Professional Documents
Culture Documents
Milliman, 2013
The alignment of network adequacy standards across Medicaid MCOs, QHPs and Medicare
Advantage Plans will promote greater coverage continuity across public and private insurance,
and create a more navigable health care system for people who are impoverished and whose
income volatility2 renders them more susceptible to churn across multiple types of insurance
coverage. We are confident that these stronger standards can be implemented in a manner that
provides states with enough flexibility to tailor their execution to meet the needs of managed
care beneficiaries within their jurisdictions.
We urge CMS to incorporate a requirement to adopt an Essential Community Provider (ECP)
standard similar to those required of QHPs. At a minimum, we ask that CMS require that MCOs
contract with ECPs as these providers are well-positioned to offer HCV care and treatment, and
the supportive services essential to maximizing a beneficiarys course of treatment. Additionally,
we strongly recommend that CMS consider innovative contracting requirements that have
proven successful with Medicaid programs in Minnesota3 and Colorado4 - states that have
required Medicaid MCOs to contract with all ECPs in their respective jurisdictions.
To promote greater access to care and treatment for people living with HCV, we recommend
that CMS set a national floor standard for maximum time and distance to access providers. This
recommendation is based on a report published by the Kaiser Family Foundation that reviewed
access standards across Medicaid programs. We suggest CMS set an access standard that
ensures access to primary care in urban areas within 30 minutes or 10 miles and for rural areas
within 30 minutes or 30 miles with exceptions for states with documented issues in meeting this
standard. For specialty care, we recommend a general standard of 30 minutes or 30 miles with
exceptions for states with documented issues in meeting this standard. Additionally, we believe
that the maximum wait time to receive a medical visit appointment should not exceed 30 days.
Finally, we also urge that CMS require states to have a meaningful public comment process
before their network adequacy standards are finalized.
PRESCRIPTION DRUG COVERAGE ( 438.3(s))
We support stronger prescription drug coverage standards for beneficiaries enrolled in MCOs.
Unfortunately, recent increases in the number of beneficiaries enrolled in Medicaid have
coincided with the intensified use of prior authorization and other utilization management (UM)
techniques by MCOs. As people living with HCV often manage other comorbid conditions, the
mandated to be covered by MCOs. Unfortunately, we believe that these clarifications alone will
not remedy the widespread restrictions that Medicaid MCOs often place on HCV treatment.
These factors compel us to strongly recommend that CMS adopt the following measures:
First, we believe that MCO formularies should be comparable to those of traditional fee-forservice (FFS) Medicaid programs. While we understand that relative to FFS Medicaid, MCOs
are often granted discretion regarding the structure of their benefit designs, we know that in
the absence of additional protections this flexibility frequently leads to unfounded
restrictions on access to new curative HCV treatments. In many states, MCO prior
authorization and other utilization management requirements continue to create barriers to
access to medically recommended treatment regimens. Furthermore, we believe that MCOs
should be able to implement UM practices that are more rigorous than those the FFS
Medicaid program in their jurisdiction.
Next, CMS should prescribe standards for the use of medical need in prior authorization
programs. Prior authorization is almost always inappropriate for HCV given that prescribers
must assess the unique needs and medical history of each affected patient. Further, if prior
authorization is applied then the evaluating professional should be a physician specialist with
expertise in the care and treatment of HCV.
Finally, we believe that CMS should take a more active oversight role for MCO formulary
compositions. We would like to a see final regulatory language that assigns a strong federal
oversight role in this area, with details about how CMS will fulfill this role.
APPEALS ( 438.408)
We support the proposed modifications to the appeals process including: (1) the inclusion of
PAHPS in the appeals process; (2) the requirement that states implement an online system for
tracking and monitoring status of grievances and appeals; and (3) the shortening of the
timeframe for appeal decisions from 45 days to 30 days as well as new expedited review timeline
of 72 hours.
