Medicaid/CHIP Managed Care Regulations:
Network Adequacy and Access to Care
Joan Alker
Abbi Coursolle
Kelly Whitener
August 5, 2016
Children in Managed Care
•  CMSfinalizedsweepingchangestoMedicaidand
CHIPmanagedcareregula;onsinMay2016
•  Regula;onssetminimumstandards;stateshave
flexibilitytodomore
•  Manyopportuni;esforlegalandhealthadvocates
totakeac;on
Flagpoten+alac+onsforlegalandhealth
advocates
2
Why are these rules so important?
11% of
children in
Medicaid/
CHIP are
enrolled in
FFS
22% of
children in
Medicaid/
CHIP are
enrolled in
PCCMs
66% of children in
Medicaid/CHIP are
enrolled in MCOs
Source:CMSMedicaidManagedCareEnrollment
Report2013
3
Managed Care Project
•  Seriesofsixexplainerbriefsandwebinars
① 
② 
③ 
④ 
⑤ 
⑥ 
LookingattheRulethroughaChildren’sLens(6/17)
ImprovingConsumerInforma;on(6/23)
EnhancingtheBeneficiaryExperience(7/19)
AssuringNetworkAdequacyandAccesstoServices(8/5)
AdvancingQuality(9/8)
EnsuringAccountabilityandTransparency(9/29)
•  Fallmee;nginD.C.withchildhealthandlegal
advocatestostrategizeoverimplementa;on
•  ThankstoRobertWoodJohnsonFounda;on
4
Our Topic Today: Assuring Network
Adequacy and Access to Services
• 
• 
• 
• 
• 
• 
NetworkAdequacyandAvailabilityofServices
ProviderInclusionRules
CareCoordina;on
ServiceAuthoriza;on
Appeals
CHIP
Flagpoten+alac+onsforlegalandhealth
advocates
5
NETWORK ADEQUACY AND
AVAILABILITY OF SERVICES
Kelly Whitener
6
Network Adequacy &
Availability of Services
Sec$on
Topic
438.206
AvailabilityofServices
438.207
AssurancesofAdequateCapacityandServices
438.68
NetworkAdequacyStandards
438.14(b)
RequirementsInvolvingIndians&IndianHealthCare
Providers(IHCPs)
438.602(g)(2)
Transparency&Documenta;on
438.10(h)
ProviderDirectories
438.4(b)(3)
AssurancesofAdequateCapacity&ActuarialSoundness
438.340(b)(1)
ManagedCareQualityStrategy
438.358(b)(1)(iv)
EQRAc;vi;es
Source:CMCS,presentedatCCF2016conference
7
Availability of Services§438.206
•  BasicRule:Eachstatemustensurethatall
servicescoveredunderthestateplanare
availableandaccessibletoenrolleesof
managedcareplansina>melymanner.
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
Nolaterthan12-monthra;ngperiodstar;ngonorajer
July1,2018
8
Delivery Networks
•  Managedcareplansmustmaintainand
monitoranetworkofappropriateproviders
sufficienttoprovideadequateaccesstoall
servicescoveredunderthecontract
•  Iftheprovidernetworkisunabletoprovide
necessaryservices,theplanmustadequately
and;melycovertheseservicesout-ofnetworkandnoaddi;onalcosttothe
enrollee
9
Delivery Networks
•  Femaleenrolleesmusthavedirectaccesstoa
women’shealthspecialistinnetwork
•  Thenetworkmustincludesufficientfamily
planningproviderstoensure;melyaccess
Whilefreedomofchoicepermitsenrolleestoreceive
familyplanningservicesfromout-of-network
providers,encouragestatestorequireplansto
contractwithanywillingfamilyplanningproviderso
thatenrolleeshaveachoiceofin-networkandoutof-networksproviders.
10
Timely Access
•  Managedcareplansmustrequirenetworkproviders
tomeetstatestandardsfor;melyaccesstocare,
takingintoaccounttheurgencyoftheneededservice
•  Hoursofopera;onmustbenolessthanthehoursof
opera;onofferedtocommercialenrollees
•  Servicesmustbeavailable24/7whenmedically
necessary
Encourageyourstatetoadoptnewor
improvedquan>ta>ve>melyaccesstocare
standards.
