How the New Medicaid/CHIP Managed Care Regulations Seek to Improve Network Adequacy and Access to Services

31022156 - medical team working on patient in emergency room
31022156 - medical team working on patient in emergency room

Thanks to a grant from the Robert Wood Johnson Foundation, CCF has teamed up with NHeLP to launch a series of explainer briefs that unpack the new Medicaid/CHIP managed care regulations. Three briefs in the series have been released already: Looking at the New Medicaid/CHIP Managed Care Regulations Through a Children’s Lens, Medicaid/CHIP Managed Care Regulations: Improving Consumer Information, and Medicaid/CHIP Managed Care Regulations: Enhancing the Beneficiary Experience. Today, we are releasing the fourth brief of the six-part series on “Medicaid/CHIP Managed Care Regulations: Network Adequacy and Access to Services.”

These rules are critical. Nearly nine out of ten children in Medicaid and CHIP receive care through some kind of managed care arrangement.

As managed care, and particularly mandatory managed care programs, have become the predominant model for delivering care in Medicaid, there has been a growing recognition of the need to ensure that Medicaid plans contract with a sufficient number and range of providers to deliver all covered Medicaid benefits.

To this end, the modernization of federal Medicaid and Children’s Health Insurance Program (CHIP) Managed Care regulations released in May 2016 seek to ensure that enrollees have access to needed care by improving the standards and procedures related to network adequacy and access to services. The regulations continue to require states to adhere to a basic rule requiring that all services covered under the state plan are available and accessible to enrollees of managed care plans in a timely manner. In order to make this basic rule easier to implement and monitor, the regulations include new requirements for states to develop quantitative network adequacy standards and carefully monitor access to care. In addition, the new rule enhances existing provisions that require plans to coordinate care for their enrollees, authorize services according to clinically appropriate criteria, and allow enrollees to appeal plan decisions to deny, terminate, or reduce services.

We’ll be reviewing the brief and covering the network adequacy and access provisions in a webinar on Friday, August 5th at 1:30pm. Click here to register for the webinar.

Look for upcoming briefs in the series to include advancing quality and ensuring accountability and transparency. If you missed the webinars featuring the first three briefs, you’ll find the slides and a recording here.

Kelly Whitener
Kelly Whitener is an Associate Professor of the Practice at the Center for Children and Families