Medicaid Managed Care Rule: Complex Care for a High-Risk Population

July 28, 2016 · Amy Maciejowski

Medicaid managed care is complex. It must constantly evolve in order to deliver and pay for health care for the poorest populations, many of whom face particularly high health risks. Because of this, high-quality care—of coverage, access, efficiency and value—is essential. The newly updated Medicaid Managed Care (MMC) rule modernizes current regulations to better align with current Marketplace and Medicare policies, and describes expectations for value-based payments.

Not only does the final rule unify requirements across all forms of managed care, it formalizes expectations for oversight of long-term services and supports (LTSS), a growing function within state Medicaid managed care contract arrangements.

NCQA has been following this trend and has released new LTSS standards to support states, their managed care plans and their subcontractors as they navigate the complex environment of person-centered care coordination under managed care.

Next Steps for States.

NCQA officially released LTSS standards for two levels of the delivery system: health plans and community based organizations. The LTSS Distinction standards will be presented as an optional module within NCQA’s existing Health Plan and Managed Behavioral Health Organization (MBHO) Accreditation requirements. Health plans and MBHOs that elect to complete the LTSS module will have the opportunity to earn an accreditation status with LTSS distinction. Plans and MBHOs that earn NCQA Distinction will have their status listed on NCQA’s public directory.

Because implementation of managed LTSS varies across the country, we have not made the LTSS distinction a mandatory part of the health plan accreditation review. However, LTSS distinction will support the goals of the guidelines outlined in the final MMC rule.

NCQA LTSS distinction is not yet required as part of our existing accreditation program. States intending to require plans responsible for LTSS to earn NCQA Accreditation must add the LTSS Distinction module to contract requirements.

NCQA offers accreditation for LTSS-only plans and community based organizations. For more information about these programs, access our online Webinar.

As we launch the NCQA LTSS Distinction program, and as you decide what works best for your state, feel free to contact Kristine Thurston Toppe, Director of State Affairs, at

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