11
Side Note on Medical Necessity
Adults
•  Statedefini;onsbasedon
federallawslike:
–  Mandatoryversusop;onal
benefits
–  Therequirementthatservices
mustbecoveredinsufficient
amount,dura;on,andscope
toreasonablyachievetheir
purpose
•  Defini;onshavenarrowed
over;me
Children
•  Statedefini;onsbasedon
EPSDTwhichrequiresa
determina;onofwhether:
–  Theserviceisnecessaryto
correctoramelioratea
physicalormentalhealth
condi;on
–  Forapar;cularchild(i.e.,
mustbemadeoncase-bycasebasis)
12
Network Adequacy Standards§438.68
•  Statesmustdevelop,enforce,andvalidate;meand
distancestandards
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
New!
Nolaterthan12-monthra;ngperiodstar;ngonorajer
July1,2018
13
Time and Distance Standards
•  Primarycare,adultand
pediatric
•  OB/GYN
•  Behavioralhealth
(mentalhealthand
substanceusedisorder),
adultandpediatric
•  Specialtycare,adultand
pediatric
•  Hospital
•  Pharmacy
•  Pediatricdental
•  Addi;onalprovidertypes
determinedbyCMS
14
However, the Rule does not….
•  Specifywhatthe;meand
distancestandardsmustbe
•  Imposeana;onalstandard
forprovidertoenrollee
ra;os,appointmentwait
;mes,orothertypesof
standards
•  Preventstatesfromadop;ng
addi;onalstandards
CMSindicatesstateflexibilityisimportantduethedifferingscopeofstateprograms,
popula>onsserved,anduniquedemographicsandcharacteris>csofeachstate.
15
Scope of Time & Distance Standards
•  Mustincludeallgeographicareascoveredin
contracts
•  Permitsvaryingstandardsforsameprovidertype
basedongeographicareas(i.e.,rural)
•  RequiresseparatestandardsforLTSSprovidertypes
-  Enrolleemusttraveltoprovider
-  Providermusttraveltoenrollee
16
Factors in Developing
Network Adequacy Standards
•  An;cipatedenrollment
•  Numbersandtypes(in
termsoftraining,
•  Expectedu;liza;onof
experienceand
services
specializa;on)ofnetwork
•  Characteris;csandhealth
providersneededtofurnish
careneedsofspecific
contractedservices
popula;onscovered
•  Availabilityofalterna;ve
•  Geographicloca;on
access:screening,
•  Abilitytocommunicatewith
telemedicine,e-visits,
LEPenrollees
evolvingtechnology
•  Physicalaccessand
•  Numberofprovidersnot
accommoda;ons
accep;ngnewpa;ents
17
State Flexibility to Allow Exceptions
•  Ifallowed,thestatemust:
-  S;pulatetheextenttowhichexcep;onsareallowed
-  Specifythestandardbywhichanexcep;onwillbe
evaluatedandapproved
-  Monitorenrolleeaccesstothatprovidertypeonan
ongoingbasis
-  ReporttoCMSaspartofstatemonitoringrequirements
(§438.66)
•  Excep;on(s)policy
-  Mustbespecifiedincontracts
-  Based,ataminimum,onthenumberofprovidersinthat
specialtyprac;cingintheapplicableservicearea
18
Public Input
•  Noexplicitrequirementforstakeholderinput
•  But,inthepreamble,CMSencouragesstates
toincludeappropriateandmeaningful
stakeholderengagementandfeedbackwhen
seqngtheirnetworkadequacystandards
Reviewanyexis>ngstate>meanddistancestandards
toensurethattheyapplytoallofthelistedproviderand
servicetypes.Encourageyourstatetoinvolve
stakeholdersintheestablishmentandupdateof>me
anddistancestandardstoensuretheyarereasonable.
19
Assurances of Adequate Capacity &
Services §438.207
•  Plansmustprovideassurancestothestatethatthey
meetthestandardsandsuppor;ngdocumenta;on
•  Statesmustreviewthedocumenta;onandcer;fy
theplansiftheyareincompliance
•  Thedocumenta;onmustbepostedonthestate’s
website
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
Nolaterthan12-monthra;ngperiodstar;ngonorajerJuly
1,2018
20
State Monitoring Requirements
§438.66
•  ReadinessReviews
-  Statesmustassessplanreadinesspriortoimplementa;on
ofanewmanagedcareprogram,whentheplanhasnot
previouslycontractedwiththestate,orwhentheplanis
coveringnewpopula;ons
-  Mustbecompletedwithsufficient;metoensuresmooth
implementa;on
•  AnnualProgramReport
-  Beginningwiththera;ngperiodthatfollowstherelease
ofCMSguidance,statesmustsubmitanannualreportto
CMSandpostitonthestate’swebsite
21
Additional Oversight
Mechanisms
ExternalQualityReview
•  Valida;ngnetwork
adequacyisanew,
mandatoryac;vityforthe
externalqualityreview
process
Encourageyourstateto
useanindependent
en>tytovalidateplan
networks
Stay
tuned!
