CMS Proposes Rule to Strengthen Managed Care for Medicaid and CHIP enrollees

On May 26, 2015, the Centers for Medicare and Medicaid Services (CMS) proposed to modernize Medicaid and Children’s Health Insurance Program (CHIP) managed care regulations to update the programs’ rules and strengthen the delivery of quality care for beneficiaries.  This proposed rule is the major update to Medicaid and CHIP managed care regulations in more than a decade.  It would improve beneficiary communications and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way, and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage.  Overall, this proposed rule supports the agency’s mission of better care, smarter spending, and healthier people.

For more information, click here.

Teaching Suggestions

  • Ask students to visit the CMS.gov website to learn how the healthcare delivery landscape has changed and grown substantially since 2002.
  • Ask students how CMS might strengthen the quality of care provided to beneficiaries.

Discussion Questions

  1. Why is the CMS proposing new rules to strengthen managed care for Medicaid and CHIP enrollees?
  2. How does the CMS plan to modernize Medicaid and CHIP regulations?

Increased Oversight Needed For Growing Managed Care Expenditures

In fiscal year 2013, the Medicaid program covered about 71.7 million people at a cost of $431.1 billion, of which Centers for Medicare and Medical Services (CMS) estimated that $14.4 billion (5.8 percent) were improper  payments.  In 2014, the Government Accountability Office (GAO) examined how state and federal agencies ensure comprehensive integrity efforts, such as payment review, auditing, and investigating fraud.  To improve the efficiency and effectiveness of Medicaid program, the GAO recommends that the Administrator of CMS should:

  • update its Medicaid managed care guidance on program integrity practices,
  • provide the states with additional support in overseeing Medicaid managed care program integrity, and
  • require states to audit payments to and by managed care organizations.

For additional information and complete GAO report go to http://www.gao.gov/products/GAO-13-34.

Teaching Suggestions

  • Ask students what are typical benefits that Medicaid provides.
  • Ask students to prepare a summary report on how to prevent or reduce the Medicaid fraud.

Discussion Questions

  1. What is Medicaid and how it assists low-income individuals and families?
  2. How is Medicaid financed?
  3. Do people with Medicaid need to buy supplemental medical insurance?