The Final Rule: Updated Regulations for Medicaid Managed Care

Medicaid and Medicare have long provided access to a spectrum of healthcare services, particularly for underprivileged populations. Direct Care Innovations has been following the Centers for Medicare and Medicaid Services (CMS) as they have been updating regulations to provide efficient fiscal and operational administration without compromising quality health services. With the final CMS rule rollout in April, there are several additional regulations involving the use of managed care by Medicaid and Children’s Health Insurance Program (CHIP) enrollees and managed care organizations.

Importance of the Final Rule

It’s no surprise to anyone that enrollment and overall healthcare costs have significantly increased. Medicaid managed care expenses are responsible for more than half of all annual Medicaid spending. This final rule addresses the federal oversight of Medicaid managed care, including federal financing for state programs, regulations surrounding quality of and access to health care services, and oversight of risk-based managed care and CHIP plans.

Changes to Managed Care

The final rule involves several changes regarding Medicaid managed care, such as specific wait time parameters for particular services, availability of web-based state provider directories, and reportable analyses of annual Medicaid plan payments versus Medicare payment rates. Additional regulations include:

• Enrollee Experience Surveys: Evaluation of access to services, network providers, and quality of care, and assurance of compliance rates for appointment wait times
• Reporting Requirements: Additional state requirements such as secret shopper assessments, provider payment analysis, and corrective action plans added to all state reporting requirements
• Medical Loss Reporting: Adherence to spending 85% of pre-set Medicaid rates for plan administration and health care services, plus specific federal requirements for calculating medical loss ratio reporting
• User-friendly Websites: New requirements to design state health websites with user-friendly presentations, simple navigation, and accessible customer service
• In Lieu of Services: Expansion of in lieu of services benefits to include cost-effective alternatives that meet current needs and prevent future health care interventions.

Greater Fiscal Accuracy & Improved Home Care Services

Managed care organizations, state Medicaid agencies, and self-directed parties require effective business and fiscal management solutions to provide superior healthcare services for clients and their families. Direct Care Innovations' all-inclusive healthcare management software offers EVV tracking, billing and claim management, EVV data aggregation, and additional modules to assist your agency in remaining compliant with these new regulations. 

Flexible & Robust to Meet All Your Needs

The team at DCI can have your organization live in less than 90 days with our healthcare business management modules that best suit your business needs. Request a sales demo today or call us at (480) 295-3307.

Rosenbaum, Sara and Casoni, Maria, "The Medicaid Managed Care Rule Is A Blockbuster," Health Affairs Forefront, Academy Health, May 13, 2024, Visit here.