Medicaid Issues Final Rules on Beneficiary Protections
HHS published new regulations today in the Federal Register to provide for "greater patient protections" for beneficiaries enrolled in Medicaid managed care plans. The regulations, which will be enforced by HCFA, implement provisions of the 1997 BBA, and will take effect 90 days after publication. The rules include strengthened beneficiary protections and new provisions "designed to protect the rights of otherwise vulnerable" Medicaid beneficiaries. Published regulations for Medicaid managed care plans include the following:
- Quality Care: States will be required to assure continued care access for Medicaid beneficiaries who have "ongoing health care needs" and switch from fee-for-service to a managed care plan, from one health plan to another or from a health plan to fee-for service. In addition, states and participating plans must identify beneficiaries with "special health care needs" and "assess the quality and appropriateness" of their care.
- Health Plan Marketing: Medicaid managed care plans must provide consumers with "comprehensive, easy-to-understand information" about heath plans and offer "most" beneficiaries a choice between at least two "qualified" health plans. States must also approve health plan marketing materials used to enroll and re-enroll Medicaid beneficiaries, and plans are restricted from engaging in "door-to-door, telephone and other forms of 'cold call' marketing."
- Emergency Services: Medicaid managed care plans are required to cover emergency health care service costs "wherever and whenever the need for such services arises." Plans "are prohibited" from requiring prior approval for emergency services or from requiring beneficiaries to obtain care at "approved facilities." Emergency services are "based on a 'prudent layperson' standard that requires payment in situations where the beneficiary reasonably assumes that he or she is in an emergency situation."
- Health Assessment: Medicaid managed care plans must provide expedited health assessments to beneficiaries "at risk of having special health care needs" or to those who already have special health care needs.
- Reimbursement: States are required to set managed care capitation rates that are "actuarially sound." The new regulations omit the "generally outdated regulatory ceiling on what states may pay managed care plans." An HHS release notes that this provision is "particularly important," as "more state Medicaid programs include people with chronic illnesses and disabilities in managed care" who require more expensive care. This provision implements a "new approach" to regulating capitation payments, and will have a 60-day comment period.
- Eligibility: States have the option to guarantee Medicaid eligibility to enrollees for up to six months, in order to "ensure continued enrollment to families who otherwise move in and out of eligibility due to work status or income changes."
- Access to Care: Female beneficiaries may have "direct access" to a woman's health specialist within a health plan's provider network for routine and preventive health care services. Also, beneficiaries will be allowed to obtain a second opinion from a "qualified" health professional.
- Patient-Provider Communication: Medicare managed care plans may not impose restrictions, such as "gag rules" that interfere with patient-provider communications.
- Network Adequacy: Plans must "assure" that they maintain the capacity to serve the "expected enrollment" in their service area.
- Grievance Systems: Managed care plans must implement a system to address appeals and grievances, and all grievances must be resolved in "state established time frames" not exceeding 90 days. Resolution of appeals must occur "in accordance with medical needs," and not later than 30 days. "Expedited" time-frames of no more than 72 hours are required for certain grievances and appeals."
These regulations "fulfil[l]" President Clinton's promise to "extend a Patients' Bill of Rights to all Americans enrolled in public health care programs," the HHS release states. Outgoing HHS Secretary Donna Shalala added, "Managed care provides the promise of better coordinated health care at a more reasonable cost. But all Americans -- whether they are in Medicare, Medicaid or private health plans --deserve the basic protections that a Patients' Bill of Rights provides" (HHS release, 1/18).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.