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Policy and Legislative Positions
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Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-2104-P
P. O. Box 8016
Baltimore, MD 21244-8016
To Whom It May Concern:
The Association for Health Center Affiliated Health Plans (AHCAHP) is pleased to comment on the proposed regulations governing managed care in Medicaid. We appreciate the Administration’s willingness to review the original regulation and make changes to ensure the viability of Medicaid managed care.
AHCAHP is made up of 17 member plans which serve primarily the Medicaid and SCHIP population. Our mission is to improve the health of medically underserved populations through the development, survival, promotion and growth of Community Health Center-affiliated health plans. The 17 member plans serve over one million beneficiaries in thirteen states.
The AHCAHP were especially pleased about several provisions in the regulations.
- States must provide to the plans information on race, ethnicity and primary language. This information is crucial to help plans better serve their beneficiaries in a culturally appropriate manner. However, contrary to the statement in the preface to the regulations, our experience has been that states do not yet have adequate access to this information now and may need technical assistance and financial support to get it. In addition we would suggest that states be required to provide the date of redetermination to the plans so that the plans could do outreach to ensure that eligible beneficiaries continue to receive services. (§438.204(b)(2))
- AHCAHP agrees that the provisions related to assessment and treatment of people with special health care needs are much more realistic and allow States and plans to develop timelines and procedures that meet the needs of their population. (§438.208)
- Grievance procedures are more reasonable and realistic. Having several potentially conflicting federal and state laws related to grievance is, however, troubling for plans. If a Patients Bill of Rights is enacted, CMS should review the provisions of this regulation to make it in keeping with the provisions in the Patients Bill of Rights and with the Department of Labor’s ERISA rules.
- AHCAHP agrees that some standardization of performance measures and improvement projects is appropriate. AHCAHP would be willing to convene a group of Medicaid plans to provide input to CMS on what these measures should be. AHCAHP would like to stress that how to achieve these measurements and to improve upon them should be left up to the plan and not micro-managed by the State or CMS. (§438.204 and §438.240)
- AHCAHP would recommend that plans be given 1 year to come into compliance after the regulations become effective.
AHCAHP continues to have the following concerns with the regulations.
- The current regulation requires plans in rural areas with no competitor plans to allow their members to access out of network providers for two months if the member had a ongoing relationship with that provider. This is certainly preferable to an unlimited access to out-of-network providers. While this provision does diminish plans’ ability to manage care for the initial two month period, it is an adequate compromise with the needs of the members to have continuity of care. AHCAHP is concerned, however, with the provisions that allows States to have discretion to add further occasions when out-of-network costs must be covered. Sustained out-of-network provider care undermines the basic tenets of managed care and is not in the beneficiaries’ long term best interest. AHCAHP would suggest that the language allowing States to define further latitude for out-of-network care be eliminated. (§438.52(b)(2))
- AHCAHP recognizes that there are occasions when out-of-network providers will need to be seen by their members. In many cases today, out-of-network providers will charge plans full cost or even higher. AHCAHP suggests that to the extent the regulation allows out-of-network provision of care, that the regulation also state that out-of-network providers be paid no more by the plan than the Medicaid agency would have paid for the services. (§438.52 (b)(ii)(B))
- AHCAHP believes the 105% limit on a risk corridor is too tight as 5% difference can often be well within the margin of error in rate setting. As rate setting is clearly an art and not a science, we would not want to set a cap that could easily be overshot not because the plan is spending more than would have been spent in fee-for-service but rather only because the estimation process is inexact. We acknowledge, however, the concern that plans and States need to have some limit on how high the capitation rates are set and how much leeway plans have to overspend these limits. Therefore, we would suggest that the risk corridor provisions be set at 110%.(§438.814 &§438.6(c)(5)(ii))
- AHCAHP believes that the provision requiring plans to continue paying for disputed services through the Fair Hearing process is too broad. We support that plans should only have to pay through the period that the provider had originally requested the authorization. This reduces the incentive on the beneficiary to drag out the appeals process while they are getting services. While technically beneficiaries would be required to reimburse the plans should they ultimately lose, this is unlikely given the low income of our beneficiaries. (§438.420)
- AHCAHP is pleased that CMS has decided to retain the provision setting rates based on actuarial soundness for the services required as opposed to based on old fee-for-service data. We would suggest, however, that states be required to provide information to plans on assumptions on unit costs and growth rates that are built into the rates. The State and the plan could then negotiate on an even footing if both parties understand the assumptions underlying the rates. We would suggest that States be specifically required to provide information on the base year costs of pharmaceuticals, hospital spending and physician spending, as well as the trend rates that are inflating the base year costs. (§438.6(c))
Again, AHCAHP is pleased with the Administration’s willingness to work with the Medicaid plans to ensure a viable and high quality Medicaid managed care program.
Sincerely,
Margaret A. Murray
Executive Director
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