As states continue to move toward wider use of managed care organizations (MCOs) in their Medicaid systems, the US Centers for Medicare and Medicaid Services (CMS) is looking at ways to guide the evolution while maintaining state flexibility. A few of those ideas have been fleshed out in a recently released proposed rule from CMS on both Medicaid and the Children's Health Insurance Program (CHIP).
APTA regulatory affairs staff members are analyzing the proposed rule, and the association will provide comments to CMS by the January 19, 2019, deadline. In the meantime, here are a few basics:
Allowing temporary pass-through payments for states transitioning to MCOs. Currently, providers in fee-for-services Medicaid arrangements are eligible for additional payments, known as "pass-through" payments, but these payments are being phased out for MCO Medicaid arrangements, and new payments are prohibited. But what about states that are transitioning to managed care? In response to some states' requests that pass-throughs continue to be allowed as a part of the transition process, CMS is proposing that new payments be allowed during a limited time period.
Easing network adequacy standards and providing flexibility in the definition of "specialist." CMS proposes moving away from network adequacy standards based on travel time and geographic location, and toward a system that allows states to factor in other issues, including the availability of contracted providers who are accepting new patients, maximum wait times for appointments, and a facility's hours of operation. Additionally, the agency would like to give states more flexibility in defining which providers are considered "specialists."
Loosening requirements for state quality-rating systems (QRS). CMS would like to allow states more leeway in their QRS systems: rather than requiring that the approaches provide data substantially similar to data provided by the CMS-developed QRS, the agency is proposing that state QRS systems need only be "comparable to the extent feasible to enable meaningful comparison across states." The proposed rule also would eliminate a requirement that states get CMS approval before starting up an alternative QRS.
Making it easier for enrollees to navigate the appeals system. Under the proposed rule, Medicaid enrollees would no longer be notified of claims denials based on administrative errors; they would only receive notification of "substantive" denials. Additionally, enrollees who submit an oral appeal to a denial would no longer be required to submit an additional written and signed appeal.