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Contract Review

The managed care regulation sets forth requirements for states to submit their contracts with managed care plans to the Centers for Medicare & Medicaid Services (CMS) for review and approval.

Guidance to States Regarding Inclusion of Contract Language Addressing Managed Care Activities that may be Vacated by the Court

This document (PDF, 179.05 KB) outlines expectations for States to include specific contract language in their Medicaid and Children’s Health Insurance Program (CHIP) managed care plan contracts to address situations where managed care activities have been vacated by the court. States should execute contract amendments to include the additional language in their managed care plan contracts no later than December 31, 2020.  We are issuing this guidance as part of our ongoing effort to provide greater transparency and consistency across CMS’ managed care plan contract review process.

State Guide to CMS Criteria for Medicaid Managed Care Contract Review and Approval

This guide (PDF, 1.61 MB) covers the standards that are used by CMS staff to review and approve state contracts with Medicaid MCOs, PIHPs, PAHPs, primary care case managers, primary care case management entities, and health insuring organizations. This guide is based on existing requirements and CMS policy at 42 CFR §438.

Medicaid Managed Care Contract Review Redesign Pilot Project

This CMCS Informational Bulletin (PDF, 130.6 KB) introduces a new pilot project that CMS has developed in collaboration with the National Association of Medicaid Directors to improve managed care plan contract review by increasing efficiencies and transparency, while decreasing administrative burden. The project will expedite the review process so that states and CMS can rebalance their resources on assuring accessible, high quality health care, and improving health outcomes for Medicaid beneficiaries.