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. Two Informational Bulletins released on June 28, 2021 and July 6, 2022 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.
- 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.