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CMS Issues Medicaid Managed Care Final Rule

The Centers for Medicare and Medicaid Services (CMS) issued a Final Rule for Medicaid and Children’s Health Insurance Program (CHIP) Managed Care programs. The Final Rule finalizes policies form a Notice of Proposed Rulemaking issued in November 2018. These new rules follow a substantial update made to the same regulations in 2016 to Medicaid and CHIP managed care programs. CMS noted the impetus of the new rules as the result of state and provider feedback charging that the 2016 rules were overly prescriptive and administratively burdensome. CMS worked with the National Association of Medicaid Directors and state Medicaid Directors to inform the rule making process.

The new final rule significantly alters the following areas:

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)

A fact sheet on the Final Rule is available here.

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