CMS Seeks to Increase State Flexibility, Promote Telehealth in Medicaid Managed Care

| Brittany McCullough
Medicaid puzzle piece being put into place

In a recently proposed rule, CMS announced plans to streamline managed care regulations, enhance state flexibility, promote transparency and innovation, and reduce regulatory burden.

My previous blogs on innovation in Medicaid have highlighted value-based drug pricing contracts in Oklahoma, the incorporation of initiatives to address social determinants of health in Colorado, and how integrated delivery networks are looking to transform behavioral health in New Hampshire.

This notice of proposed rulemaking serves as a nice close to my series as CMS looks to restructure the current Medicaid program to encourage even greater innovation among the states.

In a November 8, 2018 press release, CMS states the 2016 Medicaid managed care final rule under the Obama Administration was a “substantial and comprehensive rewrite” but it “included provisions that many states and stakeholders identified as unnecessarily prescriptive…without contributing to the improvement of health outcomes.”

According to CMS’s fact sheet, roughly two thirds of all Medicaid beneficiaries were enrolled in a comprehensive managed care organization (MCO) in 2016 which is almost a three percent increase from 2015.

Given the far reach of Medicaid managed care, it isn’t surprising that CMS would revise the accompanying regulations to create a strong framework while giving states the flexibility to best meet the needs of their respective populations.

One of the more notable ideas included in the proposed rule was the allowance of telehealth in consideration of network adequacy standards. CMS notes that time and distance standards might not be the most effective means to determine network adequacy especially among regions with a “heavy reliance on telehealth.” This is rather remarkable because it is the strongest stance CMS has taken on the potential of telehealth as it relates to ensuring adequate access to contracted health services for consumers.

For example, a consumer may live in an area where the nearest specialist is physically 50 miles away, but they can readily access another provider for the same service using a virtual platform. Fifty miles might not meet the typical time and distance standard which may lead to the network being considered inadequate even though the consumer has timely access via telehealth.

As part of their network adequacy requirements, CMS is removing the time and distance standard requirement and requiring states to “set a quantitative minimum access standard for specified health care providers and [long term services and supports] providers.” This change ensures consistency for network adequacy standards across all providers. 

Despite this proposal advancing the use of telehealth in managed care, states can still opt to not allow health plans to use telehealth to make the case for meeting network adequacy standards.

Here are other highlights of provisions in the November 14, 2018 proposed regulation:

  • Contract Provisions – Explicitly require risk-sharing mechanisms to be documented in contract and related rate certification documents in advance of the contract effective date
    • Bans retroactive modifications to risk-sharing mechanisms
  • Information Requirements – Require taglines in prevalent non-English languages must be on materials that are considered vital to obtaining services
    • Previously taglines in prevalent non-English languages were required on all written materials
    • Also modifying requirement for taglines to be at least size 18 point to “conspicuously visible”
  • Provider Termination Notice Requirements – Require managed care plans to issue notice to enrollees of a change in a participating provider’s network status to the later date between 30 calendar days before the termination effective date or 15 calendar days after receiving or issuing a termination notice
    • Currently managed care plans must provide notice within 15 days after receiving or issuing a termination notice
  • Provider Directories – Allow quarterly updates to the paper provider directory if the managed care plan has a “mobile-enabled directory”
    • Managed care plans without a mobile enabled directory must update paper directory monthly
  •  Grievances and Appeals – Eliminate the requirement for enrollee oral appeals to be followed up with a signed, written appeal
    • Managed care plans note they currently can’t issue a resolution prior to obtaining the written appeal which unnecessarily extends the timeline for a decision

To read more about how telehealth can improve outcomes, check out our newly released industry insight report.

Brittany McCullough photo

Brittany McCullough, Health Policy Specialist.

Brittany McCullough, URAC's health policy specialist, focuses on tracking and analyzing legislation and regulations of importance to URAC stakeholders. She also helps manage URAC’s public policy external engagement. Most of her policy and research work has been related to the ACA, Medicaid managed care, Part D, telehealth and mental health parity. She holds a B.S. in Neuroscience and a Master of Health Administration.

Views, thoughts and opinions expressed in my articles belong solely to me, and not necessarily to my employer.

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