CMS Releases 2015 Guidance for Managed Care Rate Setting
- The Centers for Medicare & Medicaid Services (CMS) is announcing the availability of the 2015 Managed Care Rate Setting Consultation Guide. It is used by states when developing their Medicaid managed care rate certification packages and includes elements needed when submitting rate certifications for initial rate certifications or any amendments to managed care rates that start on or after Jan. 1, 2015.
Managed care is a healthcare delivery system that is organized to manage cost, utilization, and quality. For Medicaid, it provides delivery of benefits and additional services through contracted arrangements between state agencies and managed care organizations (MCOs). By using various types of MCOs to delivery services, states are able to lower program costs and better manage utilization of health services. Approximately 70 percent of Medicaid enrollees are served through managed care delivery systems.
This is where the guide comes into play. It includes questions about critical elements for setting actuarially sound rates with respect to coverage of the new adult population in Medicaid managed care plans. This has increased the transparency of the rate development process and led to a better understanding of expectations between states and CMS on Medicaid managed care rate setting, as well as, CMS’s oversight of the processes. The guide comes in two sections. The first applies to all Medicaid managed care capitation rates and the second focuses more on issues that are specifically related to capitation rates for the new adult population to address the limited experience covering this group of individuals.
The latest version of the guide aims to continue this transparency and prepare the way for an efficient and effective review process. The required information will help CMS and states ensure that Medicaid managed care rates meet several standards. These include:
Integrated Community Oncology Practices Need Cost Efficiency Cerner Earns Top Revenue Cycle Management Outsourcing Vendor CMS updates Health Plan Identifier system • Medicaid managed care capitation rates and the rate development process comply with all applicable laws, regulation and other guidance for Medicaid managed care.
• Rate development reflects program compliance with all applicable laws, regulation and other guidance for the Medicaid program, including eligibility, benefits, financing, any applicable waiver or demonstrated requirements and program integrity.
• Final capitation rates are reasonable and have proper documentation.
“CMS anticipates that the information discussed in this guide is already part of the actuarial work and program management work ongoing in states,” the report reads. “However, delineating the specific elements provides a way to ensure that states are fully informed in advance of the information needed for federal review and state consultation and that such information is consistently addressed.”
The CMS does not have a specific format for submitting the information required and instead hopes to jump start a conversation about the elements in the actuarial certification and expedite the review with wide spread best practices.
