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Get Ready For Medicaid Compliance Regime

Get Ready For Medicaid Compliance Regime

Long frustrated with the lack of quality in the Medicaid program and poor compliance records of states and plans alike, the Obama administration launched an initiative to overhaul and modernize Medicaid. The so-called Medicaid “mega” or “Uber” rule was finalized in his last year as he was heading out of office. When Donald Trump was elected, it was believed that this rule would go by the wayside.

There are indeed two opposing forces that impact the rule’s implementation. On one hand, the Trump administration chose not to interrupt the rollout of the rule, and is busy working with states on implementation. On the other hand, the Centers for Medicare and Medicaid Services (CMS) is working with a number of states on Section 1115 waivers. These waivers aim at changing or waiving mandates, streamlining or waiving benefits and adding beneficiary copays and personal responsibility measures. House Republicans are keen on taking another stab at a per capita cap or block grant program that will make many of these measures a permanent part of Medicaid law. They failed to pass this as part of the Obamacare repeal bill.

Sophisticated states, such as New York and California, have long practiced fairly robust oversight of Medicaid managed care. The New York quality program (Quality Assurance Reporting Requirements or “QARR”) shines as a solid example of regulatory investment in quality at the state level. Others, such as Florida, have made tremendous leaps forward and have built an extremely accountable infrastructure.

Notwithstanding the probable watering down of Medicaid in some states through waivers, the thought is that the mega rule eventually will have substantial reach and robustness. We expect that CMS will force states to have very rigorous compliance and quality requirements. This is so despite recent announcements to streamline and reduce Medicaid burdens and paperwork at the state level as well as a June 30, 2017 CMS memo committing to a further review of the regulation. CMS was clear in the memo that it plans on prioritizing beneficiary outcomes. The Trump administration can honor its burden-reduction commitments with states as these rules will largely be passed on to private health plans because Medicaid managed care dominates most states now. Further, the rules will mirror Medicare Advantage and Part D, where CMS’ success on both the compliance and quality front has been stellar.

Reforms will include:

  • Strict adherence to timeliness of case turnaround times..
    • Standard Medical Authorization – As expeditiously as the health of the member demands, but no more than 14 days
    • Expedited Medical Authorization – As expeditiously as the health of the member demands, but no more than 72 hours
    • Pharmacy Authorization – 24 hours, with a 72-hour supply for emergency situations. This provision already exists, and is in some ways stricter than Medicare
    • Appeals – filed within 60 days of adverse decision and decided within 30 days
    • Expedited Appeals – 72 hours
    • Authorization and Appeal extension timeframes – up to 14 days
    • Grievance – filed anytime and decision within 90 days
  • An audit regime and requirements for liquidated damages/civil monetary penalties/enrollment suspensions
  • Delegated oversight requirements
  • Consistent use of evidence-based criteria for pharmacy and medical similar to Medicare
  • Enhanced Health Risk Assessment requirements for all enrolled populations, with a stratification of requirements tied to risk (Non-Special Needs, Special Needs and MLTC)
  • Providers and plans would also need to collaborate on sharing and establishing a health record for each member
  • Formulation of treatment plans (similar to Interdisciplinary Care Teams) and ongoing reassessments and interventions
  • Authorization of services that are included in any long-term care member’s treatment plan
  • A Star quality performance program in each state that may be modeled after Medicare Star
  • Provider network adequacy enhancements
  • New member material requirements
  • Minimum medical loss ratio requirements
  • A restatement of actuarial soundness standards
  • Encounter data reforms

Dual demonstration Medicare-Medicaid Plans (MMPs), integrated Dual Eligible Special Needs Plans (D-SNPs), and Managed Long-Term Care (MLTC) Plans growth will also add additional compliance and quality discipline.

All things considered, states and Medicaid managed care plans need to get ready. States that lag behind will be in for the biggest shock.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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