CMS Final Medicaid Managed Care Rule Summary

On April 22, CMS released the final rule, Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-F). The rule helps build stronger managed care programs to better meet the needs of the people enrolled in Medicaid and CHIP by improving access to, and quality of, care.

Building on the access and quality standards established in the 2016 and 2020 managed care final rules and informed by the results of a 2022 request for information related to access, the final rule adopts new standards for access to care for services delivered through a managed care model, and new and enhanced requirements related to program quality and finance. CMS largely adopted the rules as proposed, with key revisions to state directed payment and quality provisions based on its request for public comment.

Didn’t have time to view the final rule? Sellers Dorsey summarized everything you need to know related to

• Access – provider payment analysis, secret shopper surveys, wait time standards
• State Directed Payments – submission timeframes, total payment rates, payment rate limitations, financing
• Medical Loss Ratio Standards – provider incentives, reporting of SDPs in the MLR, level of MLR data aggregation
• In Lieu of Services and Settings – enrollee rights and protections, medically appropriate and cost-effective, payment and rate development, state and CMS oversight
• and more!