HHS issues new Medicaid regulation

August 1, 2002
Pharmaceutical Representative

The Department of Health and Human Services has issued a final regulation to give Medicaid beneficiaries enrolled in managed care plans the same types of protection that participants in private plans would receive under patient rights legislation now under consideration in Congress.

The Department of Health and Human Services has issued a final regulation to give Medicaid beneficiaries enrolled in managed care plans the same types of protection that participants in private plans would receive under patient rights legislation now under consideration in Congress.

The regulation guarantees Medicaid beneficiaries access to emergency room care, a second opinion when needed, a timely right to appeal adverse coverage decisions and other patient protections. Under the new regulation, states have significant flexibility to decide how best to implement patient protections and use managed care in their Medicaid plans.

"This new rule ensures Medicaid beneficiaries get the rights and protections enjoyed by other Americans enrolled in managed care plans," said HHS Secretary Tommy Thompson. "It also gives states the flexibility to implement these protections without jeopardizing healthcare services."

New patient protections

The rule retains and expands upon all the protections created for Medicaid beneficiaries under the 1997 Balanced Budget Act. Under the new rule, beneficiaries will have the following rights:


• Health plans must pay for a Medicaid beneficiary's emergency room care whenever and wherever the need arises.


• All beneficiaries will be allowed to get a second opinion from a qualified health professional.


• Women will be allowed to directly access a woman's health specialist in the network for routine and preventive healthcare services as available in Medicaid fee-for-service.


• Managed care plans will be prohibited from establishing restrictions, such as gag rules, that interfere with patient-provider communications.


• Managed care plans will be required to ensure that they have the capacity to serve the expected enrollment in their service area.


• States will be required to approve marketing materials used by the managed care plans to enroll Medicaid beneficiaries.


• All managed care plans must have a system in place to accommodate enrollee grievances and appeals. Grievances must be resolved within state-established time frames that may not be longer than 90 days, and must be resolved by managed care organizations within 45 days. However, expedited time frames exist for resolving appeals when the life or health of the enrollee is in jeopardy.

The final regulation is published in the Federal Register (vol. 67, no. 115) and becomes effective Aug. 13, 2002. States and health plans must come into full compliance within a year. PR