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CENTERS FOR MEDICARE & MEDICAID SERVICES Medicaid and CHIP Managed Care Final Rule (CMS-2390-F) Implementation Dates Center for Medicaid and CHIP Services

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  • CENTERS FOR MEDICARE & MEDICAID SERVICES

    Medicaid and CHIP Managed Care Final Rule (CMS-2390-F)

    Implementation Dates

    Center for Medicaid and CHIP Services

    https://share.cms.gov/center/CMCS/Connecting%20Kids%20to%20Coverage/200488800-001_22.jpghttps://share.cms.gov/center/CMCS/Connecting%20Kids%20to%20Coverage/200488800-001_22.jpg

  • Key Dates and Resources

    Publication of Final Rule On display at the Federal Register on April 25th Published in the Federal Register May 6th (81 FR 27498)

    Effective Date of the Final Rule is July 5, 2016 Medicaid.gov Landing and Managed Care Pages

    Link to the Final Rule 8 fact sheets and implementation timeframe table Link to the CMS Administrators Medicaid Moving

    Forward blog [email protected] to submit questions on the

    final rule

    2

    mailto:[email protected]:Medicaid.gov

  • Topics for Todays Presentation

    Provisions starting: May 6, 2016 July 5, 2016 July 1, 2018

    Relevance of the Rating Period Provisions for rating period for contracts starting on or after

    July 1, 2017 July 1, 2018 July 1, 2019

    Provisions starting after CMS guidance, protocols or notice Discussion of Continuation of 2002 Regulations CHIP provisions

    3

  • May 6, 2016

    438.370 and 431.15(b)(10): Federal Financial Participation for External Quality Review Activities

    FFP at the 75 percent rate will be available only for EQR (including the production of EQR results) and EQR-related activities performed on MCOs and conducted by qualified EQROs and their subcontractors

    FFP at the 50 percent match rate will be available for EQR and EQR-related activities performed on entities other than MCOs (including PIHPs, PAHPs, PCCM entities, or other types of integrated care models) or performed by entities that do not meet the requirements of an EQRO

    4

  • Effective Date July 5, 2016

    There are a number of provisions that States must comply with asof the Effective DateJuly 5, 2016of the Final Rule. Many of these provisions were unchanged from the 2002 rule

    We note that a number of the citations changed from provisions in the 2002rule; we will not require contracts to be updated to reflect the new citations

    New Provisions of note include: 438.3(a) and 438.7(a): CMS review and approval of contracts and rate

    certifications

    438.3(e): In-Lieu-of-Services Generally

    438.4(b)(1): Differences in amount of capitation rates per rate cell must bebased on valid rating factors

    438.4(b)(5): Payments rom any rate cell must not cross-subsidize or be cross-subsidized by payments from any other rate cell

    438.6(e): Capitation Payments to MCOs and PIHPs for Enrollees with a ShortTerm Stay in an IMD 5

  • July 1, 2018

    Managed Care Quality Strategy and most EQR provisions

    438.340: Managed care state quality strategy 438.350: External Quality Review 438.354: Qualifications of EQR organizations 438.356: State contract options for EQR 438.358: Activities related to EQR 438.360: Nonduplication of mandatory activities 438.362: Exemption from EQR 438.364: External quality review results

    6

  • Relevance of the Rating Period

    What does it mean when CMS says: The rating period for contracts starting on or after July 1, 2017 (or 2018 and 2019)? The rating period is relevant to implementation dates because

    there are States that operate multi-year managed care contracts

    Rating Period is defined in 438.2 as a period of 12 months selected by the State for which the actuarially sound capitation rates are developed and documented in the rate certification submitted to CMS as required by 438.7(a).

    It DOES NOT mean the period for which historical data is derived for purposes of rate setting

    7

  • Relevance of the Rating Period

    If the State amends the contracts and rates during ratingperiod, the implementation date specified in the final rule isNOT accelerated.

    An amendment is not the start of the rating period for a contract EXAMPLE:

    If a State has Calendar Year contract and rating period (Jan-Dec 2017).

