The final Medicaid managed care rule released on April 25, 2016 provides a comprehensive modernization of Medicaid managed care rules and regulations. As a way of educating clients about the rule, Milliman is developing a series of papers that examine different implications for states, plans, and others.
Overview of guidance related to actuarial soundness in final Medicaid managed care regulations
This paper provides a summary of the final Medicaid managed care rule’s significant impacts on the development of actuarially sound capitation rates and required supporting documentation.
Medical loss ratio (MLR) in the “Mega Reg”
While the Medicaid medical loss ratios (MLR) formula itself largely follows the commercial and Medicare Advantage (MA) MLR formula, there are key differences between the Medicaid minimum MLR standards and those currently established for the commercial and MA markets.
Institution for Mental Disease (IMD) as an "in lieu of" service
Federal monies for Medicaid services are generally not available to individuals between the ages of 21 and 64 living in an Institution for Mental Disease (IMD), but a combination of inpatient psychiatric capacity constraints and rapid enrollment growth in Medicaid may be leading to changes in state and Medicaid policies regarding the use of IMDs as an "in lieu of" service.
Encounter data standards: Implications for state Medicaid agencies and managed care entities from final Medicaid managed care rule
Encounter data provides the most transparent view of a managed care entity's delivery of healthcare services, but encounter data that is incomplete, missing information, or reported incorrectly can severely limit its effectiveness.
Pass-through payment guidance in final Medicaid managed care regulations: Transitioning to value-based payments
This paper provides an overview of pass-through payment provisions in the new Medicaid managed care regulations, including the rationale and phase-out timing of the Centers for Medicare and Medicaid Services.