CMS Medicaid Managed Care Final Rule Q&A from MAXIMUS Webinar

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May 23, 2016

Recently, the Centers for Medicare & Medicaid Services (CMS) released a final rule (the Rule) affecting state Medicaid programs that use managed care organizations (MCOs) to deliver services to their beneficiaries. We held a webinar on Tuesday, May 3 summarizing the Rule and what it means for states. If you would like to view the webinar in its entirety or see the slides, click here.

We received some questions during the webinar that we were not able to answer in the time allotted – here are those questions – answered with our perceptions of the Rule.

Q: Is there anything in the new rule impacting fee-for-service (FFS) Medicaid that FFS-only states would need to know or be aware of?

A: Yes, if the FFS model in the state has any risk-based components, much of the Rule applies (PIHPs/PAHPs or PCCM). Even if the state only has regional PCCM entities, there are aspects of the Rule that they must address – including provider enrollment, etc. If the state has only FFS, with no capitation arrangements in either Medicaid or CHIP, then there is no application. However, while the new Rule is limited to managed care, it is very clear that CMS is trying to harmonize requirements between Medicare, the Health Insurance Marketplaces and Medicaid. FFS-only states should consider if this harmony is foreshadowing for future alignment that may be inclusive of FFS as well.

Q: Do states have a specified amount of time to transition/meet the new enrollment requirements?

A: While there are no specific deadlines that apply to every state and every part of the Rule, there is a representative timeline that a state can use to plan implementation of the requirements found here. States should expect that any time after July 2017 or July 2018 (depending on the requirement) CMS will request compliance or a timeline for reaching compliance. There are some specific timelines that states should review in the schedule based on the planning, contracting and structure needed to comply. For example, the enrollment deadline for states to screen MCO providers is technically July 1, 2018, which is not much time, considering the infrastructure that a state may need to implement beforehand.

Q: Have you found any specific language talking about conflict-free level of care determinations for home and community-based waivers?

A: The preamble does discuss the difference between conflict-free eligibility assessments prior to enrollment, and a health plan’s ongoing assessments (including functional assessments that may determine long-term services and supports (LTSS) program benefits and budgets) once an individual is enrolled in a plan. In the care coordination requirements, CMS changed the language regarding who should do assessments from “health care professional” to “provider” and acknowledges the importance of using appropriate individuals to meet LTSS service coordination requirements.

Q: Will the provider directories indicate whether or not the provider is accepting new patients?

A: CMS has not offered any guidance on the specific requirements for the provider directories and appears to leave these details up the states. While this information would be helpful when identifying an appropriate provider, this may not be logistically reasonable, as this information changes on a daily basis.

Q: Do you know when the new EQRO review protocols will be published?

A: It appears that the EQRO review protocols will be developed by HHS in cooperation with NGA. Based on pure speculation, it will be at least a year before those are finalized. Additional information may be available on CMS technical calls in the near future.

If you are interested in continuing the conversation with us, we will be holding three more webinars regarding the Rule that you can register for here. You can also email us with more questions or for guidance on how to bring your state into compliance.

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