June 01, 2015

Proposed Rule on Managed Care in Medicaid and CHIP


On May 26, the Centers for Medicare and Medicaid Services (CMS) released a long-awaited, nearly 700-page proposed rule to set national standards for managed care in Medicaid and the Children’s Health Insurance Program (CHIP). It is the first time in over a decade that regulations on this topic have been issued. The consulting firm Avalere Health estimates that about 46 million Medicaid beneficiaries are enrolled in managed care, an increase of 48 percent in the past four years.

Medicaid & Chip: Improving the Beneficiary ExperienceAs outlined in this fact sheet, the proposed rule seeks to improve network adequacy by requiring states to:

  • Assess and certify the adequacy of a health plan’s provider network at least annually and when there is a substantial change to the program design (e.g., new population, benefits, service area, etc.);
  • Develop and implement time and distance standards for primary and specialty care, behavioral health, OB/GYN, pediatric dental, hospital, and pharmacy providers if covered under the managed care contract; and
  • Develop and implement network adequacy standards for managed long term services and supports programs that include criteria for providers who travel to the enrollee to provide services.


Among other provisions, the proposed rule is also intended to:

  • Ensure that Medicaid and CHIP managed care plans coordinate and facilitate transition of services between settings of care and make every effort to complete an initial health risk assessment within 90 days of enrollment for all new beneficiaries;
  • Ensure that enrollees with special health care needs and/or using long term services and supports receive an assessment and treatment plan that is regularly updated; and
  • Improve plan communication with beneficiaries by requiring that enrollee materials (such as provider directories, member handbooks, appeal and grievance notices, and other informational notices):
  • Include taglines in each prevalent non-English language explaining the availability of written materials in those languages as well as oral interpreter assistance if requested;
  • Include a large print tag line to reflect the availability of the materials in alternative formats;
  • Include additional information in the provider directory (such as provider’s group/site affiliation, website URL and physical accessibility for enrollees with physical disabilities); and
  • Include certain information about the plan’s drug formulary.


In addition, the proposed rule would establish a 14-day plan selection period to allow beneficiaries time to research and assess managed care plan options and would establish standards for consistent informational notices to beneficiaries and use of default enrollment processes. For CHIP, the proposed rule sets standards for states that assign a child to a plan when the family does not pick one.

The proposed rule would also require states to provide unbiased information on managed care plans or provider options and answers to related questions (“choice counseling”) for any new enrollee or enrollees with the opportunity to change enrollment.

Quality improvement standards are also included in the proposed rule, as outlined in this fact sheet.

The deadline to submit comments on the proposed rule is July 27, 2015. Family Voices and other child health advocates will be reviewing the proposed rule and preparing comments.

For more information about the proposed rule, see this webpage from www.Medicaid.gov and this story from The Hill.