Does congress have to approve proposed rule changes by the centers for medicaid and medicare

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The requirements related to the federal oversight of full-risk Medicaid managed care programs can be found in Section of the Social Security Act the Act as well as in implementing regulations 42 CFR Section of the Act prescribes the managed care enrollment process, beneficiary protections, and requirements governing information and communication, but establishes in subsection c only two direct oversight and monitoring requirements for CMS and for states:.

Federal regulations that implement Section define state and federal oversight responsibilities in much greater detail, but states have considerable flexibility in how they operationalize these requirements and determine how the plans meet them. The federal rules at 42 CFR specify:. However, differences in managed care program design among states and the use of multiple federal authorities has made it challenging for CMS to implement a consistent federal managed care oversight approach once the programs are implemented.

In , CMS updated the federal rules for Medicaid managed care to expand the federal oversight role, standardize the expectations for states across all managed care authorities, and update program standards to reflect the current scope of Medicaid managed care programs.

Below is a summary of the key federal managed care accountability requirements, reflecting the changes that will be implemented under the new regulations. As noted above, states can implement managed care in their Medicaid programs using one or more federal authorities. CMS is responsible for reviewing and approving state requests to implement managed care under these authorities.

All Medicaid managed care programs, regardless of authority, are subject to the provisions of Section and 42 CFR unless specifically waived. There are different state application and CMS approval processes depending on the authority that is used. For example, the Section state plan amendment SPA application form also referred to as the preprint requires the state to indicate key programmatic features, such as which populations are being enrolled in managed care, the enrollment process, and covered benefits.

The Section b waiver template requests similar programmatic information with significantly greater level of detail than the Section template and requires the state to provide extensive information regarding its monitoring process. When these waivers are renewed, the state submits the results of its monitoring efforts to CMS.

Section waiver applications are often unique to each state and can contain varying amounts of detail. States with demonstrations are also required to submit periodic monitoring reports and formal waiver evaluations. The policies that the state and CMS agree to are ultimately codified in approval documents. Approval of SPAs is quite general in nature, and is typically conveyed in a brief letter to the state. In contrast, approval of Section b requests includes standard terms and conditions STCs.

The variation in the level of detail in some respects reflects the policies under different authorities. Sections b and waive statutory requirements and the terms and conditions enumerate specific conditions under which those waivers are being granted. In the case of Section waivers, the STCs are detailed and state specific, and also establish evaluation requirements, reflecting that waivers under Section are for demonstration purposes.

States provide Medicaid managed care services through contracts with MCOs. Each contract constitutes a legal agreement between the state and MCO for the delivery of services to enrollees and functions as a mechanism to enforce the standards specified by states and the federal government.

MCO contract terms vary among states in the level of specificity of plan requirements, but all include a basic set of activities and specific requirements mandated by federal law and regulation.

Federal law stipulates that states can receive federal Medicaid reimbursement for their payments to Medicaid managed care entities only if their contracts include the following provisions in Section of the Act. The U. Department of Health and Human Services HHS and the state shall have the right to audit and inspect any books and records of the entity.

In addition to these requirements, CMS regulations outline a number of other requirements that must be contained in plan contracts, such as compliance with federal and state contracting rules, inspection and audit of financial records, and prohibition of enrollment discrimination 42 CFR States typically include state-specific and detailed operational requirements in contracts that go beyond the minimum federal contract standards.

For example, state Medicaid managed care contracts will typically include customer service requirements, detailed provider network standards, state-specific financial solvency requirements, data collection and reporting requirements, claims processing and payment standards, and corrective actions. For additional information on Medicaid managed care contract provisions, see Comprehensive Risk-based Contract Requirements. CMS reviews and approves each plan contract in a state, as well as contract amendments.

For states that select plans through a competitive procurement process, the contract approval process begins with the state submitting its proposed request for proposal or other solicitation document to CMS for approval.

Procurements for contracts that are funded with federal dollars are subject to the requirements of 45 CFR 74, including that they be conducted, to the maximum extent practical, in a manner that provides free and open competition.

CMS and states have typically conducted pre-implementation readiness reviews to ensure that MCOs are prepared to comply with program and contract requirements and ready to deliver services to enrollees prior to enrollment.

Readiness reviews assess the ability and capacity of the MCO to perform satisfactorily in all major operational areas, including oversight of subcontractors, enrollee and provider communications, grievance and appeal procedures, member services and outreach, provider network management, program integrity and compliance, case management, utilization review, quality improvement, financial management, claims processing, reporting, and encounter data.

Readiness reviews can include a desk review of documents and an on-site review, including interviews with MCO staff. While readiness review was not an explicit requirement in federal statute or regulation before , CMS has imposed terms and conditions requiring readiness reviews as part of the waiver approvals for many states operating managed care under b or waiver authority. As part of the updated federal regulation that went into effect in , states are now required to conduct MCO readiness reviews when implementing a new managed care program, contracting with a new MCO, or expanding an MCO contract to include new eligibility groups or additional covered benefits 42 CFR The readiness review must be started at least three months before the effective date of the program or contract, completed in time to ensure a smooth implementation, and submitted to CMS for consideration as part of the contract review process described above.

A key aspect of federal oversight is ensuring that state payments to providers comply with federal rules. For managed care payments, the fundamental payment principle is that capitation rates be actuarially sound. This means that they are certified by an actuary that meets the standards set forth in 42 CFR States are required to submit the capitation rates that correspond to the populations and services covered in the managed care program, actuarial certifications for those rates, and data and documentation to support the rate certifications for federal review.

