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Medicaid and CHIP Managed Care Monitoring and Oversight Initiative

CMS is committed to strengthening the monitoring and oversight of Medicaid and CHIP managed care programs.  To do so, the agency is developing a series of reporting templates and technical assistance toolkits.  Three Informational Bulletins released on June 28, 2021, July 6, 2022, November 7, 2023, and June 12, 2024 provide additional information on the Medicaid and CHIP Managed Care Monitoring and Oversight Tools.  CMS looks forward to engaging and collaborating with states on the implementation of these tools, and anticipates issuing additional tools periodically to improve its monitoring and oversight activities.

Reporting Templates for Required State Reports

The May 2016 Medicaid and CHIP managed care final rule strengthened the federal oversight of state managed care programs in several ways, one of which was to create new reporting requirements for states on their managed care programs and operations.  CMS has developed reporting templates for each of the following reports: the Annual Program Oversight Report required in 42 CFR § 438.66(e), the Medical Loss Ratio (MLR) Summary Report required in 42 CFR § 438.74(a), and the Access Standards Report required in 42 CFR § 438.207(d) and (e).  CMS intends to develop these templates in a web-based reporting portal, thereby creating a single submission process and repository for all state reporting requirements related to managed care.  For more information about each report and the web-based reporting portal, visit the Medicaid and CHIP Managed Care Reporting page.

Technical Assistance Toolkits to Improve State Compliance and Oversight

CMS is developing a series of technical assistance toolkits to assist states in complying with various managed care standards and regulations, and to help improve state monitoring and oversight of their managed care programs.  In addition to the available toolkits listed below, CMS will continue to develop additional resources and make them available on an ongoing basis.

  • Tribal Protections in Medicaid and CHIP Managed Care Oversight Toolkit

    This toolkit is a resource for states, managed care plans, and Indian Health Care Providers (IHCP) to assist in implementing the Indian protections in Medicaid and CHIP managed care in their respective states.  This toolkit highlights promising practices and strategies that state Medicaid agencies and managed care plans that can use to: (1) improve state-Tribal relationships including Tribal consultation; (2) establish a Tribal liaison position to improve access to care for American Indians and Alaska Natives (AI/AN) and improve claim processing; (3) improve contracting between managed care plans and IHCPs by using the model Medicaid and CHIP managed care contract addendum; (4) develop internal processes to improve understanding of the managed care delivery system for AI/ANs and IHCPs; and (5) partner with Tribes or Tribal organizations to develop an Indian Managed Care Entity.

  •  Promoting Access in Medicaid and CHIP Managed Care: Managed Long-Term Services and Supports Access Monitoring Toolkit

    This toolkit is intended as a resource for state Medicaid and CHIP agency staff who are developing or implementing monitoring practices to oversee access in Managed Long-Term Services and Supports (MLTSS) programs.  It highlights effective or promising practices currently used in states as examples.  The toolkit was developed in response to the growth in MLTSS programs in recent years and concerns raised by federal oversight agencies about access to services and quality of care for individuals enrolled in MLTSS programs.

  • Behavioral Health (BH) Access Toolkit

    The expanded role that Medicaid managed care plans play in delivering behavioral health services—and the greater demand for such services among Medicaid beneficiaries—raises the importance of access to these critical services through robust provider networks.  This toolkit aims to help state Medicaid agencies and the managed care plans with which they contract meet the network adequacy requirements for behavioral health care providers.  Numerous state Medicaid agencies have developed innovative approaches to strengthen their behavioral health workforce and improve access to services within Medicaid managed care.  This toolkit highlights promising practices and strategies implemented by state Medicaid agencies and managed care plans.

  • Quality Strategy Toolkit

    Under regulations at 42 CFR §§ 438.340(a) and 457.1240(e), CMS requires state Medicaid and CHIP agencies that contract with MCOs, PIHPs, PAHPs, and certain PCCM entities to develop and maintain a Medicaid and CHIP quality strategy to assess and improve the quality of health care and services provided by managed care plans.  To support states in implementing managed care quality strategy requirements, CMS has developed the Medicaid and CHIP Quality Strategy Toolkit.  CMS recommends that states use this toolkit as a part of their quality strategy development, revision, and submission processes to ensure that their quality strategies address regulatory requirements and leverage best practices. 

  • 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.

  • Medicaid Managed Care Plan Transitions: A Toolkit for States on Promoting Continuity of Care When Plans Enter, Leave, or Merge or are Acquired

    This toolkit provides helpful resources when the MCOs, PIHPs, and PAHPs operating in States’ Medicaid managed care programs change. In these circumstances, States and managed care plans must ensure there are no disruptions in enrollees’ access to care.  States can mitigate the risk of disruption through planning, implementation, and monitoring of plan transitions, as well as developing associated managed care contractual requirements.  This toolkit provides steps that States can take during each phase of a transition to support successful movement of enrollees from one plan to another, clear communications with enrollees about the impact of a transition and their rights and options, and facilitation of continuity of care with established and new providers. 

  • Program Integrity Compliance Program Requirements 

    This toolkit discusses the compliance program requirements that States must follow when entering into contracts with managed care plans.  Specifically, CMS regulations at 42 CFR § 438.608(a)(1) require that States, through contracts with managed care plans, must require managed care plans to implement and maintain arrangements or procedures designed to detect and prevent fraud, waste, and abuse.  These arrangements or procedures must include a compliance program that meets several minimum elements. 

  • Treatment of Overpayments and Recoveries 

    This toolkit discusses how recoveries of network provider overpayments may be treated under requirements found in 42 CFR §§ 438.608(d) and (a)(2).  These regulations provide States with flexibility on how to handle recoveries made by managed care plans to create incentives for managed care plans to proactively oversee network provider billing practices and identify fraud, waste, and abuse. 

  • Prompt Referrals of Potential Fraud, Waste, or Abuse 

    This toolkit outlines the requirements of managed care plans to promptly report and establish clear timelines for referrals of potential fraud, waste, or abuse to the State Medicaid Program Integrity (PI) Unit or Medicaid Fraud Control Unit (MFCU), as required in 42 CFR § 438.608(a)(7).  When referring potential fraud, waste, or abuse, States have the discretion to stipulate the ways managed care plans can report potential fraud. 

  • Payment Suspensions Based on Credible Allegations of Fraud 

    This toolkit discusses managed care-related payment suspensions and the procedures in place to suspend payment when there is a credible allegation of fraud, consistent with requirements found in 42 CFR § 438.608(a)(8).  States have an important oversight responsibility when implementing payment suspensions for network providers, and CMS encourages States and managed care plans to collaborate throughout this process.