Medicaid Managed Care Programs Regulations Released
NAMI E-News June 18, 2002 Vol. 02-77
On June 14, the Centers for Medicare and Medicaid Services (CMS) released final
regulations governing state Medicaid managed care programs. These revised final
rules are very similar to draft regulations put forward in August 2001. They are
intended to set forth binding standards for states that require Medicaid
beneficiaries (including children and adults with severe mental illnesses who
are SSI eligible) to enroll in managed care plans. These standards include
access to specialists, coverage of emergency care, grievance procedures, binding
external appeals and patient-provider communications. The final rules also
include revised provisions restricting managed care plans from marketing of
other insurance products by telephone and door-to-door.
These Medicaid managed care regulations were originally authorized by Congress
as part of a 1997 law that allowed states increased authority to enroll Medicaid
beneficiaries in managed care plans - and "behavioral health carve-out" plans
that manage mental illness treatment. Since 1998, the number of Medicaid
beneficiaries in managed care plans has increased significantly to 22 million
people, or 58% of Medicaid enrollees. Medicaid managed care plans must begin
complying with the rules by August 2003 at the latest.
The final regulations contain few major changes from the August 2001 draft.
Among the changes that were made from last year’s draft are new standards
governing expedited grievance processes that all Medicaid managed care plans
must have in place for beneficiaries whose life or health is in jeopardy. The
revised final rules would require such grievances to be resolved within three
working days, with the possibility that plans could receive two-week extensions.
A previous proposal put forward in the final days of the Clinton Administration
would have required such appeals to be heard within 72 hours. In non-emergency
grievances, beneficiary appeals would have to be resolved within 45 days (up
from the 30 days in the original draft rules).
NAMI will continue to monitor implementation of these new final regulations to
ensure that states, and the Medicaid managed care plans they contract with,
protect the rights of children and adults with severe mental illnesses. NAMI’s
comments on the proposed revised Interim Final regulations can be viewed at:
http://www.nami.org/update/20011025.htm
The full text of the Medicaid Managed Care Regulation can be viewed at:
http://www.hcfa.gov/medicaid/omchmpg.htm
http://www.hhs.gov/news/press/2002pres/20020613a.html
Additional information on Medicaid managed care regulations is also available
at:
http://www.nami.org/update/20010821.htm
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