AHA: Medicaid/CHIP managed care rule should balance need for standards, flexibility

The AHA generally supports the direction of the Centers for Medicare & Medicaid Services’ proposed rule revising managed care regulations for Medicaid and the Children’s Health Insurance Program, and urges the agency to continue to be mindful of the need to strike the appropriate balance between federal standards and state flexibility, AHA Executive Vice President Rick Pollack said in comments submitted today. Among other actions, AHA recommends that CMS require states to periodically report on how capitation rates affect patient access and provider networks, and that CMS and the states provide greater guidance to managed care plans on what constitutes health care or quality expenses when calculating medical loss ratios. In addition, CMS should direct Medicaid programs to adopt the 15 quality improvement areas identified in the Institute of Medicine’s recent “Vital Signs” report; consider expanding the 15-day stay limit for adults subject to the Institution for Mental Disease exclusion; and require states to provide clear and consistent guidance on the methods managed care plans can use to verify the delivery of services by network providers, AHA said.