The Centers for Medicare and Medicaid Services (CMS) released a pair of proposed rules on April 27, 2023 that make substantial changes to the structure of Medicaid and the Children’s Health Insurance Program (CHIP), both in the traditional fee-for-service setting and for services provided through managed care organizations (MCOs), and incorporate feedback from stakeholders in
managed care
CMS Proposes Overhaul of Medicaid/CHIP Managed Care Rules
By Debra A. McCurdy on
CMS has published a proposed rule that would update Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations to more closely align with Medicare Advantage (MA) and private health plan standards and to strengthen quality safeguards. The proposed rule, which represents the first major revisions to Medicaid and CHIP managed care standards in more…
OIG Report: Access to Care, Provider Availability in Medicaid Managed Care
By Debra A. McCurdy on
The OIG has issued a report entitled “Access to Care: Provider Availability in Medicaid Managed Care,” which found that more than half of Medicaid managed care providers could not offer appointments to Medicaid enrollees, and one third could not be found at the location listed by the plan. The OIG observed that there…
OIG Examines Varying State Standards for Access to Care in Medicaid Managed Care
By Debra A. McCurdy on
The OIG has issued a report evaluating state standards for access to care for Medicaid managed care program enrollees, an issue which the OIG notes has taken on heightened importance as enrollment in such programs grows. Based on a review of the 33 states with comprehensive, "full risk" Medicaid managed care, the OIG concluded…
CMS Seeks Input on Potential Delivery Innovations in Medicare Part D, Medicare Advantage, & Other Programs
By Debra A. McCurdy on
CMS is seeking input on initiatives to test care delivery innovations in the Medicare Part D program, Medicare and Medicaid managed care plans, and other government programs. CMS notes that while “[h]ealth plans increasingly have responded to market developments and fiscal pressures with innovations in care delivery, plan design, beneficiary and provider incentives, and…
GAO Calls for Greater Medicaid Managed Care Program Integrity Efforts
By Debra A. McCurdy on
A recent GAO report, “Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures," identified gaps in both state and federal Medicaid managed care program integrity efforts. For instance, based on a review of Medicaid activities in seven states, the GAO found that five state program integrity units and four Medicaid…
CMS Letter to States on Quality Considerations for Medicaid and CHIP Integrated Care Models
By Debra A. McCurdy on
CMS has posted a November 22, 2013 letter to state health officials on “Quality Considerations for Medicaid and CHIP Programs,” the fourth in a series of guidance documents intended to assist states with designing and implementing integrated care models, such as medical/health homes, accountable care organizations, and managed care. The latest letter provides…
OIG Examines Employment of Excluded Individuals by Medicaid Managed Care Entity Providers
By Debra A. McCurdy on
A recent OIG report assesses the extent to which provider networks of managed care entities (MCE) that contract with state Medicaid agencies employ excluded individuals. Based on an examination of the 2011 employee rosters of a sample of 500 hospitals, nursing facilities, home health agencies, and pharmacies in 12 MCEs, the OIG identified 16…
State Collection of Medicaid Rebates for Drugs Paid Through Medicaid MCOs
By Debra A. McCurdy on
The OIG has examined the extent to which states collect accurate drug utilization data and associated drug manufacturer rebates for drugs paid through Medicaid managed care organizations (MCOs). According to the OIG, this data is important to enable states to realize the full savings under an ACA provision that requires drug manufacturers to pay…
GAO Information on States’ Use of Medicaid Managed Care
By Debra A. McCurdy on
The GAO has provided a report to Congress describing states’ use of managed care in their Medicaid programs, including the type of managed care arrangements states have in place and their enrollment of populations with complex health care needs. The GAO points out that this data “may be informative as states consider expanding their…