While there are numerous summaries of the Center for Medicare and Medicaid’s (CMS’s) Medicaid and CHIP Managed Care Final Rule, including those provided by CMS, this paper highlights expected and specific changes states will need to make to address requirements of the final rule.
Guidehouse's Government Healthcare Solutions practice reviewed Medicaid managed care contracts for 30 of the 45 states with comprehensive risk-based managed care. The goal was to identify potential changes that the states must make to meet new provider network adequacy requirements. States will need to establish or leverage existing standards and methodologies for determining network requirements, develop enhanced monitoring approaches and document clear processes for monitoring exceptions.
“States should begin to evaluate their current provider network monitoring and oversight practices in light of the new focus on transparency, pediatric access, and documentation requirements. States will likely need to aggregate available provider network data across contractors to gain an understanding of overall enrollee access under Medicaid managed care and to demonstrate value to stakeholders.”
Contracts were reviewed to determine:
Compliance with the new CMS regulations relative to network adequacy (42 C.F.R. 438.68 and 438.207) in four key areas
Time and Distance Standards
Exceptions to Provider Network Standards
Required Elements for Establishing Provider Network Standards
Provider Network Documentation
Monitoring approaches the states rely on to enforce access requirements
While other regulatory sources may include network adequacy requirements (e.g., state Medicaid and insurance regulations, policy guidance), Guidehouse reviewed risk-based contracts because they are the primary Medicaid managed care arrangement used to enforce program requirements and hold contractors accountable.
Most states will need to develop time and distance standards for up to seven required provider types.
Nearly every state must delineate specific time and distance standards for adults and children related to the following provider types: primary care providers, specialists, and behavioral health.
All states must reevaluate the elements they require for establishing network standards as compared to new regulations.
States should formalize approaches for overseeing exceptions to standards.
States must examine existing managed care contract language to determine where network adequacy provisions require updates to comply with new regulation.
Given the elevated focus on network adequacy, states should evaluate their current monitoring and oversight practices on two fronts:
Are managed care contractors meeting provider network adequacy requirements?
Do the network adequacy requirements translate into sufficient and / or improved access for Medicaid members?
States can play a key role partnering with Medicaid enrollees, providers, managed care contractors and other stakeholders to support appropriate provider access.