The key word defining the first significant federal changes to Medicaid managed care in 14 years is “flexibility”—for states, that is.
The CMS laid the responsibility of ensuring that some of the country's poorest residents receive timely, high-quality care to the 39 states and the District of Columbia that contract with private managed-care plans to provide Medicaid services.
But those states will need money, manpower and some detailed direction to implement the provisions of the sweeping Medicaid managed-care rule. And some states are more prepared than others to meet the challenge. That could lead to disparities in the improvements to healthcare quality and access the regulations seek to achieve.
“How states implement this is really going to be the key to whether it does lead to better outcomes,” said Judy Solomon, a vice president for health policy at the left-leaning Center on Budget and Policy Priorities. “There's a tremendous amount of flexibility and tremendous amount of work that needs to be done to support states.”
The CMS did not change much from the proposals published last May. The agency outlined several major reforms, including installing a medical-loss ratio for insurers and provisions intended to make provider networks more robust. The goal is to ensure that a program meant to cut costs and constrain budgets doesn't lead to inadequate or unattainable care for the estimated 46 million low-income people enrolled in Medicaid managed-care plans.
But it's up to cash-strapped states—many of which have refused to expand Medicaid eligibility under the Affordable Care Act and have severely cut Medicaid resources over the past several years—to take the CMS up on its policy suggestions. “You can't just sit back and think it's going to happen if (states) don't have the resources,” Solomon said.
State programs are now responsible for ensuring the adequacy of provider networks, conducting more provider screenings and submitting more details for rate certifications.