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10 takeaways on CMS' updated Medicare managed care rules

In April, CMS issued its final regulations to bolster its Medicare managed care rules, according to

Here are 10 updates on the rules.

1. Quality of care. Per the updates, states are required to have a written quality strategy, which is comprised of performance measures, performance improvement projects, a mechanism for identifying enrollees with long-term services and supports or special health care needs and a plan to limit health disparities, among others. States must also identify over- and under-utilization and the quality and appropriateness of care providers offering long-term services and supports users.

2. Transparency and accountability. The rule enhances data, transparency and accountability requirements at the state and plan levels. States are mandated to screen and enroll all managed care network providers who are not already enrolled in the state's fee-for-service system.

3. Enrollment and disenrollment protections. If states choose health plans for beneficiaries and passively enroll them, CMS mandates those states notify the beneficiaries and give them an allotted 90 days to change plans. For voluntary managed care programs, beneficiaries can change plans or opt to remain in the fee-for-service system. Those enrollees who use long-term services and support plans can disenroll from their plan if their LTSS provider leaving the plan's network impacts the enrollee's residence or employment.

4. Payment & delivery changes. In the updates, CMS clarifies state payment tools to support enhanced managed care plan's performance. The rules also support state authority to mandate plans to implement value-based purchasing models and participate in multi-state or Medicaid-specific delivery system reform initiatives.

5. Medical loss ratio standard. CMS set the minimum medical loss ratio in Medicaid at 85 percent. The standard also applied to Medicare Advantage and private large group plans.

6. Network adequacy and access to care. For long-term services and supports providers who travel to enroll, CMS is requiring states to establish time and distance standards for 11 specified types of providers and other network adequacy standards. Additionally, states need a continuity of care policy for beneficiary moving from fee-for-service care to managed care, or from one managed care plan to another plan.

7. Continued services during appeals. The rules allow managed care enrollees to have access to continued services during denials' appeals. CMS updated the Medicare appeal timeframes to more adequately align with Medicare Advantage and Marketplace rules.

8. Beneficiary support and information. Per the updates, states are required to implement an independent beneficiary support system that offers enrollees the choice of counseling and information, as well as additional assistance to enrollees who use long-term services and supports.

9. Short-term IMD stays. States can obtain federal matching funds for capitation payments for those adults who receive psychiatric or substance use disorder inpatient or crisis residential services in an IMD for no more than 15 days in a month.

10. Managed long-term services and supports. States are required to identify those enrollees with long-term services and supports needs. Plans also must be able to comprehensively evaluate such enrollees, and comply with CMS' person-centered planning and home and community-based setting regulations.

More articles on coding & billing:
GAO: Medicare failing to control appeals; wait time increases 8%+ : 6 things to know
HHS aims to improve ACA marketplaces: 5 points
Assister Programs helps 5.3M Americans gain coverage — 10 survey findings

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