of the team helping to design Colorado’s Delivery System Reform Incentive Payment (DSRIP) program. Ms. Kaplan Howe also provides broad policy and regulatory support to PCG’s other health care clients across the country, analyzing policy and regulatory developments, providing strategic advice relative to regulatory questions, and drafting policy briefs and position papers. Lisa is a managing editor of PCG’s monthly health practice area newsletter, Health Policy News.
Prior to joining PCG, Lisa served as Policy Director at New Hampshire Voices for Health, where she led legislative and regulatory analysis, strategic planning, and implementation of the organization’s policy agenda. Her work included drafting bills, amendments, testimony, and communications and testifying at hearings. Lisa also held the positions of Private Market Policy Manager and Consumer Health Policy Coordinator at Health Care for All of Massachusetts. While there, she managed private insurance market policy work and was a member of the organization’s internal health reform team. Lisa also practiced law in the Ropes & Gray health care department, advising health care provider and insurer clients.
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