Guidance

As part of the state-federal partnership in administering the Medicaid programs, the Centers for Medicaid and CHIP Services (CMCS) issues technical assistance in the form of letters to State Medicaid Directors, Informational Bulletins, Issue Briefs, and Frequently Asked Questions (FAQs) to communicate with states and other stakeholders regarding operational issues related to Medicaid. Managed care technical assistance is available to assist state Medicaid agencies in developing, enhancing, implementing, and evaluating managed care programs.

Notice of Proposed Rulemaking

On November 8, 2018, the Centers for Medicare & Medicaid Services (CMS) released a Notice of Proposed Rulemaking (NPRM) for Medicaid and Children’s Health Insurance Program (CHIP) managed care. This proposed rule advances CMS’ efforts to streamline the Medicaid and CHIP managed care regulatory framework and reflects a broader strategy to:

  • Relieve regulatory burdens
  • Support state flexibility and local leadership
  • Promote transparency, flexibility, and innovation in the delivery of care

These proposed revisions of the Medicaid and CHIP managed care regulations are intended to ensure that the regulatory framework is efficient and feasible for states to implement in a cost-effective manner and ensure that states can implement and operate Medicaid and CHIP managed care programs without undue administrative burdens. See the NPRM fact sheet and webinar slides, which provide an overview of the regulatory revisions in the proposed rule. These proposed changes are not effective unless finalized.

Final Rule

On April 25, 2016, CMS released the Medicaid and CHIP Managed Care Final Rule, which aligns key rules with those of other health insurance coverage programs, modernizes how states purchase managed care for beneficiaries, and strengthens the consumer experience and key consumer protections. This final rule is the first major update to Medicaid and CHIP managed care regulations in more than a decade. View the related blog co-authored by the CMS Administrator and CMCS Director, Medicaid Moving Forward. For questions regarding Managed care, please email ManagedCareRule@cms.hhs.gov.  

Use of New or Increased Pass-Through Payments in Medicaid Managed Care Delivery Systems

On January 17, 2017, CMS released a final rule that finalizes changes, consistent with the CMCS Informational Bulletin (CIB) The Use of New or Increased Pass-Through Payments in Medicaid Managed Care Delivery Systems, published on July 29, 2016. The final rule addresses the pass-through payment transition periods and the maximum amount of pass-through payments permitted annually during the transition periods under Medicaid managed care contracts and rate certifications. The final rule prevents increases in pass-through payments and the addition of new pass-through payments beyond those in place when the pass-through payment transition periods were established in the final Medicaid managed care regulations effective July 5, 2016.

Medicaid and CHIP Managed Care Medical Loss Ratio Credibility Adjustment

In alignment with medical loss ratio (MLR) requirements for health plans operating in the private market and Medicare Advantage, the Medicaid and CHIP managed care rule provides a credibility adjustment to account for the potential variation in smaller managed care plans. As defined in 42 CFR 438.8(b), the credibility adjustment is used to account for random statistical variation related to the number of enrollees in a managed care plan. CMS will publish MLR credibility adjustment factors annually. 

CMS has published the MLR credibility adjustment factors for Medicaid and CHIP managed care plans—managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs)—with contract rating periods starting on or after July 1, 2017. The CIB provides the Office of the Actuary methodology for developing the MLR credibility adjustments, as well as examples of how states should apply the MLR credibility adjustments.

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

This guide 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.

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.

2019-2020 Draft Medicaid Managed Care Rate Development Guide

The 2019-2020 Draft Medicaid Managed Care Rate Development Guide is developed for states to use when setting rates for any managed care program subject to federal actuarial soundness requirements during rating periods starting between July 1, 2019 and June 30, 2020. The draft guide provides preliminary detail around CMS' expectations of information to be included in actuarial rate certifications, and the final guide will be used as a basis for CMS’ review. The guide is being released in draft form until CMS receives its Paperwork Reduction Act clearance for this version of the guide, after which CMS will provide the final guide. Consistent with the letter from the Administrator on March 14, 2017, and the Informational Bulletin released on June 30, 2017, CMS has engaged in a comprehensive review of the managed care rules to prioritize beneficiary outcomes and more effective program management, culminating in release of the NPRM. Pending adoption of a final rule amending them, the regulations currently in place continue to govern the rate-setting practices for Medicaid managed care plans that are outlined in this rate guide. Please direct any questions related to this guide to MMCratesetting@cms.hhs.gov.  

View previous years’ rate setting guidance:

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.

Managed Care Encounter Data Toolkit

This toolkit provides a practical guide to collecting, validating, and reporting Medicaid managed care encounter data. It is designed as a step-by-step guide for state Medicaid staff responsible for managing the daily operations involved in encounter data, as well as for senior managers and policymakers who oversee this function. It contains case studies, checklists, and links to resources that provide helpful tips and tools.

Assessing the Usability of 2011 Behavioral Health Organization Medicaid Encounter Data

CMS released the Assessing the Usability of 2011 Behavioral Health Organization Medicaid Encounter Data technical assistance brief. This brief assesses the completeness and quality of encounter data for Medicaid managed care behavioral health organizations (BHOs) in 2011. It provides an update to a similar study conducted using Medicaid Analytic eXtract 2009 data. It describes state variation in the use of delivery systems, which benefits are covered, and the types of Medicaid beneficiaries enrolled in BHOs. Please direct any questions related to this issue brief to managedcareTA@mathematica-mpr.com.

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.