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Awaiting New Medicaid Managed Care Rules: Key Issues to Watch

Introduction
  1. Medicaid Managed Care Market Tracker, Kaiser Family Foundation, https://www.kff.org/data-collection/medicaid-managed-care-market-tracker/

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  2.   Vernon Smith et al. Medicaid in an Era of Health and Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015, Kaiser Family Foundation, October 2014, https://www.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/

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  3. MaryBeth Musumeci, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers, Kaiser Commission on Medicaid and the Uninsured (November 2014), https://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/

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  4. Ibid. Table at https://www.kff.org/other/state-indicator/total-medicaid-mco-spending/

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  5. Mostly in Sections 1903(m) and 1932 of the Social Security Act (42 U.S.C. § § 1396b(m), 1396u-2) and 42 CFR Part 438.

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  6. Virgil Dickson, “Coming Medicaid plan rules will set new access standards,” Modern Healthcare, “October 28, 2014, http://www.modernhealthcare.com/article/20141028/NEWS/310289915

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  7. Comprehensive Medicaid managed care organizations (MCOs) provide comprehensive acute care, and in some cases, long-term services and supports as well, to Medicaid enrollees. States pay MCOs a fixed monthly premium or “capitation rate” on behalf of each enrollee. Limited-benefit prepaid health plans (PHPs) provide a limited set of inpatient or outpatient Medicaid benefits, such as mental health services, usually on a capitation basis.

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Issue Brief
  1. See, e.g., 28 C.F.R. § 35.104 (defining auxiliary aids and services under ADA Title II, which applies to state and local governmental entities)

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  2. Mara Youdelman and Elizabeth Edwards, Medicaid Managed Care Model Provisions: Accessibility & Language Access, Issue 4, National Health Law Program,  http://www.healthlaw.org/issues/medicaid/managed-care/medicaid-managed-care-model-provisions-issue-4#.VONaWPnF-So

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  3. Sarah Somers, Medicaid Managed Care: Modernized Federal Regulations are Long Overdue, Health Advocate, E-Newsletter of the National Health Law Program (September 2014). For ACA information transparency requirements, see 45 CFR 155.205, 155.220 and 156.230.

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  4. Section 1932(a)(3) of the Social Security Act (42 U.S.C. § 1396u-2)

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  5. States are prohibited from mandating enrollment in MCOs for children with special health care needs, beneficiaries dually eligible for Medicaid and Medicare, and Native Americans unless they obtain a federal waiver to do so.  42 U.S.C. § 1396u-2(a)(2)

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  6. Social Security Act, § 1932(a)(4) [42 U.S.C. § 1396u-2(a)(4)]

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  7. Ibid.

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  8. MaryBeth Musumeci,  A Guide to the Medicaid Appeals Process, Kaiser Commission on Medicaid and the Uninsured (March 2012), https://www.kff.org/wp-content/uploads/2013/01/8287.pdf

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  9. 42 CFR Part 438, Subpart F

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  10. Sarah Somers, Medicaid Managed Care Model Provisions: Grievances and Appeals, Issue No. 1, National Health Law Program (September 17, 2014), http://www.healthlaw.org/publications/medicaid-managed-care-model-provisions-series-issue-1#.VRFjSvnF98E

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  11. Compare 42 C.F.R. § 438.420 with 42 C.F.R. § 431.230; see also Medicaid Managed Care: Grievances and Appeals, Fact Sheet #4, National Health Law Program (April 2012), http://www.healthlaw.org/issues/medicaid/managed-care/MMC-Fact-4#.VOtkm_nF98E

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  12. Medicaid Managed Care Model Provisions: Grievances and Appeals, op. cit.

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  13. 42 CFR § § 438.206, 438.207

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  14. State Standards for Access to Care in Medicaid Managed Care, Department of Health and Human Services, Office of the Inspector General (September 2014), http://oig.hhs.gov/oei/reports/oei-02-11-00320.pdf

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  15. Access to Care: Provider Availability in Medicaid Managed Care, Department of Health and Human Services, Office of the Inspector General (December 2014), http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf

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  16. See, e.g., Abbi Coursolle, Medicaid Managed Care Model Provisions: Network Adequacy, Issue 3, National Health Law Program (September 16, 2014),  http://www.healthlaw.org/issues/medicaid/managed-care/medicaid-managed-Care-model-provisions-issue-3#.VRFkevnF98E and Medicaid Managed Care for People with Disabilities: Policy and Implementation Considerations for State and Federal Policymakers, National Council on Disability (March 18, 2013), http://www.ncd.gov/publications/2013/20130315/

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  17. Medicaid Managed Care Model Provisions: Network Adequacy, op. cit.

