CMS Releases Medicaid Managed Care Final Rule
April 27, 2016 09:24 AM
On Monday, April 25, the Centers for Medicare & Medicaid Services (CMS) finalized a major rule that focuses on Medicaid managed care related to minimum operation standards, care delivery, quality of care, and more. The rule is of significant interest as more and more states move their Medicaid programs into one form or another of managed care. Further, since the rule also addresses Medicaid Managed Long Term Services and Supports (MLTSS), it is of specific interest to the home care community.
“We’re taking a next step in [our] work today by finalizing a long-anticipated rule that updates how Medicaid works for the nearly two-thirds of beneficiaries who get coverage through private managed care plans. These improvements modernize the way these managed care health plans operate so that Medicaid and CHIP continue to provide cost-effective, high quality care to consumers,” Andy Slavitt, Acting Administrator of CMS, and Vikki Wachino, CMS Deputy Administrator and Director for the Center for Medicaid and CHIP Services, wrote in a blog post announcing the final rule.
The National Association for Home Care & Hospice (NAHC) has long advocated for the institution of federal standards to govern states shifting from a traditional fee-for-services (FFS) approach in Medicaid to a managed care delivery model. As states increasingly shift to managed care, the need for such standards has grown since managed care plans have limited experience in providing the type of services, particularly personal care, that are the mainstay of MLTSS.
The central feature of the MLTSS guidance in the rule is the codification of the 10 elements that CMS included in its 2013 guidance regarding MLTSS. NAHC worked with both the diverse provider and beneficiary communities on the development of this “pro-home care” guidance.
CMS sets out in formal regulations that an MLTSS program must be evaluated to determine if it has the following:
Adequate Planning: The states must use a deliberative process and maintain state monitoring and accountability relative to the development of, transition to, and operation of MLTSS.
Stakeholder Engagement: States must go beyond the standard Medicaid Care Advisory Committee with a structure for engaging stakeholders regularly in ongoing monitoring and oversight of MLTSS programs. The proposal uses a flexible “sufficiency” standard rather than setting quantitative parameters. The key on stakeholder engagement is for the stakeholders to push the states to permit engagement.
Enhanced Provision of Home and Community Based Services: This maybe the most important part of the MLTSS proposed rule. It requires that the MLTSS programs be implemented consistent with the Americans with Disabilities Act and the Supreme Court’s 1999 decision in Olmstead v. L.C. Experiences to date indicate that CMS is very serious about this element, requiring states to assure that plans favor home care over institutional care.
Alignment of Payment Structures and Goals: The plan must be designed to support community integration and reduce costs. It is hoped that this provision will limit managed care plans’ efforts simply to reduce costs to gain profits.
Support for Beneficiaries: This would include choice counseling services, enrollment and disenrollment assistance, and advocacy support services. Also, it includes creating an access point for complaints and concerns, education on grievance and appeal rights, assistance to beneficiaries in handling appeals, and ongoing state oversight on systemic issues. CMS also includes authority for beneficiaries to dis-enroll from a plan if the beneficiary’s provider leaves the MLTSS plan network.
Person-centered Process: A standard feature for CMS in all MLTSS areas: The design is to help achieve the greatest level of independence for the beneficiary.
Comprehensive Integrated Service Package: It is intended that the state and the plan coordinate all functions needed for a successful delivery of services.
Qualified Providers: This is a combination of provider credentialing and adequate access to care requirements. CMS does not spell out what each must be in quantitative terms. Instead, CMS sets out certain areas that states must develop standards. For example, certain provider types must be available within state-defined time and distance standards. Other components include a requirement that the state specify minimum factors in developing the standards such as the expected enrollment size. CMS suggests, but does not mandate the use of enrollee-to-provider ratio standards in MLTSS. Overall, significant flexibility is afforded the states in establishing access standards. Some states have addressed access standards by allowing beneficiaries to continue with an existing provider for a period of time and permitting plans to establish limited networks of providers after the transition period closes. However, CMS does indicate that a beneficiary with the power to choose the provider albeit from whatever limited network the plan ultimately offers.
Participant Protections: This requirement is all about grievance and appeals processes and adequate communications.
Quality: As usual, the quality standards are vague and leave virtually all discretion to the state Medicaid programs. CMS does provide that three principles must be adhered to—Transparency; Alignment with other systems of care; and Consumer and Stakeholder Engagement.
After the rule was proposed in July 2015, NAHC submitted comments with several recommendations for improving the rule, including specifically requiring states and contractors to develop plans to comply with the Americans with Disabilities Act (ADA) and the U.S. Supreme Court decision in Olmstead v. L.C. (see previous NAHC Report article here).
NAHC is reviewing the 1,425-page final rule to determine the extent to which it provides a solid framework for establishing MLTSS, with preference given to home and community-based care. Stay tuned to NAHC Report for further analysis.