Overview of January 18, 2022 Updates to the State Guide to CMS Criteria for Medicaid Managed Care Contract Review and Approval

On January 18, 2022, the Center for Medicare and Medicaid Services (CMS) released an update to the State Guide to CMS Criteria for Medicaid Managed Care Contract Review and Approval. The Guide lists the standards used by the CMS Division of Managed Care Operations (DMCO) to review and approve state contracts with managed care organizations (MCO). The Guide is intended to help states ensure that their MCO contracts meet CMS requirements under 42 CFR Part 438 and other applicable laws, including requirements incorporated into the Medicaid and Children’s Health Insurance Program Managed Care Final Rule (referred to as the “2020 Final Rule”) published November 13, 2020 and effective on December 14, 2020.

The updated Guide incorporates changes tied to specific contract standards and includes a section with tips to assist states in their interpretation of federal requirements as well as a glossary of key terms. Updates include revisions pertaining to pass-through payments, state-directed payments, network adequacy standards, risk sharing mechanisms, appeals and grievances, and requirements for beneficiary information.  The Guide also covers standards used to review and approve state Medicaid contracts with prepaid inpatient health plans (PIHP), prepaid ambulatory health plans (PAHP), non-emergency transportation prepaid ambulatory health plans (NEMT PAHP), primary care case management entities (PCCM) and health insuring organizations (HIO).