ActuarialSoundness
•  Inorderforcapita;onrates
tobeapprovedbyCMS,
theymustbeadequateto
meettherequirementsof
–  AvailabilityofServices
(§438.206)
–  AdequateCapacityand
Services(§438.207)
–  Coordina;onandCon;nuity
ofCare(§438.208)
22
PROVIDER INCLUSION RULES
Abbi Coursolle
23
Screening & Enrolling Providers
§§438.602(b) & 438.608(b)
•  Plansmustensurethatallnetworkprovidersare
screenedbythestate
•  Plansmayonlyenterintocontractswithproviders
thathavesuccessfullycompletedscreening
-  Thereisanexcep;onforshort-termcontractsupto120
dayswhiletheoutcomeofthescreenispending
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
PrimaryCareCaseManagement(PCCM)
PrimaryCareCaseManagementEn;;es
(PCCMen;;es)
Nolaterthan12monthra;ngperiod
star;ngonorajer
July1,2018
24
Numbers & Types of Providers
Medicaid
MarketplaceandMedicare
•  Theruledoesnotrequireplansto
contractwithpar;cularprovider
typesornumberofprovidersper
enrollee
•  Medicaidstatuterequires
coverageof:
•  Marketplaceplansrequire
contractswithaspecified
propor;onofessen;al
communityproviders
•  MedicareAdvantagerequires
specificprovider-to-covered
personra;os
–  FQHCs&RHCs
–  Free-standingbirthcenters
–  Nurse-midwives&cer;fiednurse
prac;;oners
Encourageyourstatetorequireplanstocontractwithanywilling
safetynetprovider.
Workwithyourstatetoincorporateprovider-coveredperson
ra>os,especiallywhenthereareknownaccessproblems.
25
Special Rules for Indian Health Care
Providers §438.14
•  Plansmust:
-  Ensure;melyaccesstoIndianHealthCareProviders
-  Payout-of-networkIndianHealthCareProviderswhen
theydelivercaretoeligibleNa;veAmericanenrollees
-  PermiteligibleNa;veAmericanenrolleestoselectan
IndianHealthCareProviderasaprimarycareprovider
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
PrimaryCareCaseManagementEn;;es
(PCCMen;;es)
Nolaterthan12monthra;ngperiod
star;ngonorajer
July1,2017
26
CARE COORDINATION
Abbi Coursolle
27
Coordination & Continuity of Care
§438.208
•  Theruleexpandstheexis;ngrequirement
thatplansmustimplementproceduresto
delivercaretoandcoordinateservicesforall
enrollees
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
Nolaterthan12-monthra;ngperiod
star;ngonorajerJuly1,2017
28
General Coordination Requirements
•  Screeningwithinthefirst90daysfornew
enrollees
•  Designeetocoordinate:
- 
- 
- 
- 
- 
Servicestheplanprovidestotheenrollee
Careduringtransi;onsfromoneseqngtoanother
Servicestheenrolleereceivesfromanothermanagedcareplan
Carved-outservices
Communityandsocialsupportservices
EncourageyourstatetoincludeProtec>onandAdvocacy
organiza>ons,legalservicesorganiza>ons,AgingandDisability
ResourceCenters,CentersforIndependentLiving,AreaAgencies
onAging,UnitedWay211Lines,andlocalandstategovernment
agencies.
29
Coordination for Enrollees with Special
Health Care Needs
•  ApplicabletoenrolleeswhouseLTSS
•  Plansmust:
-  Iden;fyenrolleeswithspecialhealthcareneedsand
thosewhoneedLTSS
-  Assesstheirneeds
-  Designatreatmentplanbasedonthoseneeds
-  Allowenrolleestoseeaspecialistdirectly
Urgeyourstatetodevelopandincludeaspecificdefini>onof
“childrenandyouthwithspecialhealthcareneeds”forwhomthe
LTSSandcon>nuityofcareprovisionsshouldapply.