    The State DOES NOT need to amend the contract to complywith provisions with an implementation date of the ratingperiod for contracts starting on or after July 1, 2017.

    The contract and rating period starting January 1, 2018 would need to be in compliance with those provisions.

    8

  • Rating Period Examples

    Provisions with implementation date of the rating period for contracts starting on or after July 1, 2017

    Calendar Year contract and rating period Implementation of provisions for the rating cycle period for contracts starting January 1, 2018

    State Fiscal Year contract and rating period Implementation of provisions for the rating cycle (assuming July-June cycle) period for contracts starting July 1, 2017

    Federal Fiscal Year contract and rating period cycle (or State Fiscal Year that runs on FFY cycle)

    Implementation of provisions for the rating period for contracts starting October 1, 2017

    Any other contract and rating period cycle The contract and rating period that starts after July 1, 2017

    9

  • Rating Period Starting On or After

    July 1, 2017

    Exhaustive list in Compliance Date section of final rule at 81

    FR 27499 and Implementation Date Table on Medicaid.gov 438.3(s): Covered Outpatient Drugs 438.5: Rate Development Standards 438.6(b)(3): Withhold Arrangements 438.6(c): Delivery System and Provider Payment Initiatives 438.6(d): Pass-through Payments 438.8: Calculation and Reporting of Plan Medical Loss Ratio 438.242: Health Information Systems 438.330: Quality Assessment and Performance Improvement Subpart F: Appeals and Grievances Subpart H (except 438.602(b) and 438.608(b): Program Integrity

    10

    http:Medicaid.gov

  • Rating Period Starting On or After

    July 1, 2018

    Exhaustive list in Compliance Date section of final rule at 81 FR27499 and Implementation Date Table on Medicaid.gov 438.4(b)(3): Actuarial Soundness - Capitation rates adequate to meet

    438.206, 438.207, and 438.208

    438.4(b)(4): Actuarial certification to capitation rate per rate cell 438.7(c)(3): Ability to increase or decrease certified capitation rate per rate

    cell by 1.5 percent without revised rate certification 438.62: Continued Services to Enrollees (Transition of Care Policies) 438.68: Network Adequacy Standards 438.71: Beneficiary Support System 438.206: Availability of Services 438.207: Assurances of Adequate Capacity and Services 438.602(b) & 438.608(b): Screening and Enrollment of Network Providers 438.818: Enrollee Encounter Data

    11

    http:Medicaid.gov

  • Rating Period Starting On or After

    July 1, 2019

    438.4(b)(9): Actuarial Soundness - Development of capitation rates so that a managed care plan can reasonably achieve an MLR of at least 85 percent

    12

  • Rating Period that Start After Release of CMS Guidance

    438.66(e): Annual Program Report EXAMPLE: CMS Issues Guidance on Form and Content of the Annual Program

    Report in January 2017 Calendar Year contract and rating period cycle

    Rating period for contract starting January 1, 2018

    State Fiscal Year contract and rating period cycle (assuming July-June cycle)

    Rating period for contract starting July 1, 2017

    Federal Fiscal Year contract and rating period cycle (or State Fiscal Year that runs on FFY cycle)

    Rating period for contract starting October 1, 2017

    Any other contract and rating period cycle Rating period for contract that starts after January 2017

    13

  • No Later than 3 Years from Date of Final Notice Published in Federal Register

    438.334: Medicaid and CHIP Managed Care Quality Rating System A public engagement process to develop a proposed QRS

    framework and methodology

    Similar to process used for Marketplace QRS including multiple state and stakeholder listening sessions and technical expert panel

    Publication of a proposed QRS in the Federal Register, with opportunity to comment, followed by notice of the final Medicaid and CHIP QRS expected in 2018

    14

  • No Later than One Year from Issuance of Associated EQR Protocol

    438.358(b)(1)(iv): New mandatory activity - validation of MCO, PIHP, and PAHP network adequacy during the preceding 12 months

    CMS expects to issue protocols for the pre-existing mandatory and optional EQR activities in the Fall of 2017.

