Medicaid Managed Care
Medicaid managed care regulations govern how states contract with managed care organizations (MCOs) to deliver Medicaid benefits. Most states now enroll the majority of their Medicaid population in managed care. These rules establish requirements for network adequacy, enrollee rights, quality, grievances, and rate setting.
Key Points
States must ensure managed care networks are adequate to provide timely access to covered services
Enrollees have the right to file grievances and appeals with their MCO, plus a state fair hearing
MCOs must meet quality assessment and performance improvement requirements
Capitation rates must be actuarially sound and approved by CMS
States must provide enrollees with plan choice and the ability to change plans
Key Areas
Network Adequacy
Provider network requirements, access standards
Enrollee Rights
Grievances, appeals, information requirements
Quality
Quality assessment, external review, performance measures
Key Provisions
Network Adequacy
MCOs must maintain a network sufficient in number, mix, and geography to provide adequate access. This is the most common compliance issue in Medicaid managed care.
Grievance and Appeal Systems
Detailed requirements for how MCOs handle member grievances and appeals. Strict timelines and notification requirements.