Modernizing Medicaid: Mega-Reg implications health plans should know

64m_blog-graphicPayers manage a multitude of responsibilities as it relates to their Medicaid membership. From regulatory adherence, and payment integrity optimization to enrollment management, the current, and sometimes, complex canvas of Medicaid oversight is now growing.


The Department of Health and Human Services (HHS) issued a new ruling earlier this year with the intention to modernize Medicaid. Commonly called the Mega-Reg due to its vast and voluminous 1,400-plus pages of documentation, its timing is also significant as it represents the first ruling of its kind for Medicaid in over a decade. With a lens to the future, states are now implementing new goals and increased guidelines to address a number of processes and procedures such as value-based care, network adequacy strategies, and fraud, waste and abuse standards.medicaid-membership_blog-graphic


States and health plans now have the overwhelming task of understanding the applicability of the Mega-Reg on all fronts, including timing of implementations. However, there are key implications to help you break down the Mega-Reg now and assess future ramifications, read more here.

  •  Evaluate your plan’s current Medicaid membership metrics, including member-facing communications and back-office administration.
  •  Assess the major categories that the Mega-Reg addresses, such as:

-Consumer communications and education
-Network access and management of high-quality physicians
-Payment integrity strategies
-Performance metrics for strengthening health outcomes
-Innovating techniques to support delivery of care

  • Implementation speed as well as resources to execute, measure and maintain programs.

As you meet, and potentially exceed, Medicaid regulation recommendations, understanding the future state and identifying areas of opportunity now will support the on-going evolution of your business and the regulations to follow.

1. 2015 CMS Actuarial Report:, accessed August 2016.
2. 2016 Optum payer research, based on an unpublished survey of 57 health plan respondents.

About the Author:

chuck-wacker-photoChuck Wacker is Vice President for Medicaid Solutions at Optum. He supports the Midwest and West Coast states in enabling Medicaid payers and plans to improve their business operations. Prior to joining Optum, Chuck was Vice President, Business Development, with a major BPO organization focused on providing Medicaid services and systems, and also worked for a major consulting firm in business development and operations. Chuck has nearly 30 years of experience supporting clients in the health care and Medicaid markets to improve their business operations and processes through the utilization of technology and outsourcing.

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