Medspan’s Tri-Weekly Newsletter–See What We Have Learned and You Should Know

June 23, 2015 at 9:32 AM Leave a comment

picture Changes to Managed Medicaid

In May 2015, the Center for Medicare and Medicaid Services (CMS) released a 653-page rule that is likely to create the largest changes in managed Medicaid in over ten years.

Most importantly, the proposed rule would:

  • Cap insurer benefits by requiring that managed Medicaid plans use 85 cents of each premium dollar to cover medical care.
  • Require states to more meticulously oversee the adequacy of managed Medicaid plans’ provider networks.
  • Encourage states to establish quality rating programs for plans.
  • Allow more behavioral healthcare in institutional settings.
  • Encourage the growth of managed long-term care.

Approximately 46 million Americans, or 75% of all Medicaid beneficiaries, are in managed-care plans. That number is rising rapidly through state initiatives to control costs and ACA’s expansion of Medicaid to low-income adults (pending King vs. Burwell).

The millions of children covered under the Comprehensive Health Insurance Plan (CHIP) also would be affected by the proposed rule.

When structuring their provider networks, managed Medicaid plans would have more specific time and distance standards for certain types of providers: hospitals, primary care physicians and OB-Gyns. Time and distance standards more accurately address access to care than the current measure of enrolee-to-provider ratios.

It is unclear as to how states that are struggling financially may respond to the proposed rule.

Source: Dickson, V., & Herman, B. (2015, May 30). New CMS rule could reshape Medicaid managed care. Retrieved June 15, 2015.


Entry filed under: Affordable Care Act, ASP, CHIP, cms, Comparative Effectiveness Data, cost of care, cost of healthcare, cost reduction, fee-for-service, Government programs, healthcare costs, Healthcare Economics, Healthcare innovation, Healthcare marketing, Healthcare Policy, Healthcare Reform, managed medicaid, Medicaid, State Medicaid Expansion. Tags: , , , , , , , , , , , , .

MedSpan Research’s Tips for Conducting Payer Research Here’s a MedSpan Research tip!

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

Trackback this post  |  Subscribe to the comments via RSS Feed

Enter your email address to follow this blog and receive notifications of new posts by email.

Like this? Share it!


%d bloggers like this: