In balancing the review and approval requirement with the need for state flexibility, CMS proposes two options for states to meet the review and approval requirement. Under the first option, states could implement a review and approval process that is as stringent as a private accreditation entity’s process, the standards for which, as CMS notes, would be purchased by the state. The process would be required every three years. Under the second option, states could rely on evidence that the MMC plan has been accredited by a private accrediting entity recognized by CMS; the state would receive a copy of the accreditation survey. For either option, this information would be publicly available on the state’s website. The Proposed Rule would also permit states to apply both options at the same time, which could result in different standards being applied to current MMC plans. CMS requests comments on the review and approval process and stakeholders should consider the challenges … [Read more...] about CMS Issues Broad-Reaching Proposals to Better Align Medicaid Managed Care with the Commercial and Medicare Markets
Health law managed care
Labor and Employment LawLaws affecting the workplace are in a state of flux, but changes are on the horizon under the new administration, which is generally viewed as being pro-employer. Hospital executives are eager to see how the DOL will be steered on issues such as overtime, worker safety and collective bargaining, to name a few. … [Read more...] about Key Takeaways From FHA’s Health Law Summit
Support States’ efforts to encourage delivery system reform initiatives within managed care programs that aim to improve health care outcomes and beneficiary experience while controlling costs; andStrengthen the quality of care provided to beneficiaries by strengthening transparency and measurement, establishing a quality rating system, and broadening state quality strategies and consumer and stakeholder engagement;Improve consumer experience in the areas of enrollment, communications, care coordination, and the availability and accessibility of covered services;Implement best practices identified in existing managed long term services and supports programs;Align Medicaid managed care policies to a much greater extent with those of Medicare Advantage and the private market;Strengthen the fiscal and programmatic integrity of Medicaid managed care programs and rate setting;Align the CHIP managed care regulations with many of the proposed revisions to the Medicaid managed care rules … [Read more...] about What Changes are in store with the new CMS Proposed Rule for Medicaid Managed Care?
The Proposed Rule notes that CMS believes that "considering the MLR as part of the rate-setting process would be an effective mechanism to ensure that program dollars are being spent on health care services, covered benefits, and quality improvement efforts rather than on potentially unnecessary administrative activities." The Proposed Rule requires that states develop capitation rates that "would reasonably achieve" an MLR of 85% while providing all covered services. If a state does not impose a minimum MLR of 85% or higher, and they use the calculations required by the Proposed Rule to discover their Managed Care plans are operating at an MLR below 85%, they are required to use this information to set a future rate such that, using the projected revenues and costs for the rate year, the plan would achieve an MLR of at least 85%. In setting the rates, states also would need to "take into account" the entity's past and projected MLR. … [Read more...] about Proposed Rule’s Medicaid Managed Care Medical Loss Ratio Requirement Will Likely Impact Plans, Providers and Patients in New York
Given these challenges, the budget proposes applying a “sales tax replacement” to both Medicaid MCOs and non-Medicaid MCOs. Applying the sales tax to both types of providers will yield an estimated $854 million annually for Ohio to continue drawing down the federal Medicaid funds. Because the proposed sales tax replacement is an allowable expense under the federal Medicaid guidelines, the state’s Medicaid MCOs will be entitled to recover the entire amount of the cost of the replacement tax, however non-Medicaid MCOs will not enjoy the same benefit. … [Read more...] about Ohio Administration Proposes Changes to State’s Medicaid Managed Care Organization Sales Tax