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Additional Guidance

Report to Congress: Study and Report Related to Medicaid Managed Care Regulation Under 12002 of the 21st Century Cures Act (P. L. 114-255)

In the "Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability Final Rule" (81 FR 27497) published in Federal Register on May 6, 2016 (hereafter referred to as the 2016 final rule), the Centers for Medicare & Medicaid Services (CMS) adopted a regulation (42 C.F.R. § 438.6(e)) to permit states to use federal Medicaid matching funds to make capitation payments to managed care organizations or prepaid inpatient health plans on behalf of beneficiaries aged 21 to 64 receiving treatment in IMDs in lieu of covered Medicaid services if certain conditions are met. Section 12002 of the 21st Century Cures Act (P.L. 114-255) directed the U.S. Department of Health and Human Services (HHS), acting through the CMS Administrator, to conduct a study and submit to Congress a report on its findings on coverage by Medicaid managed care plans of services to individuals between the ages of 21 and 64 for the treatment of a mental health disorder in institutions for mental diseases (as defined in section 1905(i) of the Social Security Act. This report  draws on findings from a 2019 survey of states and territories with risk-based managed care arrangements, supplemented with findings from a targeted environmental scan and consultation with subject matter experts conducted in 2018 and 2019, to address five study topics outlined in the statute.

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.

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

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 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.