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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.  This Informational Bulletin (PDF, 214.4 KB) provides 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 is developing 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.

  • Annual Managed Care Program Report

    CMS regulations at 42 CFR § 438.66(e) require states to submit an Annual Managed Care Program Report. Under the regulation, each state must submit to CMS, no later than 180 days after each contract year, a report on each managed care program administered by the state. Additional guidance on the timing, content and form of the report are available in the CHIP Managed Care Monitoring and Oversight Tools Informational Bulletin (PDF, 214.4 KB). An excel workbook (XLSM, 135.83 KB) provides the exact indicators that will be required, along with instructions on how to complete each field.  The report will be collected electronically through a web-based submission portal that will be available no later than June 27, 2022.  This portal will collect exactly the information that is included in the excel workbook.

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.

  • 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 (PDF, 526.94 KB) 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 (PDF, 1.98 MB) 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.