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Medicaid Managed Care Final Rule

Background

On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the Medicaid and CHIP Managed Care Final Rule (Final Rule), which aligns the Medicaid managed care program with other health insurance coverage programs in several key areas:

  • Modernizes how states purchase managed care for beneficiaries;
  • Adds key consumer protections to improve the quality of care and beneficiary experience; and
  • Improves state accountability and transparency. 

 

The Final Rule was the first significant overhaul of the federal Medicaid managed care regulations since 2002, which was a response to the predominant shift to managed care delivery system occurring nationwide. The Final Rule is effective July 5, 2016 with a phased implementation over several years. There were due dates prior to July 1, 2017. 
 
In California, the Final Rule regulations are applicable to Medi-Cal Managed Care Plans, County Mental Health Plans, Drug Medi-Cal Organized Delivery System, and Dental Managed Care Plans. This webpage contains posting requirements for the Quality Strategy, Network Adequacy, and Mental Health Parity components of the Final Rule.

 
This portal provides support to beneficiaries both prior to and after enrollment in medical and dental managed care.

Managed Care Quality Strategy

The Final Rule requires each state Medicaid agency to implement a written quality strategy to assess and improve the quality of health care and services furnished by all Medicaid managed care entities within the state.

Network Adequacy

To strengthen access to services in a managed care network, the Final Rule requires states to establish network adequacy standards in Medicaid managed care for key types of providers, while leaving states the flexibility to set the actual standards.

Mental Health Parity

On March 29, 2016, CMS issued the Medicaid Mental Health Parity Final Rule (Parity Rule) to strengthen access to mental health and substance use disorder services for Medicaid beneficiaries. The Parity Rule was intended to create consistency between the commercial and Medicaid markets. 
Last modified on: 3/28/2018 1:47 PM