CMS Fact Sheet - Medicaid & Children’s Health Insurance Program (CHIP) Managed Care Final Rule - CMS-2408-F
Posted on: 11/9/2020
On November 9, 2020, the Centers for Medicare & Medicaid Services (CMS) released the 2020 Medicaid and Children’s Health Insurance Program (CHIP) Managed Care final rule.
Based on 2018 state Medicaid and CHIP enrollment data, eighty three percent, or around 66 million people, are enrolled in managed care arrangements that allow private health plans to administer state Medicaid benefits. In 38 states, at least 50 percent of all Medicaid beneficiaries and in 32 states, about 79 percent of CHIP children, were enrolled in managed care, as growth in managed care enrollment has continued.
In 2016, CMS issued a Medicaid & CHIP Managed Care Final Rule to update the regulations governing Medicaid and CHIP managed care programs for the first time in over a decade. In 2017 Department of Health and Human Services (HHS) and CMS issued a letter to the nation’s Governors affirming the continued HHS and CMS commitment to partner with states in the administration of the Medicaid and CHIP programs, and noting key areas where we would improve collaboration with states and move toward more effective program management.
Since their issuance of that letter, CMS received feedback that the 2016 regulations were overly prescriptive and add costs and administrative burden to state programs. CMS formed a working group with the National Association of Medicaid Directors (NAMD) and state Medicaid Directors to prioritize areas of concern within the managed care regulations and inform the proposals. Together the working group identified ways to achieve a better balance between appropriate federal oversight and state flexibility, while also maintaining critical beneficiary protections, ensuring fiscal integrity, and promoting accountability for providing quality of care to people with Medicaid and CHIP.
The recommendations from this group culminated in many of the proposals put forward for comment in November 2018. This rule finalizes many of those proposals and helps ensure that state Medicaid and CHIP agencies are able to work efficiently and effectively to design, develop and implement Medicaid and CHIP managed care programs that best meet each state’s local needs and populations.
The rule includes significant revision in the following areas of the managed care regulatory framework:
1. Setting Actuarially Sound Capitation Rates (Medicaid)
2. Pass-Through Payments (Medicaid)
3. State-Directed Payments (Medicaid)
4. Network Adequacy Standards (Medicaid and CHIP)
5. Risk Sharing Mechanisms (Medicaid)
6. Quality Rating System (Medicaid and CHIP)
7. Appeals and Grievances (Medicaid and CHIP)
8. Requirements for Beneficiary Information (Medicaid and CHIP)
Read the press release >>>
Read the final rule >>>
The Centers for Medicare and Medicaid Services and ACMA Public Policy Committee contributed to this information.
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