New Medicaid Managed Care Rules: What the Rules Mean for You

Posted by Reeve Foundation Staff in Daily Dose on April 28, 2016 # Advocacy and Policy

Centers for Medicare and Medicaid ServicesThe Centers for Medicare and Medicaid Services (CMS) – the national office that governs Medicare and Medicaid – has released new final regulations updating the rules for managed care, the private health insurance companies that provide Medicaid services in most states. CMS has not updated the rules in over a decade. Since that time, managed care has proliferated across the states. Now, approximately 75% of Medicaid beneficiaries are enrolled in a managed care program, including people with disabilities. States are also starting to include more disability-specific Medicaid programs into managed care, like long-term services and supports (LTSS) and employment supports. The privatization of Medicaid has concerned advocates for many years, and the new federal rules offer new important protections.

The new rules include provisions to improve care better for beneficiaries, including network adequacy, quality measures, and minimum standards for “medical necessity”. If you are enrolled in Medicaid managed care, here are the most important items for you to know:

  • The state must allow a period of choice before you are enrolled in a managed care plan, then allow 90 days from enrollment for you to change plans
  • The state must establish a stakeholder group regarding LTSS, and ensure that the views of people using LTSS are heard in the design, implementation, and oversight of the system
  • The state must create a Beneficiary Support System specifically designed to serve as a single point of contact for navigating the system
  • The state must ensure that all managed LTSS programs comply with the Americans with Disabilities Act and Supreme Court’s Olmstead decision
  • A managed care company cannot dis-enroll you because of a change in your health status
  • Managed care companies must continue services while you appeal an adverse coverage decision
  • Information on the physical access in provider directories, including the accessibility of offices, exam rooms, and equipment, now must be included in provider directories

Anyone using Medicaid long-term services & supports in a state with managed care should consider joining the stakeholder engagement group to ensure that the views of people living with paralysis are heard.

When CMS issued these rules as a proposal last summer, the Reeve Foundation weighed in urging CMS to strengthen consumer protections even further, especially around LTSS. While CMS did not take all of our recommendations, we are pleased with the rule and believe it will improve access and care for people on Medicaid.

Learn more about the rules from the Department of Health and Human Services press release and Centers for Medicare and Medicaid Services fact sheets (under final rule).