Medicaid Plans Get New Quality and Performance Measures
Written by Editor   
Wednesday, June 17, 2015 03:47 PM
Quick Brief: CMS announces  a proposal to “modernize the Medicaid managed care regulations” that haven’t been revised in a decade.


The Centers for Medicare and Medicaid Services (CMS) announced a proposal to "modernize the Medicaid managed care regulations," which haven't been revised in a decade.

"The proposed rule would align the rules governing Medicaid managed care with those of other major sources of coverage, including coverage through Qualified Health Plans and Medicare Advantage plans," according to a CMS statement.

Most managed care plans offer health benefits and other services through contracts between state agencies and managed care organizations (MCOs). States set up and supervise their own managed care programs within the boundaries of federal requirements spelled out in Medicaid law and additional regulations. They also receive a fixed monthly payment for each enrolled Medicaid beneficiary.

When the rule was last revised a minority of Medicaid beneficiaries received their care under managed care plans. Currently around 70% of Medicaid enrollees receive services through managed care, according to

CMS' new proposal has a three-pronged focus: to enhance consumer protection, develop better care coordination, and enable delivery system reform.

A CMS deputy administrator and director for the Center for Medicaid and CHIP Services, highlighted some of the proposed key provisions:

  • Shifting the appeals process and the level of enrollee information dissemination to practices seen in Medicare Advantage and the private market practice
  • Reducing the administrative burden on regulators and plans that offer different products in different coverage programs
  • Using advances in electronic communication to accelerate information exchange
  • Adopting the medical loss ratio (MLR), that currently applies to Medicare Advantage (85:15 ratio), while making some accommodations for state-specific concerns
  • Strengthening states' capacity to use financial incentives to reward managed care plans that meet quality measures
  • Developing a quality rating system similar to that used in Medicare Advantage and by private plans

CMS is soliciting public comment on the proposed rule through July 27.