    CMS expects to issue the protocol for the new validation of network adequacy activity in a second round after the Fall of 2017.

    15

  • No Earlier then Issuance of Associated EQR Protocol

    438.358(c)(6): New optional EQR-related activity to assist with the quality rating of MCOs, PIHPs and PAHPs consistent with the Quality Rating System (438.334)

    CMS expects to issue the protocol in time for states to begin implementing the QRS within the 3 year QRS compliance timeframe, including any states that wish to implement earlier in that 3 year timeframe

    16

  • Continuation of 2002 Regulations

    For existing regulatory sections that have changes in the final rule,States must comply with the 2002 provisions until the implementation date specified in the Final Rule. This means that the 2002 regulationsremain relevant and we recommend having a printed copy of those regulations. 438.6(g) for 438.3(h): Inspection and audit of financial records 438.6(k) for 438.3(q): Requirements for PCCM contracts (new citation

    only) 438.10: Information requirements 438.62: Continued services to enrollees 438.66: State monitoring requirements 438.206: Availability of Services 438.207: Assurances of adequate capacity and services 438.208: Coordination and continuity of care 438.210: Coverage and authorization of services 438.230: Subcontractual relationships and delegation 438.242: Health information systems 17

  • Continuation of 2002 Regulations (cont.)

    Subpart E Quality Strategy; QAPI; External Quality Review (2003 provisions for EQR)

    Subpart F Appeals and Grievances 2002 regulations permitted States the flexibility to require one level of

    internal appeal and exhaustion before proceeding to SFH States may offer external review process prior to rating period for

    contracts starting on or after July 1, 2017 Subpart H Program Integrity

    438.604: Data that must be certified 438.606: Source, content, and timing of certification 438.608: Program integrity requirements

    18

  • CHIP Implementation Dates

    States must comply with existing regulations until new provisions are implemented

    Description Compliance Date Withholding of FFP for failure to comply with federal requirements (457.204)

    July 5, 2016

    All changes to part 457, including new subpart L, except as otherwise noted; 457.10, 457.902, 457.940, 457.950, 457.955

    No later than state fiscal year beginning on or after July 1, 2018

    Mandatory EQR activity of validation of network adequacy), as applied to CHIP (438.358(b)(1)(iv), as applied to CHIP per 457.1250)

    No later than one year from the issuance of the associated EQR protocol

    Managed care quality rating system (457.1240(d))

    No later than 3 years from the date of a final notice of Medicaid/CHIP QRS framework published in the Federal Register

    19

  • Questions

    20

  • Future Presentations

    In the coming weeks, we will host in depth presentations on the following topics:

    12:00-1:30 EST June 9: CHIP June 16: Program Integrity June 23: Rate Setting, Delivery System Reform,

    MLR

    June 30: Covered Outpatient Drugs

    21

  • Additional Questions?

    Please send additional questions to the mailbox dedicated to this rule:

    [email protected]

    While we cannot guarantee individualized responses, inquiries will inform future guidance and presentations

    22

    mailto:[email protected]

    Medicaid and CHIP Managed Care Final Rule(CMS-2390-F)Key Dates and ResourcesTopics for Todays PresentationMay 6, 2016Effective Date July 5, 2016July 1, 2018Relevance of the Rating PeriodRelevance of the Rating PeriodRating Period ExamplesRating Period Starting On or After July 1, 2017Rating Period Starting On or After July 1, 2018Rating Period Starting On or After July 1, 2019Rating Period that Start After Release of CMS GuidanceNo Later than 3 Years from Date of Final Notice Published in Federal RegisterNo Later than One Year from Issuance of Associated EQR ProtocolNo Earlier then Issuance of Associated EQR ProtocolContinuation of 2002 RegulationsContinuation of 2002 Regulations (cont.)CHIP Implementation DatesQuestionsFuture PresentationsAdditional Questions?


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