Gartner Research

New Medicaid Managed Care Rules Raise the Bar for Payer CIOs

Published: 05 October 2016

ID: G00317074

Analyst(s): Bryan Cole

Summary

With the May 2016 federal Medicaid regulations, the theme is more — more compliance oversight, more reporting demands and more quality guidelines for payers in 2017. The enhanced requirements offer opportunities for Medicaid payer leaders to grow membership and CIOs to simplify IT implementation.

Table Of Contents
  • Impacts

Analysis

  • CIOs Face a More Complicated Operating Environment

Impacts and Recommendations

  • The new Medicaid regulations compound state enrollment, quality and financial data needs, driving Medicaid payer CIOs to upgrade current interfaces between state MMIS and payer systems
    • Immediate Changes
    • Longer-Term Effects
  • Due to enhanced Medicaid requirements, compliance burdens increase and become more nuanced, forcing Medicaid payer CIOs to revise internal workflows and operations
    • Program Integrity
    • Network Oversight
  • Financial and quality reporting requirements deepen due to the new Medicaid regulations, pushing Medicaid payer CIOs to quickly improve monitoring capabilities
    • Quality Reporting
    • Financial Reporting
  • The enhanced Medicaid requirements advance customer service models, prodding Medicaid payer CIOs to implement electronic member interactions
    • Electronic Document Delivery
    • Customer Service Evolution

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