Managed Care Requirements. The state must comply with the managed care regulations published at 42 CFR 438. Capitation rates shall be developed and certified as actuarially sound, in accordance with 42 CFR 438.6. The certification shall identify historical utilization of state plan and HCBS services used in the rate development process.
Managed Care Requirements. The state must comply with the managed care regulations published at 42 CFR 438. Capitation rates shall be developed and certified as actuarially sound in accordance with 42 CFR 438.6. The certification shall identify historical utilization of state plan services used in the rate development process. The state must maintain:
a) Policies to ensure an increased stability among capitated managed care plans and FFS PSNs and minimize plan turnover. This could include a limit on the number of participating plans in the five Medicaid Reform demonstration counties and, when implemented, in the MMA program. Plan selection and oversight criteria should include: confirmation that solvency requirements are being met; an evaluation of prior business operations in the state; and financial penalties for not completing a contract term. The state must report quarterly on the plans entering and leaving demonstration counties, including the reasons for plans leaving. The state must provide these policies to CMS within 90 days of the award of the MMA program demonstration amendment.
b) Requirements contained herein are intended to be consistent with and not additional to the requirements of 42 CFR 438. Policies to ensure network adequacy and access requirements which address travel time and distance, as well as the availability of routine, urgent and emergent appointments, and which are appropriate for the enrolled population. Policies must include documentation and confirmation of adequate capacity, access to care outside of the network, access to care for enrollees with special health care needs, and cultural considerations. The state must implement a thorough and consistent oversight review for determining plan compliance with these requirements and report these findings to CMS on a quarterly basis. The state must provide these policies to CMS within 90 days of the award of the MMA program demonstration amendment.
c) A requirement that each capitated managed care plan and capitated PSN maintain an annual Medical Loss Ratio (MLR) of 85 percent for Medicaid operations in the demonstration counties. These entities must provide documentation to the state and CMS at least annually to show ongoing compliance. The state must develop quarterly reporting of MLR during demonstration year (DY) 6 specific to demonstration counties. Beginning in DY 7 (July 1, 2012), plans must meet annual MLR requirements. MLR requirements are to be reported by the capitated plans 7 months after the q...
Managed Care Requirements. The State must comply with the managed care regulations published at 42 CFR section 438.
