The Medicaid Managed Care Final Rule addresses managed care plan network issues while preserving significant flexibility for the states in designing the standards.  The Rule adds a new regulation (42 C.F.R. § 438.68) on network adequacy standards for medical care and Long-Term Services and Supports (LTSS) as well as one related to availability of services (42 C.F.R. § 438.206).  Although states already regulate network adequacy, the Rule provides a new minimum level of compliance and aligns standards for Medicaid managed care plans around the country while deferring to states to actually develop the standards.  States must set time and distance standards for a variety of provider types, including, primary care (adult and pediatric), OB/GYN, behavioral health, specialist (adult and pediatric), hospital, pharmacy, pediatric dental, LTSS providers, and additional provider types that promote the objectives of the Medicaid program.  These standards must include CMS-mandated elements such as anticipated enrollment, expected utilization, the numbers and types of providers required to provide contracted services, the ability of providers to communicate with limited English proficient beneficiaries in their preferred language, and the availability of telemedicine and other “evolving and innovative technological solutions.”  42 C.F.R.§ 438.68 (c).  In the Preamble, CMS explains that time and distance standards are a more accurate measure of timely access than provider-to-enrollee ratios, which some states previously used.  States must publish these standards online and make them available, at no cost, in alternative formats for individuals with disabilities.  42 C.F.R.§ 438.68 (e).

Additionally, states must ensure that covered services are available and accessible in a timely manner, as explained in 42 C.F.R. § 438.206. The Rule requires states to enforce network maintenance and monitoring requirements for managed care plans, including direct access to women’s health specialists for female beneficiaries, appropriate access to second opinions, coordination with out of network providers for payment, and provision of sufficient family planning providers.  States also must ensure compliance with timely access requirements, including the specific requirement that network provider hours of operation are no less than the hours offered to commercial enrollees.  42 C.F.R. § 438.206(c)(1)(i).  And service delivery must be provided in a culturally competent manner and accessible to those with physical or mental disabilities.  In the Rule’s Preamble, CMS remarked that the disability access was especially critical for LTSS recipients, who have a higher rate of disability than other beneficiary groups.

For additional coverage of the Medicaid Managed Care Final Rule, click here.