Modernizing Medicaid Managed Care: Navigating CMS' Long-Awaited and Overhauled Proposed Regulations

Calculating Medical Loss Ratio, Complying with Network Adequacy Standards, Setting Capitation Rates, and More

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

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Conducted on Tuesday, July 21, 2015

Recorded event now available

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Course Materials

This CLE course will provide healthcare counsel with an in-depth review of the Centers for Medicare & Medicaid Services’ (CMS) newly proposed regulation revision that overhauls Medicaid managed care. The panel will analyze who will be impacted—and how, and addresses the likelihood of the rule being adopted and expected challenges. The panel will also address what counsel needs to do now regarding compliance that could be impacted if/when the rule is adopted.

Description

On June 1, the Centers for Medicare & Medicaid Services (CMS) issued long-awaited proposed regulations to modernize Medicaid managed care. Since CMS’ last overhaul in 2002, Medicaid managed care has exploded to reach over 39 million people – or 58% of all Medicaid beneficiaries – based on 2011 data. Currently, 39 states use managed care organizations to administer their Medicaid benefits.

The proposed regulations updates the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems and to align the rules governing Medicaid managed care with those of other major sources of coverage, including commercial markets, Exchange-based Qualified Health Plans and the Medicare Advantage and Part D Programs. Among the most significant proposed changes are new standards for network adequacy and medical loss ratios (MLRs) as well as a revised framework for setting capitation rates.

Healthcare stakeholders have until July 27, 2015, to provide comments on the proposed regulations. With proposed changes that touch everything from network adequacy to quality improvement initiatives, it is critical for healthcare counsel to understand the impact the proposed regulations will have and be prepared to respond.

Listen as our authoritative panel examines the proposed regulations, analyzes who will be impacted—and how, and addresses the likelihood of the rule being adopted and expected challenges. The panel will also address what counsel needs to do now regarding compliance that could be impacted if/when the rule is adopted.

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Outline

  1. The proposed regulations
    1. Medical loss ratio standards
    2. Provider network adequacy standards
    3. Actuarially sound capitation rates
    4. Other key changes
  2. Who will be impacted and how
  3. Likelihood of the proposed rule being adopted and expected challenges
  4. What counsel needs to do now regarding compliance that could be impacted if/when the rule is adopted

Benefits

The panel will review these and other key issues:

  • How does the proposed rule change MLR, network adequacy standards, and capitation rates?
  • What are the potential compliance impacts under the proposed rule?
  • What are the costs and risks to healthcare providers and other stakeholders?
  • What types of challenges can be expected?

Faculty

Rich, J. Peter
J. Peter Rich
Partner
McDermott Will & Emery

Mr. Rich practices almost exclusively in the healthcare field, advising hospitals, medication groups, and health plans,...  |  Read More

Ariane Tschumi
Ariane Tschumi
McDermott Will & Emery

Ms. Tschumi focuses her practice on general health matters. She previously served as an analyst at the Center for...  |  Read More

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