NU Online News Service, June 14, 5:33 p.m. – The American Association of Health Plans, Washington, is supporting the new, revised Medicaid patient protection regulation published today by the U.S. Department of Health and Human Services.

An draft released a year ago “contained a variety of unnecessarily onerous requirements,” but the new version is much better and ought to keep Medicaid managed care payment rates actuarially sound, Karen Ignagni, AAHP’s president, says in the statement.

Congress called for HHS to develop the regulation in the Balanced Budget Act of 1997.

Forty percent of Medicaid beneficiaries fall outside the scope of the regulation because they are still enrolled in Medicaid fee-for-service programs, but the regulation will affect 22 million beneficiaries enrolled in Medicaid managed care programs.

Under the regulation, which takes effect Aug. 13, Medicaid managed care plans must:

  • Pay for a Medicaid beneficiary’s emergency room care whenever and wherever the need arises.
  • Give beneficiaries access to a second opinion from a qualified health professional.
  • Allow women direct access to gynecologists.
  • Provide enough doctors to serve plan members.
  • Set up a system for handling member grievances and appeals.

The regulation also prohibits managed care plans from interfering with physicians’ communications with patients, and it requires states to regulate Medicaid managed care plans’ marketing activities.

The regulation permits states to keep in place most of their existing Medicaid patient protection rules, HHS says.

HHS has posted a copy of the regulation at http://www.hcfa.gov/medicaid/omchmpg.htm