Given the frequency of UM and the complexity of HCV care and treatment, a strong appeals
process is essential to ensure equitable access to services. The number of individuals that churn
between Medicaid and private insurance warrants an appeals standard that, at a minimum,
parallels the appeals process set forth for QHPs, including all of the protections specified in 45
CFR 147.136 - Internal claims and appeals and external review processes. In addition to these
considerations, we strongly urge CMS to set aside the proposed rules requirement that
beneficiaries exhaust the internal appeals process prior to being able to request a State Fair
Hearing. We believe that individuals exhibiting exigent circumstances may require a more
expedient process to have their claim heard.
AVAILABILITY OF SERVICES ( 438.206 & 440.262)
We support the requirement for states to report on a mix of approaches to assess the availability
of services. We believe this evaluation should be available for public inspection on an annual
basis. In an effort to curb access to treatment, many MCOs have placed restrictions on the type
We support the proposal to require MCOs to update their provider directories at least monthly
as stated in the preamble ideally the updates would be closer to real time, e.g., on a weekly
basis. In addition, we urge you to require plans to:
Identify Essential Community Providers in the directories, including by type
Indicate the date of the last update to the directory in an easily accessible location
Include a search function for providers by name or specialty as suggested in the FY 2015
letter to issuers
Additionally we urge CMS to combine subsections 438.3(d)(3) (MCOs will not, on the basis of
health status or need for health care services, discriminate against individuals eligible to enroll)
and 438.3(d)(4) (MCOs will not discriminate against individuals eligible to enroll on the basis of
race, color, national origin, sex, sexual orientation gender identity, or disability and will not use
any policy or practice that has the effect of discriminating on the basis of race, color, or national
origin, sex, sexual orientation, gender identity or disability). This would align Medicaid MCO
standards with those found in 1557 of the ACA. The appeals process should also be readily
available to beneficiaries.
PREVENTIVE SERVICES ( 438.2, 3, 10, 66 & 108)
We are very concerned that the proposed rule inadequately protects beneficiary rights to access
routine HCV testing. Recognizing the urgency of the epidemic, the United State Preventive
Services Task Force (USPSTF) assigned a B grade for HCV testing. The ACA requires that
services assigned an A or B grade are required to be covered in Alternative Benefit Plans
(ABPs) for the expansion population. We believe that the best way to save future Medicaid
program resources spend on HCV is to maximize prevention coverage opportunities. To this end,
we propose the following considerations to strengthen the prevention services standards
outlined in the proposed rule:
CMS should define preventive services and specify alignment with USPSTF standards in MCO
contracting.
Furthermore, in 438.3, CMS should require MCOs to provide for coverage of preventive
services as required by the ACA.
Finally, 438.66 should be amended to require state Medicaid programs to monitor MCO
compliance with the requirement to provide preventive services without cost-sharing.
enforce the minimum legal terms of the Medicaid statute.5 This decision indicates the need for
increased federal oversight of this critical component of the managed care system.
Finally, we support the proposed rules stance on allowing MCOs to implement value-based
purchasing models, participate in multi-payer delivery systems and to adopt provider payment
incentives. While this flexibility is essential to modernizing Medicaid, we ask that CMS monitor
MCOs that adopt these reimbursement models for compliance with beneficiary protections. New
reimbursement models should not impact the extent to which beneficiaries access the benefits
for which they are eligible.
Thank you for the opportunity to offer comments to this proposed rule. Please contact Xavior
Robinson with the National Alliance of State and Territorial AIDS Directors (NASTAD) at
xrobinson@nastad.org if you have any questions or comments.
Sincerely,
Caring Ambassadors Program, Inc. | Hepatitis C Mentor Support Group (HCMSG) | National
Alliance of State and Territorial AIDS Directors (NASTAD) | National Viral Hepatitis Roundtable |
One in Four Chronic Health | Project Inform | Robert Gish Consultants, LLC