New rules for Medicaid managed care: What do they mean for Missouri?

medicaid_blueThe Centers for Medicare and Medicaid Services (CMS) has just released new rules, the first in over a decade, for Medicaid managed programs. These rules “would cap insurer profits, require states to more rigorously supervise the adequacy of plans’ provider networks, encourage states to establish quality rating systems for plans, allow more behavioral healthcare in institutional settings and encourage the growth of managed long-term care.”

Changes also include a new rule that would create a Medical Loss Ratio of 85 percent, similar to regulation imposed on private insurance plans. This requires insurers to spend at least 85 percent of their revenue on medical care—not for administrative costs or profits.

Sounds good, right? Well not exactly!

Under the new rules, Medicaid plans would not be required to rebate the difference if they spend less than 85 percent on patient care. And how many plans currently meet this benchmark? According to the Kaiser Family Foundation, only one in four plans came close to spending 85 percent on actual care.

The new rules would require Medicaid plan provider networks to have time and distance standards. Patients would need to have access to hospitals, primary-care physicians and OB-GYNs. Why should we be concerned? As a Modern HealthCare article states, “The CMS mostly punted the task of overseeing network adequacy to the states, despite their history of lackluster oversight.”

What does this mean for Missouri and for health care advocates? Currently, three managed-care companies provide services to approximately 400,000 Medicaid participants in Missouri. Under the new budget passed by the Missouri legislature, nearly 200,000 additional Medicaid patients will be moved to managed-care plans.

As managed-care plans expand in Missouri, including to our rural communities that already lack sufficient services, it means we need to be vigilant. We need to pressure our Missouri state officials and our legislators to insist that care comes before profits and that quality services are available to patients.

We welcome the new rules, but we must work to see that they are implemented.

Mary Clemons (17 Posts)

Mary Clemons, retired but not retiring, moved from being an armchair progressive to becoming an active advocate for issues of social justice. She credits her new found skills in writing and speaking out to Women’s Voices Raised for Social Justice. She is immediate past president of the organization.