Managed Care Rules Aim to Boost Medicaid Quality, Ease of Participation As more beneficiaries turn to managed care plans, Medicaid updates regulations first issued in 2002. Policy Analysis
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Policy Analysis  |   August 01, 2016
Managed Care Rules Aim to Boost Medicaid Quality, Ease of Participation
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plans and Medicaid advocacy. lalbanhavens@asha.org
    Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plans and Medicaid advocacy. lalbanhavens@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   August 01, 2016
Managed Care Rules Aim to Boost Medicaid Quality, Ease of Participation
The ASHA Leader, August 2016, Vol. 21, 24-25. doi:10.1044/leader.PA.21082016.24
The ASHA Leader, August 2016, Vol. 21, 24-25. doi:10.1044/leader.PA.21082016.24
In issuing its final rule for Medicaid managed care programs and the Children’s Health Insurance Program (CHIP), the Centers for Medicare and Medicaid Services (CMS) addressed many of the concerns ASHA voiced in response to the proposed rule released last year. ASHA commented on provisions related to plan alignment, network adequacy, quality improvement and grievance procedures.
About 72.4 million people receive Medicaid benefits. Almost three-quarters are now covered through managed care plans rather than traditional fee-for-service programs, but rules governing these plan operations have not been updated since they were established in 2002.
The provisions of the rule affect how health care providers—including audiologists and speech-language pathologists—deliver services to Medicaid beneficiaries who are enrolled in managed care and CHIP programs. They provide specific guidance for program operations and implementation of the changes.
Alignment
Because people often move among insurers, eligibility standards for managed care programs should be the same as those for other payers, such as traditional Medicaid and Medicaid expansion plans and the plans that are part of the health insurance exchanges.
Under the rule, if a beneficiary is changing plans—for example, from fee-for-service to managed care—there are requirements to facilitate the smoother transition between plans to minimize any program disruption. The provisions also standardize plan coverage and operations.
Other alignment measures include a more consistent appeals process across plans; requirements for provider directories; and a more efficient application process, which avoids duplication for providers who want to enroll in all three programs (Medicaid Advantage, Medicaid and CHIP).

These inclusions mean that audiologists and SLPs may want to advocate with plans to be included as providers to meet the needs of medically complex and chronically ill beneficiaries.

Network adequacy
Managed care organizations should make sure they have enough providers to meet enrollees’ needs and allow providers who want to participate to enroll as spaces become available. The final rule requires plans to have an adequate number of primary care and other physicians, but doesn’t include ancillary providers, such as audiologists and SLPs.
It does, however, direct states to develop and implement network adequacy standards for long-term services—those that could be delivered by other providers, such as audiologists and SLPs—and supports programs that include criteria for other provider services.
CMS also directs states to assess and certify the adequacy of a managed care plan’s provider network at least annually—and more often as new populations, benefits and service areas are added. It also provides for development of telepractice and other innovative access solutions.
These inclusions mean that audiologists and SLPs may want to advocate with plans to be included as providers to meet the needs of medically complex and chronically ill beneficiaries—those with conditions such as multiple sclerosis and Parkinson’s disease, for example, as well as children with syndromes and developmental conditions. Tools such as ASHA’s “Essential Coverage: Rehabilitative and Habilitative Services and Devices” offer information that can help.
Quality improvement/program integrity
The final rule establishes a publicly reported quality rating system and implements program integrity measures—including procedures for internal monitoring, auditing and reporting of potential fraud and abuse. These provisions expand plan transparency and reflect the caliber of providers.
Grievance and appeal
The final rule ensures that beneficiaries and providers can continue in a program while coverage decisions are being appealed. If an authorization for services expires while a beneficiary or provider is awaiting a decision about continuation of services, the services can continue pending the decision.
The final rule became effective July 1, but implementation will roll out over the next two years. ASHA and many other organizations, including the Medicaid and CHIP Payment Advisory Commission and the National Health Law Program, will continue to provide guidance as the requirements are put into place.
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August 2016
Volume 21, Issue 8