New Proposed CMS Medicaid and CHIP Managed Care Rule Targets Access, Quality, and Payment Rates

May 11, 2023

A newly released proposed rule by the US Centers for Medicare and Medicaid Services (CMS) targets transparency, quality, care access, and payment rates for Medicaid and Children’s Health Insurance Program (CHIP) managed care. States would need to provide an annual payment analysis of all managed cares payment rates for a variety of services. In addition, states will need to develop a quality rating system for Medicaid and CHIP plans.

According to McDermott+ Consulting, “In 2016, CMS updated the regulations for Medicaid managed care and created a new option for states, allowing them to direct managed care organizations to pay providers according to specific rates or methods. Such payments are often referred to as SDPs. SDPs are commonly used “to establish minimum payment rates for certain types of providers or to require participation in value-based payment (VBP) arrangements.” CMS notes that “as of December 2022, CMS has reviewed more than 1,100 SDP proposals and approved 993 proposals since the 2016 final rule was issued.” Total federal and state spending for each SDP is almost $48 billion annually. This proposed rule would make several process and transparency-related updates to SDPs to ensure integrity of payments and that SDPs meet the goals of the Medicaid program.”

To read more, click here.