Coming Medicaid plan rules will set new access standards

CMS officials say they're on track for a January 2015 release of sweeping new Medicaid managed-care regulations intended to ensure that beneficiaries get timely access to care and better integration of services.

HHS' inspector general's office, meanwhile, is preparing a follow-up to a September report that criticized the CMS and the states for not doing enough to make sure Medicaid plans offer adequate provider networks, according to CMS officials who addressed members of the Medicaid Health Plans of America at a conference Tuesday.

While CMS officials offered limited details on what plans could expect from the agency's new rules, James Golden, director of CMS' division of managed-care plans, said the rules would focus on how to better integrate Medicaid plans, Medicare Advantage plans and insurance exchange plans to reduce disruption caused by members churning from one to another.

There also will be additional guidelines for states on how to set rates for plans, which will be in addition to some recent guidance from the agency. On top of that, there will be stronger beneficiary protection language, Golden said.

The recent OIG investigations will lead to stronger standards for network adequacy, including guidelines for how quickly a member should be able to get a physician appointment, Golden said. State officials, however, say they are concerned about tougher federal access standards when there is a shortage of doctors in many areas of the country who are available or willing to contract with Medicaid plans.

The forthcoming OIG report shows that Medicaid plans too often are offering inaccurate information to members about their available provider networks, according to Golden and Barbara Coulter Edwards, director of CMS' Disabled and Elderly Health Programs Group, who both have read the report. It will include the results of OIG's cold-calling doctors on the plans' lists of in-network providers to try to set up appointments. The staffers found instances of listed doctors who were not currently working at those practices.

This problem is not unique to Medicaid plans. Exchange plan members across the country also have faced widely reported problems with inaccurate or outdated provider lists published by health plans.

In the weeks ahead, Golden said, the CMS hopes to team up with various stakeholders, including plans and state Medicaid directors, on best practices to ensure there are consistent standards across the country on network adequacy and timely access to care.

Thirty-seven states and the District of Columbia contract with private managed-care plans to provide Medicaid coverage. Enrollment in these plans is expected to increase by 13.5 million between 2013 and 2016, accounting for 76% of all enrollees in Medicaid and the Children's Health Insurance Program, according to the consulting firm Avalere Health.

Edwards said the CMS has heard expressions of dissatisfaction from state Medicaid officials about the quality of Medicaid plans. “A statement I've been hearing from states is that managed care doesn't necessarily equal service integration,” she said. State officials particularly are concerned about the lack of integration between primary care and behavioral and long-term care services.

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