CMS Proposes Sweeping Changes to Medicaid Managed Care Regulations

The Centers for Medicare & Medicaid Services (CMS) is proposing a comprehensive overhaul of Medicaid managed care regulations, comprising over 650 pages of new rules. This shift comes as the number of Americans covered by Medicaid managed care has grown significantly, with 46 million individuals now relying on these plans, approximately 70% of Medicaid beneficiaries. The proposed regulations aim to address changes in the healthcare landscape over the past decade, bringing Medicaid in line with best practices and regulations found in other health insurance programs.

Key Takeaways:

The proposed regulations introduce new provider adequacy standards to ensure Medicaid plans have sufficient networks of healthcare providers.
The rule sets new mandates for capitated rate setting, requiring Medicaid plans to negotiate rates with providers based on predicted medical costs.
Beneficiary protections in long-term care, forthcoming quality ratings, and an 85% medical cost administrative ratio are also part of the proposed changes.
Companies like UnitedHealth Group, Aetna, and Centene have expanded their Medicaid managed care plans to meet growing demand from states, aiming to control costs.
Presbyterian Healthcare Services in New Mexico and UPMC in Pennsylvania are examples of health systems with their own health plans that have also entered the Medicaid managed care market.

Statistics:

46 million Americans are covered by Medicaid managed care, approximately 70% of Medicaid beneficiaries.
The proposed regulations address changes in the healthcare landscape over the past decade, aiming to update Medicaid regulations in line with best practices.
Medicaid managed care plans are expected to have a national 85% medical cost administrative ratio.
UnitedHealth Group, Aetna, and Centene have grown Medicaid managed care plans to meet demand from states to control costs.
Presbyterian Healthcare Services in New Mexico and UPMC in Pennsylvania are health systems with their own health plans that have expanded into Medicaid managed care.

Sources:

[Centers for Medicare & Medicaid Services (CMS) - reference not explicitly provided but mentioned in the original text]
[Andy Slavitt, acting administrator of CMS and former executive at UnitedHealth Group's Optum Company]
[America's Health Insurance Plans]
[Medicaid Health Plans of America]