Brief Issue Description
This best practice document outlines some approaches for states when reporting the eligible populations that are authorized to be enrolled in a managed care plan in the T‐MSIS Managed Care Plan file record segment MANAGED‐CARE‐PLAN‐POPULATION‐ENROLLED‐MCR00006 using the data element MANAGED‐CARE‐PLAN‐POP (MCR077). States should use this record segment to report the Medicaid or CHIP eligibility groups included in each of their managed care programs and eligible to be enrolled into a contracted managed care plan.
Background Discussion
Context
Medicaid managed care programs allow states to deliver Medicaid services to their beneficiaries through contracted managed care plans. States can target a range of eligible populations within each managed care program.
Challenge
Since the MANAGED‐CARE‐PLAN‐POP is a new data element in T‐MSIS (compared to MSIS), states need to understand how to correctly populate this field for each managed care plan. States are seeking guidance on how to code the eligibility groups that should be included as part of a managed care program population and reported via a managed care plan's record in the T‐MSIS Managed Care Plan file. States must also ensure that as managed care programs add or remove populations, the MANAGED‐CARE‐PLAN‐POP element is updated in a timely manner.
CMS Guidance
The managed care plan population enrollment segment is populated with information related to the managed care program under which the managed care plan operates. All states should report the same information on the MANAGED-CARE‐PLAN‐POP‐ENROLLMENT segment for each of their plans. That means that effective dates related to the managed care program may precede the specific managed care plan contract effective dates, as some managed care plans may be added to the managed care program after the program is implemented. Similarly, end dates related to the managed care program may fall after specific managed care plan end dates.
States should review the Medicaid enrollee groups listed in Appendix F: Eligibility Group Table of the T‐MSIS Data Dictionary to select the eligibility groups that are authorized to be included in a managed care program, and therefore, eligible to be enrolled in the program's contracted managed care plan(s). A state must use the
valid values from this list to report these groups to the data element MANAGED‐CARE‐PLAN‐POP. All eligibility group(s) that are authorized under the program to be enrolled into a managed care plan must be populated as part of each plan's record. That means that a record should be reported on the MANAGED‐CARE‐PLAN‐POP‐ENROLLMENT segment using the data element MANAGED‐CARE‐PLAN‐POP for each eligibility group authorized through the program. This data element should not reflect only the eligible populations represented by beneficiaries actually enrolled in the plan; it must reflect all populations that are authorized to be enrolled. For example, if a state's managed care program is authorized to enroll independent foster care adolescents (MANAGED‐CARE‐PLAN‐POP code = 30) and former foster care children (code = 09) into managed care plans, both codes will need to be entered. Even if no beneficiaries from these groups are actually enrolled in the plan, these eligibility groups should still be reported using this data element since they are eligible to be enrolled in that plan.
In addition, states should ensure that the MANAGED‐CARE‐PLAN‐POP‐EFF‐DATE correctly reflects the date that the population was authorized by the program to be covered by managed care plans. For example, if a managed care program started on January 1, 2014, but a particular managed care plan did not join the program until July 1, 2016, then the MANAGED‐CARE‐PLAN‐POP‐EFF‐DATE should reflect the January 1, 2014 date when the managed care program covering that population began. All data elements in the MANAGED‐CARE‐PLAN‐POPULATION‐ENROLLED‐MCR00006 record segment are in effect from the first day of the reported MANAGED‐ CARE‐PLAN‐POP‐EFF‐DATE through the MANAGED-CARE‐PLAN‐POP‐END‐DATE time span. If the managed care program is amended to add a new population, the effective date reported on the record for that population should be populated to reflect the effective date of that amendment. Similarly, if the managed care program is amended to remove a specified population, the end date should be populated to reflect the date that population ceased to be covered by that managed care program. If the managed care plan program later allows for that population to be covered by that program again, then a new record will need to be established on the MANAGED‐CARE‐PLAN‐POP‐SEGMENT for that group with the new effective date1.
Once a MANAGED‐CARE‐PLAN‐POP‐EFF‐DATE record is established for a given managed care plan population, the only data element that should be changed on that record is the MANAGED‐CARE‐PLAN‐POP‐END‐DATE. The MANAGED-CARE‐PLAN‐POP and the MANAGED‐CARE‐PLAN‐POP‐EFF‐DATE should not be updated. Renewing or amending the operating authority documents will not change the effective date for that population, as this date represents the effective date for the program which will not change.
This table provides changes (PDF, 188.62 KB) that will be made to the T-MSIS data dictionary based on guidance from this document.
1 This will ensure that end users can identify any periods that the population was not eligible for managed care enrollment under the authority.