CMS publishes annual guidance for states to assist them in developing rates and the accompanying documentation CMS CMS then conducts a review of the capitation rates for each Medicaid managed care program to determine whether:. For more information on the capitation rate-setting process, see Medicaid Managed Care Payment. The rule requires states to have a formal monitoring system for all managed care programs. These standards at 42 CFR Requiring agents and brokers to cover certain topics.

CMS proposes a list of items that all agents and brokers must address with beneficiaries in order to ensure they are enrolled in a plan that best meets their healthcare needs. Prohibiting marketing of unavailable benefits and limiting marketing regarding savings. The proposed rule would prohibit marketing of benefits in a service area where those benefits are not available, and would prohibit the marketing of information about savings available to potential enrollees that are based on a comparison of typical expenses borne by uninsured individuals, unpaid costs of dually eligible beneficiaries or other unrealized costs of a Medicare beneficiary.

Prohibiting misleading uses of the Medicare name and related logos or information. While current regulations prohibit inaccurate or misleading information, CMS proposes to expand this prohibition to misleading use of the Medicare name, CMS logo, and products or information issued by the federal government including the Medicare card.

Regulating the use of superlatives. CMS would prohibit the use of superlatives e. Requiring an explanation of effect on current coverage. Prior Authorization, Utilization Management and Medical Necessity CMS proposes several provisions governing prior authorization, utilization management and medical necessity determinations.

Generally, MAOs must follow published standards and may not apply unpublished internal criteria. Where no applicable Medicare statute, regulation, national coverage determination or local coverage determination establishes that an item or service must be covered, MAOs may develop internal clinical coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available.

The proposal sets out other requirements for such coverage criteria. When care can be delivered in more than one way or setting, and a contracted provider has ordered or requested Medicare covered items or services for an MA enrollee, the MAO may only deny coverage of the services or setting because the ordered services fail to meet the regulatory criteria.

Regulating the use of prior authorization. CMS proposes that prior authorization may only be used to confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service, to ensure basic benefits are medically necessary based on newly specified standards or to ensure that the furnishing of supplemental benefits is clinically appropriate. The proposed rule also would establish that if a plan approves the furnishing of a service through an advance determination of coverage, it may not deny coverage later on the basis of a lack of medical necessity.

Requiring a transition period for new enrollees. Establishing a utilization management committee. Requiring relevant expertise for coverage determinations. CMS would require that the healthcare professional conducting a medical necessity review have expertise in the field of medicine that is appropriate for the item or service being requested before an MAO or applicable integrated plan issues an adverse determination.

Overpayment Refund Rule The Medicare statute requires that entities report and return any overpayment within 60 days of when the overpayment is identified. Beginning with the Star Ratings, CMS proposes to implement an HEI to reward contracts that obtain a high measure-level score for the subset of enrollees with specified social risk factors i. The HEI reward would be in addition to and would not replace or change the existing categorical adjustment index.

As a result, these measures were some of the most heavily weighted measures in the Star Ratings. CMS has continued to receive significant stakeholder feedback on this approach and is reevaluating its weighting. Beginning with the Star Ratings covering the measurement period , CMS proposes to reduce the weight of these measures from 4 to 2. Removing select measures. Promoting Health Equity CMS outlines several proposals to advance health equity, ranging from culturally competent care requirements to provider directories and more.

Cultural competency requirement. Although current regulations already require MAOs to provide services in a culturally competent manner, CMS proposes to specify that this includes underserved groups beyond linguistically and culturally diverse populations. Examples of such groups include people with disabilities, people of diverse sexual orientations, and people who live in rural areas and other areas with high levels of deprivation.

Provider directories. Digital health education for telehealth. MAOs would be required to identify enrollees with low digital health literacy and to offer those enrollees digital health education. MAOs are not currently subject to digital health literacy requirements. Quality Improvement program. The proposed rule would require MAOs to incorporate activities that reduce disparities in healthcare into their quality improvement program.

Examples of such activities include improving communication, developing and using linguistically and culturally appropriate materials, and hiring bilingual staff. Expanding network adequacy requirements. CMS proposes to add three new behavioral health specialty types to the network adequacy standards in addition to the current requirements for psychiatry and inpatient psychiatric facilities , and add behavioral health services to the general access to services standards.

Closing gaps between physical and behavioral health services.

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Medicare Watch. By Casey Schwarz April 28, Share on facebook. Share on twitter. Share on linkedin. Share on email. The Latest. By Lindsey Copeland. January 12, By Julie Carter. January 5, By Casey Schwarz.

Medicare Answers. By Mitchell Clark. More importantly, the appeals process must be streamlined so that people who are denied drugs can get a denial notice from their plan at the pharmacy counter. CMS also points to drug prices as a primary reason for scaling back the protected drug classes. Baker recognizes that these concerns are valid, but that CMS should not pursue policies that unduly restrict access in order to address the problem.

These significant savings could be achieved without increasing beneficiary costs or restricting access. Read the testimony. Posibles ahorros en los medicamentos recetados y primas de Medicare para los adultos mayores. Older adults face Medicare hurdles for substance use treatment.

New Medicare enrollment rules that eliminate coverage gaps take effect in Spread the word! Back to Media Center. February 28, Share on facebook. Share on linkedin. Share on twitter. Share on email. Media Inquiries.