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HMA Tool Helps MCOs Implement Medicaid Managed Care Rules

On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the final Medicaid managed care rules to modernize federal Medicaid managed care regulations. Many of the new rules go into effect July 2017. The hard work of implementing the new Medicaid managed care regulations will fall squarely on the shoulders of states and Medicaid managed care health plans. For managed care plans, they must step up their operational, administrative, and reporting capabilities to accommodate new state oversight requirements across all aspects of the contract performance.

The final rule unifies requirements across all forms of managed care, including managed care organizations (MCOs) operating under comprehensive risk contracts, prepaid inpatient and ambulatory plans (PIHPS and PAHPS), and primary care case management (PCCM), recognizing variation in size and scope. The broad implications of the new rules for health plans are:

  • More standardized approaches across and within states, particularly in financial management
    • Medical Loss Ratio and other rate setting issues
    • Appeals and grievances policies and timelines
    • Provider enrollment shifted to the state level
    • Encounter data and annual reports
  • Specific policy standards and requirements related to MLTSS
  • Substantial new reporting and oversight requirements
  • Some areas of considerable state flexibility—particularly in delivery system reform
  • Quality strategy still to be developed

On May 17, 2016, HMA provided the free webinar “Preparing for the New Medicaid Managed Care Regulations.” During this webinar, HMA experts provided a framework for assessing the final rule, analyzing your organizational needs, and implementing the operational and functional changes needed. HMA experts provided an overview of the final rule and outlined the HMA Impact Analysis and Implementation Tool, a rigorous process for identifying opportunities and challenges the new rules pose to managed care organizations. Click here to view this webinar.

In preparation for this significant overhaul to Medicaid managed care regulations, HMA geared the managed care regulation Impact Analysis and Implementation Tool toward MCOs. The purpose of the tool is to help MCOs understand and assess the impact of the new regulations. It can be used to complete a gap analysis and serve as a tracking document and work plan/project plan to bring the organization into compliance. The tool can also help MCOs proactively engage in discussions with states about implementing the new rules.

Organizations can purchase the tool as a stand-alone, or work with HMA to help complete the analysis, manage implementation, and/or incorporate new requirements into operations. HMA also can amend the tool to address compliance for non-MCO organizations.

For more information about the tool or assistance from HMA in implementation, operations, education and training, or understanding the impact of the new rules to your organization, please contact your current HMA project manager/contact, Anne Winter, or Nicole McMahon.

Meet the HMA blog contributors

Nicole McMahon

Nicole McMahon

Associate Principal
Indianapolis, IN