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Additional Guidance

Institution for Mental Disease (IMD) Frequently Asked Questions (FAQs)

This document (PDF, 71.91 KB) is the second set of published FAQs and addresses common questions related to section 438.6(e) for payments to managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs) for an enrollee that is a patient in an IMD in the Medicaid and Children's Health Insurance Program (CHIP) Managed Care Final Rule.

Health Insurance Providers Fee for Medicaid Managed Care

Section 9010 of the Affordable Care Act imposes a fee on specified covered entities engaged in the business of providing health insurance. This fee is referred to as the Health Insurance Providers Fee, and covered entities include health insurance issuers, health maintenance organizations, private insurance companies, and insurers that provide coverage under Medicare and Medicaid. For more information, see the Internal Revenue Service website.

For information to assist states as they consider the implications of the Health Insurer Providers Fee for their managed care plans and for Medicaid managed care rate setting, see Frequently Asked Questions (PDF, 159.2 KB).

Medicaid Managed Care Marketing Regulations

With the implementation of the Marketplaces, states and managed care plans have been requesting clarification on the marketing regulations at 42 CFR 438.104 and how those regulations may impact marketing activities. To respond to these inquiries, CMS developed this list of Frequently Asked Questions. These FAQs address:

  • Activities by issuers that offer both a qualified health plan and a Medicaid managed care plan
  • How to respond to consumer inquiries
  • Plans' ability to conduct outreach for eligibility renewal

Promoting Access in Medicaid and CHIP Managed Care: Strategies for Ensuring Provider Network Adequacy and Service Availability

This toolkit compiles effective and promising network adequacy and service availability strategies and analysis techniques, as well as valuable data sources that states are using to develop and assess the availability of providers and services in their states. The toolkit provides detailed descriptions of state access strategies and techniques that states can easily replicate, or states can customize the strategies and techniques to produce measures that address unique access challenges in their Medicaid and CHIP programs. The toolkit is not intended to be an exhaustive list of approaches and describes various standards and approaches that may offer states new and reasonable ways to promote access to care.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit for Children and Youth in Managed Care

On January 5, 2017, CMCS issued an Informational Bulletin (PDF, 59.09 KB) that informs states that use managed care to deliver some or all of the services included in the EPSDT benefit. It is important that managed care plan contracts clearly reflect the extent to which the plan is responsible for services included in the EPSDT benefit. Services included in the EPSDT benefit that are not covered by a plan remain the responsibility of the state Medicaid agency, which must ensure that eligible individuals under age 21 have access to the full EPSDT benefit.