Medicaid and CHIP Managed Care Reporting

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 Managed Care Program Annual Report (MCPAR) 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). Information on each report can be found below, including the reporting templates.

CMS is also creating a web-based reporting portal for these reports, thereby creating a single submission process and repository for all state reporting requirements related to managed care.  The portal will be part of the existing Medicaid Data Collection Tool (MDCT) in a separate module called Managed Care Reporting (MDCT MCR).  More information about MDCT-Managed Care Reporting can be found below.

Information available below:

• Managed Care Program Annual Report
• Medical Loss Ratio (MLR) Report
• Network Adequacy and Access Assurances Report
• Medicaid Data Collection Tool (MDCT) for Managed Care Reporting

Managed Care Program Annual Report (MCPAR)

Background

CMS regulations at 42 CFR § 438.66(e) require states to submit a Managed Care Program Annual Report (MCPAR). 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. The following resources can help states complete their MCPAR:

• Additional guidance on the report's timing, content, and form are available in the Medicaid and CHIP Managed Care Monitoring and Oversight Tools Informational Bulletin.
• This excel workbook provides the exact indicators that will be required, along with instructions on how to complete each field.
• These FAQs address the most common questions and errors made by states in their reporting.
• Technical Guidance:
  • MCPAR Appeals and Grievances Technical Guidance

Submission to CMS

The MCPAR report is collected through MDCT-Managed Care Reporting. The web-based forms collect exactly the information that is included in the excel workbook. The Managed Care Program Annual Report is available for state input in MDCT-Managed Care Reporting. As described in the Informational Bulletin above, the report is required annually, and must be submitted through MDCT-Managed Care Reporting. More information about MDCT-Managed Care Reporting can be found below.

Public Access to MCPARs

CMS is undertaking efforts to improve transparency by publicly posting MCPARs on a regular basis. Visit this webpage to learn more and access MCPAR files. 

Due Dates

The requirement to submit the annual report was triggered by the June 2021 CIB, and the due dates are dependent upon the Contract Year of each managed care program. The due dates for the next rounds of reports are listed below.

Medical Loss Ratio (MLR) Report

Background

CMS regulations at 42 CFR § 438.74(a) require that states must submit, with their annual rate certification required in 42 CFR § 438.7, a summary description of the MLR report(s) received from the managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs) under contract with the state. An excel workbook provides the required fields and instructions for completing the report.

Submission to CMS

The report will be collected through MDCT-MCR, which requires the same information that is outlined in the excel workbook. The MLR report must be submitted at the same time as the corresponding annual rate certification. States are required to submit summary MLR reports to CMS for rating periods starting on or after July 1, 2017. For rating periods beginning on or after July 1, 2024, states are required to submit MLR reports through MDCT-MCR; submissions using the excel workbook will no longer be accepted. More information about MDCT-MCR can be found below.

Public Access to MLRs

CMS is undertaking efforts to improve transparency by publicly posting MLR reports in a public use file. Visit this webpage to learn more and access MLR data.

Due Dates

This report is required to be submitted at the same time as the annual rate certification.

Network Adequacy and Access Assurances Report

Background

CMS regulations at 42 CFR § 438.207(d) require that states:

• Submit an assurance of compliance to CMS that the each MCO, PIHP, and PAHP meets the state’s requirement for availability of services; and
• Include documentation of an analysis that supports the assurance of the adequacy of the network for each contracted MCO, PIHP, or PAHP related to its provider network.

Submission to CMS

The requirement for states to submit this information to CMS began with all contracts with rating periods beginning on or after July 1, 2018. As of October 1, 2022 states are required to use the reporting template.

• The current reporting template provides the required fields and instructions for completing the report: Reporting Template
• The template may  be submitted to mcgdmcoactions@cms.hhs.gov.

In the future, this report will be collected through MDCT-Managed Care Reporting. CMS will notify states when the web-based forms are available, and will provide adequate notice prior to requiring submission through the web-based forms.  More information about MDCT-Managed Care Reporting can be found below.

Due Dates

The information is required to be submitted:

• At the time the state enters into a contract with each MCO, PIHP, or PAHP;
• On an annual basis; and
• Any time there is a significant change in the operations that would affect the adequacy of capacity and services of an MCO, PIHP, or PAHP.
• CMS recommends that the report be submitted as supporting documentation at the same time a state submits the associated managed care contract to CMS for approval, including a new contract, a renewal, or an amendment.

NAAAR Payment Analysis Template (Optional)

At 42 CFR 438.207(d)(2), states are required to report certain data in the NAAAR from payment analyses reflecting payments made by managed care plans for certain services. The optional Payment Analysis template can assist states in collecting data from managed care plans that is necessary to complete data fields that will be added to the NAAAR for all rating periods beginning on or after July 9, 2026. This template includes instructions and pre-populated formulas that plans can use to conduct the payment analyses required at 42 CFR 438.207(b)(3) and states can use to collect and analyze plans’ data.

Payment Analysis data required at 42 CFR 438.207(d)(2) are required for all rating periods beginning on or after July 9, 2026. This means any NAAARs submitted to CMS on or after January 1, 2028 must contain this Payment Analysis data. CMS anticipates the Medicaid Data Collection Tool (MDCT) will be ready to accept entry of Payment Analysis data by January 1, 2028; we encourage states and plans to use this template to familiarize themselves with the requirements.

• Payment Analysis Template

Medicaid Data Collection Tool (MDCT) for Managed Care Reporting

The Centers for Medicare & Medicaid Services (CMS) collect data from states and territories to better understand the Medicaid and Children’s Health Insurance Program (CHIP) programs.  The Center for Medicaid and CHIP Services (CMCS) has developed the Medicaid Data Collection Tool (MDCT) and underlying applications to collect the data required to best monitor, manage, understand and review the Medicaid and CHIP programs for each state.

A new module, Medicaid Data Collection Tool Managed Care Reporting (MDCT MCR), is being developed to collect the reports described above.  MDCT MCR will consist of fillable webforms to be completed by States based on the data they collected using the indicators contained in the excel template(s).  The structured data captured by this system will allow CMS to generate and analyze state-specific and nationwide data across the universe of managed care programs and requirements.  This data analysis will allow CMS to identify areas for technical assistance and to target efforts to assist states in improving their managed care programs, while also ensuring compliance with managed care statutes and regulations, such as ensuring access to care.

At this time, the Annual Managed Care Program Report is available in MDCT MCR.  As additional web-based forms are developed, CMS will announce their availability to states.  At those times, states will be able to enter their information directly into the fillable webforms, creating efficiency for states and CMS.  The fillable webforms will collect exactly the same information that is included in the excel templates for each report.  CMS anticipates that the Annual Managed Care Program Report will be available first, in early November 2022.

Access to MDCT MCR is limited to state staff that have been granted access to complete the fillable forms.  CMCS has reached out to states directly to make sure that appropriate state staff are granted access.  Additional resources on MDCT are available.