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Proposed Rule on Medicaid Managed Care: A Summary of Major Provisions

On June 1, 2015, the Centers for Medicare & Medicaid Services (CMS) published a Notice of Proposed Rulemaking (NPRM) to modernize federal Medicaid managed care regulations. Since the rules were last updated, in 2002, states have significantly expanded their managed care programs to include beneficiaries with more complex needs; larger geographic areas; additional services; and millions of adults newly eligible for Medicaid under the Affordable Care Act. Today, over half of all Medicaid beneficiaries are enrolled in comprehensive risk-based health plans and many also receive some services, such as behavioral health care, through limited-benefit risk-based plans. In addition, millions of beneficiaries are enrolled in managed fee-for-service arrangements.CMS has articulated several principles and goals that underlie the NPRM. In particular, the proposed rule aims to: strengthen beneficiary protections; better align Medicaid managed care rules with standards for other coverage programs; increase fiscal integrity in rate-setting; address delivery and payment system reform in the context of managed care; improve the quality of care across Medicaid delivery systems; increase health plan and state accountability; and strengthen state and federal oversight of Medicaid managed care programs.

This issue brief summarizes major provisions of the NPRM. In it, we review proposed changes in the following key areas, among others:

  • Beneficiary support and information;
  • Enrollment and disenrollment;
  • Provider network adequacy and access to care;
  • Managed long-term services and supports;
  • Appeals;
  • Capitation rate-setting;
  • Quality of care;
  • State monitoring; and
  • Program integrity

The proposed rule will affect a variety of stakeholders, including states, health plans, providers, and beneficiaries. The public comment period closes on July 27, 2015, and the provisions of the final rule may be revised in light of stakeholder input.

Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.