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
Medicaid managed care
CMS Proposes Easing State Requirements for Demonstrating Medicaid Beneficiary Access to Care
The Centers for Medicare & Medicaid Services (CMS) has proposed rescinding current procedural standards that must be met for states to demonstrate that Medicaid fee-for-service (FFS) payments are sufficient to assure beneficiary access to covered services.
As we previously reported, regulations adopted in 2015 require states to establish and periodically update access monitoring review…
CMS Proposes Easing Rules for State Medicaid FFS Access Monitoring
The Centers for Medicare & Medicaid Services (CMS) is proposing to exempt states with high rates of Medicaid managed care enrollment from current requirements to analyze and monitor access in fee-for-service (FFS) delivery systems. The proposed rule also would loosen current state access analysis requirements when states make what CMS contends are “nominal” reductions in…
Trump Administration Outlines Planned Regulatory — and Deregulatory — Actions for 2018
The Trump Administration has updated its “Unified Agenda of Regulatory and Deregulatory Actions,” which lists the scope and anticipated timing of pending and future regulations. In releasing the agenda, the Administration highlights its “ongoing progress toward the goals of more effective and less burdensome regulation,” including its plans to finalize three deregulatory actions…
CMS Finalizes Tighter Rules for New Medicaid Managed Care Pass-Through Payments
CMS has finalized without change its proposed rule to block states from adopting or increasing Medicaid managed care “pass-through” payments to hospitals, nursing facilities, and physicians beyond those in place when pass-through payment transition periods were established in a May 6, 2016 final Medicaid managed care rule. As we previously reported, CMS considers…
CMS Proposes Restrictions on New Medicaid Managed Care Pass-Through Payments
CMS is proposing to prohibit states from adopting new or increased “pass-through” payments to hospitals, nursing facilities, and physicians under their Medicaid managed care contracts beyond those in place when the pass-through payment transition periods were established in a May 6, 2016 final Medicaid managed care rule. CMS considers pass-through payments to be amounts…
OIG Faults State Efforts to Identify 340B Drug Claims; Cites Risk of Duplicate Discounts, Forgone Rebates
The OIG recently examined how states that pay for drugs through Medicaid managed care organizations (MCOs) identify and exclude 340B drug claims when collecting Medicaid rebates, since states are prohibited from collecting “duplicate discounts” (i.e., when manufacturers pay Medicaid rebates on drugs sold at the discounted 340B price). The OIG also reviewed potential vulnerabilities that …
OIG, GAO Examine Medicare & Medicaid Program Integrity/Provider Screening Issues
The HHS Office of Inspector General (OIG) and the Government Accountability Office (GAO) have recently examined a number of Medicare and Medicaid provider screening and related program integrity issues. The OIG reports include the following:
Continue Reading OIG, GAO Examine Medicare & Medicaid Program Integrity/Provider Screening Issues
CMS Finalizes Major Reforms of Medicaid/CHIP Managed Care Rules
On May 6, 2016, CMS will publish a final rule to 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, promote quality, and strengthen the actuarial soundness of payment provisions. The last major update to the Medicaid/CHIP managed care rules occurred in 2002; since that time, states have expanded the use of managed care, both geographically and in terms of the populations served, including seniors and persons with disabilities and those needing long-term services and supports (LTSS).
The sweeping new rule (the advance version is more than 1,400 pages) addresses numerous aspects of program requirements and responds to the nearly 900 comments received from the public in response to the June 1, 2015 proposed rule. Among other things, the final rule:Continue Reading CMS Finalizes Major Reforms of Medicaid/CHIP Managed Care Rules
House Unanimously Approves Legislation to Remove Terminated Providers from Medicaid, CHIP
The House of Representatives has unanimously approved H.R. 3716, the Ensuring Access to Quality Medicaid Providers Act. The bill, which still awaits Senate consideration, would implement several OIG recommendations to improve CMS oversight of terminated providers and state screening of providers. Among other things, H.R. 3716 would require states and Medicaid managed care plans…
CMS Proposes Overhaul of Medicaid/CHIP Managed Care Rules
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 Issues 2015 Compendium of Unimplemented Recommendations
The OIG has released its March 2015 “Compendium of Unimplemented Recommendations,” which highlights the OIG’s top 25 recommendations for cost savings and/or quality improvements in HHS programs, along with other significant unimplemented recommendations. High-priority recommendations address the following areas, among others:
- Payment Policies and Practices: Expand the DRG window to include additional days prior to
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CMS Proposed Rules in the Pipeline
CMS recently sent several major proposed rules to the White House Office of Management and Budget for regulatory clearance – the last step before publication in the Federal Register. OMB is reviewing proposed rules to update the skilled nursing facility, inpatient rehabilitation facility, and inpatient psychiatric facility prospective payment systems (PPS) for fiscal year (FY)…
OIG Examines Varying State Standards for Access to Care in Medicaid Managed Care
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…