A highlight of medical beneficiary protection rulesIn this regulations which HCFA will enforce are going to become effective 90 days after being published and will also be an implementation of 1997 BBA provisions. Generally speaking, these rules feature strengthened protection of the beneficiaries and also includes new provisions that are designed for protection of rights for the vulnerable beneficiaries of Medicaid.

According to HHS, the most significant improvements are the increased protection for people with special needs. The regulations published for Medicaid managed care plan include:

Quality care

The states will now be required to ensure that Medicaid beneficiaries access care continually for those with ‘ongoing health care needs’. They will be switching from the fee for service the managed care plan, switch among different health plans and from one health plan to a fee for service. Besides this, the states together with the participating plans are required to identify those beneficiaries with some ‘special health care needs’ as well as assess the appropriateness and quality of their health care.

Health assessment

The new rules require that Medicaid managed care plans should provide beneficiaries with expedited health assessments at a risk of having the special health care needs or offer beneficiaries already with special health care requirements.

Health plan marketing

All Medicaid managed care plans are required to provide their customers with easy to understand and comprehensive information about the health plans and also offer most of the beneficiaries the option of choosing between not less than two health plans that are qualified. The states are also required to approve any health plan marketing material that is used for enrolling or re-en-rolling to Medicaid. Plans are also restricted from engaging in telephone, door to door and any other kind of ‘cold call’ marketing.

Medicaid emergency services

All Medicaid managed care plans show offer coverage for the costs of emergency health care whenever and wherever there is a need for such services. Plans are not allowed to offer a requirement for emergency services to be approved or asking the beneficiaries to get the care from the so called approved facilities. In this regard, emergency services will be based on the standard of ‘prudent layperson’ where payments should be made in a situation where the beneficiary assumes he or she needs the emergency services.


The law requires states to set capitalization rates for managed care, which are ‘actuarially sound’. These new regulations do not allow generally outdated regulatory ceiling as to what a state can pay for the managed care plans. According to a release by HHS, such a provision is very importance considering that most state Medicaid programs now include people with disabilities and chronic illnesses.

Other crucial items that were included in the new regulations include those touching on access to care, patient provider communication, and network adequacy as well as grievance systems.