HCFA Publishes Medicaid Managed Care Rule with New Patient Protections

The Health Care Financing Administration ("HCFA") published on January 19 a final rule intended to give States more flexibility in administering Medicaid managed care provisions. DHHS said in a press release that the new regulation, which implements provisions of the Balanced Budget Act of 1997, fulfills President Clinton's promise to extend a Patients' Bill of Rights to all Americans enrolled in public healthcare programs.

The rule includes strengthened beneficiary protections and some new provisions designed to protect Medicaid beneficiaries. The rule increases protections for individuals with special healthcare needs, and requires managed care plans serving Medicaid beneficiaries to provide consumers with comprehensive, easy-to-understand plan information. Plans also must cover the cost of emergency healthcare services wherever and whenever the need for such services arises, and to screen and assess all enrollees of a health plan within a certain time frame. The final rule establishes specific requirements for state rate-setting of upper payment limits to ensure that all managed care capitation rates are actuarially sound. Other protections include increased access to services; prohibitions on gag rules; adoption of a grievance and appeal system that addresses issues within certain time frames; and new quality performance standards for States regarding health plans.

The rule is effective on April 19. Read the final rule in the January 19 Federal Register, 66 Fed. Reg. 6228. Also, read the DHHS press release on the rule.