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  18. 42 CFR §§ 438.202, 438.204

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  19. Section 402(a) of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires identification of children’s core quality measures and Section 2701 of the Affordable Care Act requires identification of adult core quality measures. For more information, see the CMS Technical Assistance Center at http://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/quality-of-care.html

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  20. MaryBeth Musumeci, Measuring Long-Term Services and Supports Rebalancing, Kaiser Commission on Medicaid and the Uninsured (February 2, 2015), https://www.kff.org/medicaid/fact-sheet/measuring-long-term-services-and-supports-rebalancing/ (See endnotes 11 and 12)

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  21. MaryBeth Musumeci, Rebalancing in Capitated Medicaid Managed Long-Term Services and Supports Programs: Key Issues from a Roundtable Discussion on Measuring Performance, Kaiser Commission on Medicaid and the Uninsured (February 2,  2015), https://www.kff.org/medicaid/issue-brief/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-key-issues-from-a-roundtable-discussion-on-measuring-performance/

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  22.  Ibid.

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  23. Julia Paradise, Medicaid Moving Forward, Kaiser Commission on Medicaid and the Uninsured (March 9, 2015), https://www.kff.org/medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/

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  24. Rebalancing, op. cit.

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  25. MaryBeth Musumeci, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers, Kaiser Commission on Medicaid and the Uninsured (November 2014), https://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/

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  26. Guidance to States using 1115 Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports Programs, Centers for Medicare and Medicaid Services (May 2013), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf

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  27. Ibid.

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  28. Section 1903(m)(2)(A)(iii) of the Social Security Act requires states to pay Medicaid health plans rates that are actuarially sound. Actuarial soundness is defined through regulations at 42 CFR §438.6(c)(i).

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  29. Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs Improvement, U.S. Government Accountability Office  (August 2010), http://www.gao.gov/assets/310/308487.pdf

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  30. 2015 Managed Care Rate Setting Consultation Guide, Centers for Medicare and Medicaid Services (September 2014), http://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/downloads/2015-medicaid-manged-care-rate-guidance.pdf

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  31. Letter from Association of Community Affiliated Plans to Cindy Mann, Director of the Center for Medicaid and CHIP Services, dated April 29, 2014. Letter from American Hospital Association to Cindy Mann, dated December 5, 2014.

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  32.  MaryBeth Musumeci, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS, Kaiser Commission on Medicaid and the Uninsured (July 24, 2014), https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/

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  33. Medicaid Managed Care Encounter Data: A Toolkit for Data Collection, Validation, and Reporting, prepared by Mathematica Policy Research for Centers for Medicare and Medicaid Services (November 2013), http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/downloads/medicaid-encounter-data-toolkit.pdf

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  34. Medicaid Managed Care Encounter Data: Collection and Use, U.S. Department of Health and Human Services, Office of Inspector General (May 2009), http://oig.hhs.gov/oei/reports/oei-07-06-00540.pdf

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  35. 42 U.S.C. § § 1396(I)(25), 1396b(r)(1)(F), 1396b(m)(2)(A)(xi)

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  36. MaryBeth Musumeci, Financial Alignment Demonstrations for Dual Eligible Beneficiaries: A Look at CMS’s Evaluation Plan, Kaiser Commission on Medicaid and the Uninsured (July 18,  2014),  https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-a-look-at-cmss-evaluation-plan/

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  37. Embry M. Howell, “Medicaid Managed Care Encounter Data: What, Why, and Where Next?” Health Care Financing Review 17(4), Summer 1996.

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  38. 42 USC § 1396a(a)(37)(B) and 42 USC § 1396b(m)(2)(A)(iv); § 1396u-6

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  39. Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures, U.S. Government Accountability Office (May 2014), http://www.gao.gov/assets/670/663306.pdf

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