CMS Set to Release Medicaid Managed Care “Uber Rule”

The CMS is poised to release in the coming weeks what stakeholders and advocates are calling an “uber rule” that will completely overhaul the Medicaid managed care marketplace. Agency officials haven’t offered much specific information about what may be included in the proposal, or even when it will be released—although it’s been under regulatory review at the OMB since March, and the agency has been working on the regulations for over a year.

CMS officials haven't offered much specific information about what may be included in the regulations. However, in its spring 2014 regulatory agenda, the HHS described the proposal aligning Medicaid managed care regulations “with existing commercial, Marketplace, and Medicare Advantage regulations.” Last fall, a CMS official said the agency wanted input from health plans and other stakeholders to make sure the rule incorporates all the changes that managed care has undergone in the decade since the last regulation was released.

Medicaid managed care regulations haven’t been updated since 2002, so whatever CMS has in store is sure to touch on essentially every aspect of managed care. John Gorman, founder and executive chairman of the Gorman Health Group consulting firm told me “this is literally the biggest healthcare regulation in a dozen years.” Gorman said it’s even a bit of a misnomer to call it a Medicaid rule, since it will impact Medicare and Medicare Advantage. He said it’s better to think of the proposal as an “omnibus rule.”

There have been some pretty major changes in the healthcare world since the latest updates to the managed care rules—the most notable of course is the Affordable Care Act, but there have also been a host of agency guidances, letters and smaller-scale rules. The internet also plays a much larger role in people’s lives today than it did back in 2002, so plans need to make sure their provider lists are constantly updated and easily accessible.

The essence of the Medicaid program is that states can individually tailor their managed care plans. The downside is there can be lots of conflicting regulations. The challenge for CMS will be to iron out those differences without being seen as too heavy-handed. States and plans need to continue to have flexibility, but CMS also needs to have oversight. Updating the rules is supposed to help bring consistency across states, private plans and all the government health programs. Whether CMS will be able to accomplish that, at least on the first try, is open to debate.

But Gorman said he has confidence the government will get it right. “It’s not like they’re floating a lot of untested ideas. Everything is pretty well vetted with industry” and is “worn territory,” he said. 

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