Medicaid Managed Care Final Rule: Calculating Medical Loss Ratio, Complying With Network Adequacy Standards and More

Recording of a 90-minute CLE webinar with Q&A

Conducted on Wednesday, August 3, 2016

Recorded event now available

or call 1-800-926-7926
Program Materials

This CLE webinar will provide healthcare counsel with an in-depth review of the Centers for Medicare & Medicaid Services’ (CMS) final regulations that overhaul Medicaid managed care. The panel will analyze who will be impacted—and how—and discuss the key components of the rule. The panel will also address what counsel needs to do to ensure compliance.


The CMS issued its long-awaited Medicaid managed care final rule. This overhaul affects the 39 states that use managed care organizations to administer their Medicaid benefits. The rule seeks to bring consistency with the requirements of Medicaid managed care and those of Qualified Health Plans, Medicare Advantage and other commercial plans.

The final rule updates the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems. Among the most significant changes are the network adequacy standards and the medical loss ratio (MLR) requirements. States must project at least an 85% MLR for rate setting purposes and require annual MLR reporting.

Medicaid managed care entities must also have processes in place for notification about a change in a network provider’s circumstances that may affect the provider’s eligibility to participate in Medicaid managed care and verification of services actually provided by network providers. Further, managed care organizations, prepaid inpatient health plans, and prepaid ambulatory health plans must have a mechanism for reporting receipt of and timely returning an overpayment. It is critical for healthcare counsel to understand the impact the regulations will have and be prepared to respond.

Listen as our authoritative panel examines the final Medicaid managed care regulations and analyzes who is impacted—and how. The panel will discuss the key components of the rule impacting providers participating in Medicaid managed care. The panel will also address what counsel needs to do to ensure compliance.



  1. The final regulations—key components
    1. Medical Loss Ratio
    2. Actuarial soundness
    3. Continued authorization of “pass-through” payments for a limited time
    4. Benefit flexibility, network adequacy/accessibility
    5. Integration of LTSS
    6. Provider screening and enrollment
    7. Other provider program integrity provisions
  2. Who is impacted and how
  3. Best practices for compliance


The panel will review these and other key issues:

  • How does the final rule change MLR, network adequacy standards, and capitation rates?
  • What are the potential compliance impacts under the final rule?
  • What are the costs and risks to healthcare providers and other stakeholders?


Deborah Dorman-Rodriguez
Deborah Dorman-Rodriguez

Freeborn & Peters

Ms. Dorman-Rodriguez is the leader of her firm's Healthcare Practice Group. She has diverse experience as...  |  Read More

Susannah Vance Gopalan
Susannah Vance Gopalan

Feldesman Tucker Leifer Fidell

Ms. Gopalan focuses on health care litigation and regulatory counseling, with a distinct focus on Medicaid...  |  Read More

Felicia Sze
Felicia Sze

Hooper Lundy & Bookman

Ms. Sze is a recognized expert in Medicaid and Medicare reimbursement matters, focusing on both the managed care and...  |  Read More

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