Topic: Medicaid

CMS Releases New Medicaid Rule, OMB in Final Review

Sunmi Janicek

Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule ‒ a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.

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What to Watch: The Fiscal Year 2017 budget

Olga Walther

President Obama released the Fiscal Year 2017 budget last Tuesday, which contains many significant proposals to government healthcare programs. Although both the Senate and House’s budget committees already rejected hearings from the President’s budget chief and unsurprisingly declared the bill “dead on arrival,” the proposals do contain many bipartisan provisions with significant cost savings. One such proposal organizations should watch carefully, for example, is using competitive bidding in Medicare Advantage plans.

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Issues That Will Define Government Health Programs in 2016

John Gorman

The new year brings a slew of issues that will define government-sponsored health programs.  Here’s what we’re watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we’d be out of business.

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Senate passes bill repealing major provisions of Affordable Care Act

Olga Walther

Last week, the Senate passed an Affordable Care Act (ACA) repeal bill, with a vote of 52-47. Although largely symbolic, this marks the first time the Senate has been able to pass such a bill.

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Proposed Changes to the CMS-HCC Risk Adjustment Model

Daniel Weinrieb

Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.

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Recommendations Made by the National Quality Forum on Medicaid Measures

Sunmi Janicek

The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care.  For the last four years, NQF started providing strategies to HHS on improving care for dual eligibles, adults, and children in the Medicaid program.  These new quality measures were created to improve healthcare quality for more than 70 million adults and children.  The key area of concentration was the beneficiaries’ behavioral health and how it affects diabetic and cardiovascular care delivery.

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How to Partner with Key Health Systems in your Service Area to Optimize Benefit Plan Offerings

Elena Martin

As we anticipate additional information this week on the Centers for Medicare & Medicaid Services (CMS) network adequacy (pilot) audit, we can’t help but consider how CMS’ rigorous access and availability standards hamper Medicare Advantage (MA) plans’ ability to be on the cutting edge of innovative network design. The Affordable Care Act, in comparison, has allowed for Marketplace plans to offer narrow networks as long as the networks have sufficient numbers and types of providers to deliver services without “unreasonable delay,” leaving states to define the meaning of “unreasonable.” This difference in network adequacy standards has widened the gap in plan offerings.

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