CMS: New Manged Care and Quality Assurance Standards

The “correct” quality assurance program will always be a question until CMS requires states to standardize their Managed Care processes among MCOs in each state. We all have the opportunity to discuss standardization now, which will not come around again for years. Please see the below information from ANCOR. I encourage people to comment on the CMS proposed rules. CMS Issues

Landmark Proposed Rule on Medicaid Managed Care

On June 1, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule titled “Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability.” The agency states that this proposed rule would modernize the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems.

Home care providers will want to be aware that the proposed rule proposes to add a definition for long term care support services (LTSS).  The CMS proposal defines LTSS as “services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the beneficiary to live or work in the setting of their choice, which may include the individual’s home, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting.”  CMS states that they intend for community based services within the scope of this definition to be largely non-medical in nature and focused on functionally supporting people living in the community.  Examples of what CMS would consider community based LTSS include Home- and Community-Based Services (HCBS) delivered through a section 1915(c) waiver, section 1915(i), or section 1915(k) state plan amendments, as well as personal care services otherwise authorized under the state plan.

HCAOA also notes that CMS is seeking to amend the existing regulation requiring each state to establish a credentialing and re-credentialing policy that addresses all the providers, including LTSS providers, covered in their managed care program regardless of the type of service provided by such providers.

Comments on the proposed rule will be accepted through July 27, 2015. A copy of the proposed rule can be found at http://www.regulations.gov/#!documentDetail;D=CMS-2015-0068-0001