30
Continued Services to Enrollees
§438.62
•  Duringcertain;mesoftransi;on,plansmust
permitenrolleestocon;nuetoseetheirexis;ng
providers,eveniftheyareout-of-network
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
PrimaryCareCaseManagement(PCCM)
PrimaryCareCaseManagementEn;;es(PCCMen;;es)
Nolaterthan12-monthra;ngperiod
star;ngonorajerJuly1,2018
31
Continued Services to Enrollees
•  Specifically,statesmustdeveloptransi;onof
carepoliciestopermitenrolleestocon;nue
seeingtheirproviderswhen:
-  EnrolleesmoveintomanagedcarefromFFSOR
-  EnrolleeschangeplansAND
-  Withoutcon;nuityofcare,theenrolleeisatriskof
hospitaliza;onorins;tu;onaliza;on
Encourageyourstatetoengagestakeholdersinthedevelopment
ofthesetransi>onrequirements.
32
SERVICE AUTHORIZATION
Abbi Coursolle
33
Coverage & Authorization of Services
§438.210
•  Thecontractbetweenthestateandtheplan
must:
-  Iden;fy,define,andspecifytheamount,dura;on,and
scopeofeachservicetheplanisrequiredtooffer
-  Theamount,dura;on,andscopemustbenolessthan
thatunderFFSorasrequiredbyEPSDT
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
Nolaterthan12-monthra;ngperiod
star;ngonorajerJuly1,2017
34
Allowable Service Limitations
•  Plansmayplace“appropriate
limits”oncoveredservices,
aslongasthelimitsare
basedoneithercriteriaused
bythestate(likemedical
necessity)orinorderto
controlu;liza;on
•  Plansmustdefinewhena
coveredservicewillbe
medicallynecessaryina
mannerthatis“nomore
restric;ve”thanthecriteria
usedinunderFFS
See§§438.210(a)(5)and438.210(a)(4)
35
Service Authorization Timelines
•  Plansmustrespondtoserviceauthoriza;on
requestswithin14calendardays
•  Ifwai;ng14dayscreatesariskofharm,
plansmustexpeditereviewanddecidewithin
72hours
•  Theresponse;memaybeextendedbyan
addi;onal14daysattherequestofthe
enrolleeorprovider,orwhentheplan
determinesitisintheenrollee’sbestinterest
36
New Service Authorization Protections
•  Plansmustmakesurethatservicesforpeople
withongoingorchroniccondi;onsare
authorizedinamannerthatreflectstheir
ongoingneed
•  Plansmustensurethatfamilyplanning
providersareavailablein-andout-ofnetwork,consistentwithfreedomofchoice
EncourageyourstatetorequirethatLTSSaimedattrea>ng
chroniccondi>onsareauthorizedfora12-monthperiodunless
thereisaclinicalreasonforashorterauthoriza>onperiod.
37
Special Rules for Prescription Drugs
§§438.3(s) & 438.210(d)
•  U;liza;oncontrolsforprescrip;ondrugsmust
alsofollowstatutoryrequirementsthatgovern
priorauthoriza;on
•  Fordrugauthoriza;onrequests,plansmust:
-  Respondwithin24hours
-  Dispensea72-hoursupplyofacoveredoutpa;entdrugin
emergencies
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans
(PAHP)
Nolaterthan12-month
ra;ngperiodstar;ng
onorajerJuly1,2017
38
APPEALS
Abbi Coursolle
39
Adverse Benefit Determinations
•  Anadversebenefitdetermina;onincludes
-  Thepriordefini;onofanac;on(e.g.,denial,reduc;on,
suspension,termina;onordelayofaservice)
-  PLUSdenialorlimitedauthoriza;ondetermina;onsbased
on:
•  Requirementsformedicalnecessity,appropriateness,seqng,or
effec;venessofacoveredbenefit,and
•  Disputesinvolvingcostsharing,copayments,premiums,
deduc;bles,coinsurance,andotherenrolleefinancialliabili;es
•  Foradversebenefitdetermina;ons,plans
musthaveanappealsystem
40
Other Matters
•  Theruledis;nguishesadversebenefit
determina;onsfrom“othermavers”
•  Forothermavers,plansmusthavea
grievancesystem
•  Thegrievancesystemallowsenrolleesto
expressdissa;sfac;onoverthingslikebeing
treatedrudelyandaplan’sauthoriza;on
decision;ming
•  Grievancescanbefiledatany;me
41
Appeal System
•  Adversebenefitdetermina;onsarehandled
throughanappealsystem
-  Therecanonlybeonelevelofappeal
-  Butenrolleesmustexhausttheappealbeforereques;ng
astatefairhearing
•  Anappealmustbefiledwithin60daysfromthe
dateoftheadversebenefitdetermina;on
•  Plansmusthaveanexpeditedreviewprocessfor
appealswhenthestandardresolu;on;mecould
seriouslyjeopardizetheenrollee’slife,physicalor
mentalhealth,orabilitytoavain,maintain,or
regainmaximumfunc;on
42
Deemed Exhaustion
•  Typically,anenrolleewillhavetoexhausttheinplanappealsystembeforeseekingastatefair
hearing
•  However,iftheplanfailstoadheretono;ceand
;mingrequirements,theenrolleeisdeemedto
haveexhaustedthein-planappealsystemandcan
immediatelyrequestastatefairhearing
Workwithyourstatetoimplementrobustproceduresfor
determiningwhenanenrolleewillbedeemedtohaveexhausted
theplanappealprocessandmonitoritsimplementa>on.
