On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) released the Medicaid and Children’s Health Insurance Program (CHIP) managed care final rule. The map shows which states will be affected by the new Medicaid rule, highlighting those with Medicaid comprehensive risk contracts with managed care organizations (MCOs).
The new Medicaid managed care rule has significant implications for states; it affects how the states will address health care coverage, access, quality, efficiency and value in the context of managed care. This is the first major update of the Medicaid Managed Care (MMC) rule since 2002, and provides a regulatory framework that updates and clarifies requirements and oversight for Managed Care Organizations and the care they provide to Medicaid beneficiaries.
The majority of states rely on comprehensive managed care contracts to provide health care services to their Medicaid population. This accounts for approximately two-thirds of the 72 million Americans enrolled in Medicaid nationwide. As of July 2015:
- Thirty-nine states, the District of Columbia and Puerto Rico had Medicaid comprehensive risk contracts with MCOs.
- Nine states did not have Medicaid comprehensive risk contracts with MCOs—but have other managed care plans in place.
- Two states (Alaska and Connecticut) do not have Medicaid managed care programs in place.
The new Medicaid rule includes five key goals:
(1) Supporting states’ efforts to advance delivery system reform and improvements in quality of care;
(2) Strengthening the consumer care experience and key consumer protections;
(3) Strengthening program integrity by improving accountability and transparency;
(4) Aligning rules across health insurance coverage programs to improve efficiency and help consumers who are transitioning between sources of coverage; and
(5) Strengthening the actuarial soundness of managed care rates.
The new Medicaid rule is very detailed (1,425 pages) and reflects the complexity involved in providing health care outside of the fee-for-service model, through comprehensive risk-managed care contracts for Medicaid populations. For more in-depth information on the implications of the CMS Medicaid Managed Care rule, resources are available from the Kaiser Family Foundation. CMS also released fact sheets and slide decks on a number of topics related to the final rule.