CMS Proposed Rule Modernizes CHIP and Medicaid Managed Care
By - Following a recent series of proposed physician fee schedules and payment rules from the Centers for Medicare & Medicaid Services (CMS), a new proposed rule, CMS-2390-P, aims to modernize Medicaid managed care policies to mirror changes within managed care delivery system usage.
The significance of the 653 pages of the proposed rule, says CMS, involves the fact that healthcare coverage provided under the Affordable Care Act (ACA) has simply been problematic in terms of coordination and alignment efforts with private insurance markets. Operational efficiencies for those health plans operating within both private and public markets require upgrading and enhancement. Those beneficiaries who move from one source of healthcare coverage to the next are not experiencing high quality care, CMS explains.
“Greater alignment between Medicaid managed care plans and qualified health plans will help these individuals transition between sources of coverage,” the proposed rule states. “Because the health care delivery landscape has changed substantially,” CMS states, “this rule proposes to modernize the Medicaid managed care regulatory structure to facilitate and support delivery system reform initiatives to improve health care outcomes and the beneficiary experience while effectively managing costs.”
The promotion of cost effective strategies for care delivery within the Medicaid and CHIP realms require identifying and implementing innovate strategies. According to CMS and the Department of Health and Human Services (HHS), this proposed rule merges the rules associated with Medicaid managed care with those from other primary coverage sources. These sources include coverage through both Qualified Health Plans and Medicare Advantage plans.
The proposed rule would implement statutory provisions. It would also enhance actuarial soundness payment provisions to advance responsibility within Medicaid managed care program rates. It advocates for boosted efforts to those reform delivery systems serving both Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries.
The proposed rule confirms suitable beneficiary protections and strengthened policies associated with program accuracy. More efficiently executed data and improved care coordination will hopefully strengthen Medicaid beneficiaries’ care quality.
States would mandatorily need to launch comprehensive quality strategies for their Medicaid and CHIP programs, according to the proposed rule. This requirement would need to be met regardless of how beneficiaries receive healthcare services.
Various stipulations of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) would be implemented under the projected rule. Additionally, there will be a focus on third party liability for trauma codes.
The primary objective of managed care and managed care organizations (MCOs) is to manage cost, utilization, and quality within the healthcare industry. Seventy percent of Medicaid enrollees are served via managed care delivery systems. The aforementioned proposed rule is the first substantial update to Medicaid and CHIP regulations in over the past 10 years. It is hopeful CMS’s proposed rule will fortify the delivery of quality care for beneficiaries. CMS confirms the proposed rule supports its mission to promote smarter spending and healthier people.
