Managed Care Rule
Effective December 14, 2020
Medicaid Disproportionate Share Hospital (DSH)
On November 13, 2020, the Centers for Medicare & Medicaid Services (CMS) published revisions to the May 6, 2016 Medicaid & CHIP Managed Care Final Rule in the Federal Register. CMS published a proposed rule for comment in November 2018, which encompassed most of the modifications finalized in the November 13 Final Rule. These revisions are effective on December 14, 2020, except for a few additions which are effective July 1, 2021. The revisions do not include major policy changes for states as the 2016 Final Rule enacted, but do impact a number of areas states should be aware of. For the full revision, see https://www.federalregister.gov/documents/2020/11/13/2020-24758/medicaid-program-medicaid-and-childrens-health-insurance-program-chip-managed-care.
CMS provided a useful fact sheet summarizing revisions in the following areas:
- Setting Actuarially Sound Capitation Rates (Medicaid).
- Pass-Through Payments (Medicaid).
- State-Directed Payments (Medicaid).
- Network Adequacy Standards (Medicaid and CHIP).
- Risk Sharing Mechanisms (Medicaid).
- Quality Rating System (Medicaid and CHIP).
- Appeals and Grievances (Medicaid and CHIP).
- Requirements for Beneficiary Information (Medicaid and CHIP).
See https://www.cms.gov/newsroom/fact-sheets/medicaid-childrens-health-insurance-program-chip-managed-care-final-rule-cms-2408-f for a summary of the changes in each of the areas listed.
Below are additional revisions which are not highlighted in CMS’ fact sheet that are also relevant.