43
Continuation of Benefits Pending
Appeal §438.420
•  Thenewrulerequiresplanstocon;nuethe
enrollee’sservicesduringanappealandstate
fairhearing,ifcertainpre-condi;onsaremet
ManagedCareOrganiza;ons(MCO)
PrepaidInpa;entHealthPlans(PIHP)
PrepaidAmbulatoryHealthPlans(PAHP)
Nolaterthan12-monthra;ngperiod
star;ngonorajerJuly1,2018
44
Conditions for Benefits Paid Pending
•  Theplanmustcon;nuetheenrollee’s
servicesifALLofthefollowingoccur:
1.  Theenrolleefilesa;melyappeal(e.g.,within60daysof
thedateontheadversebenefitdetermina;onno;ce)
2.  Theappealinvolvesthetermina;on,suspension,or
reduc;onofapreviouslyauthorizedservice
3.  Theservicewasorderedbyanauthorizedprovider
4.  Theperiodcoveredbytheoriginalauthoriza;onhasnot
expired
5.  Theenrollee;melyfilesforcon;nua;onofbenefits(e.g.,
onorbefore10daysoftheplansendingtheno;ce)
45
Benefits Paid Pending
•  Ifthesecondi;onsaremet,benefitsmustcon;nue
•  However,whenanappealorstatefairhearingis
concludedadversetotheenrollee,theplancan
recoverthecostsoftheservicesfurnishedduring
thependencyofthereview
-  Butonlytotheextentthatthebenefitswerefurnishedsolelybecause
ofthisrequirementandtotheextentthatthestaterecoupsthese
feesunderFFS
Encourageyourstatetoimplementrobustprotec>onstoensure
thatenrolleesareapprisedoftheirrighttorequestaidpaid
pendingappeal.
46
CHIP
Kelly Whitener
47
CHIP – Network Adequacy and
Availability of Services
ApplicabletoCHIP:
•  Availabilityof
Services
(§457.1230(a))
•  NetworkAdequacy
Standards
(§457.1218)
•  Assurancesof
AdequateCapacity
andServices
(§457.1230(b))
NotApplicabletoCHIP:
•  StateMonitoring
Requirements(but
seerelated
requirementat
§457.495)
Encourageyourstate
toadoptthemore
specificreview
provisionsof§438.66
toCHIP
48
CHIP – Provider Inclusion Rules
ApplicabletoCHIP:
•  Screeningandenrolling
requirements
(§457.1285)
•  Specialprovisionsfor
IndianHealthCare
Providers(§457.1209)
•  Sufficientnumbersand
typesofproviders
(§457.1230(a)and(b))
NotApplicabletoCHIP:
•  NewMedicaidrules
(describedinSHO#
16-006)requiringplans
toincludeatleastone
FQHCintheirnetworkas
wellasoneruralhealth
clinicandonefreestandingbirthcenter
49
CHIP – Care Coordination &
Service Authorization
CareCoordina$on
ApplicabletoCHIP:
•  Coordina;onand
con;nuityofcare
(§457.1230(c))
•  Con;nuedservicesto
enrollees(§457.1216)
ServiceAuthoriza$on
ApplicabletoCHIP:
•  Coverageand
authoriza;onofservices
(§457.1230(d))except
provisionsrelatedto
medicalnecessity&LTSS
•  Specialrulesfor
prescrip;ondrugs
(§457.1230(d))except
thecontractprovisions
50
CHIP – Appeals
ApplicabletoCHIP:
•  MostMedicaidprovisions
relatedtogrievancesand
appeals(§457.1260)
NotApplicabletoCHIP:
•  Norighttoaidpaid
pendinganappeal
•  Referencesto“fair
hearings”shouldberead
toreferto“reviews”
51
Stay Tuned (September 8)
5thExplainer
Brief&Webinar
52
For More Information
•  AbbiCoursolle
•  [email protected]
•  KellyWhitener
•  [email protected]