to the nation's Governors on March 14, 2017, affirming the continued HHS and CMS commitment to partnership with states in the administration of the Medicaid program, and noting key areas where we intended to improve collaboration with states and move toward more effective program management. Table 2Summary of Annual PRA-Related Requirements and Burden Under Part 438, Table 3Summary of Annual PRA-Related Requirements and Burden Under Part 457. However, we noted that the payment term in the contract would have to be updated as required in 438.7(b)(5)(iii). At 438.4(b)(1), we are not finalizing any references to paragraph (d). Additionally, we clarify that 438.10(c)(6) already requires that required enrollee information, which would include a provider directory, provided electronically by a managed care plan must be in an electronic format which can be retained and printed; the standard for mobile-enabled provider directories, which are only relevant for purposes of identifying the frequency of updates to the paper provider directory, is different than what is required by 438.10(c)(6). As finalized in the 2016 final rule, 438.6(c)(1) permits states to, under the circumstances enumerated in 438.6(c)(1)(i) through (iii), direct the managed care plan's expenditures under the contract. We also proposed at that time a corresponding requirement, at paragraph (k)(1)(iii), for submission by each managed care plan of data showing the expenditures for activities described in 438.608(a)(1) through (5), (7), and (8) and (b). Response: We agree that states should engage in robust stakeholder engagement when developing their network adequacy standards to ensure inclusion of appropriate provider types based on the needs of the covered populations. Since state Medicaid agencies are the direct administrators of the Medicaid program in their respective states, we believe that this approach is more appropriate. After consideration of the public comments and for the reasons articulated in the proposed rule and our responses to comments, we are finalizing our proposed amendments to 438.4(b)(1) with modifications and are not finalizing the proposed addition of 438.4(d); specifically, we are finalizing amendments to 438.4(b)(1) as follows: In the 2016 final rule, we finalized at 438.5(c)(3) an exception to the base data standard at 438.5(c)(2) in recognition of circumstances where states may not be able to meet the standard at paragraph (c)(2) regarding base data. In 457.1240(e) we state that 438.340(c)(1)(i) related to the MCAC does not apply to the requirements related to the managed care quality strategy for CHIP. publication in the future. We believe states are in the best position to determine the most appropriate number and type of quantitative measures to provide them with the information needed to effectively manage their programs, as well as fulfill their obligations under 438.206 and 438.207. Response: We understand commenters' concerns related to the use of rate ranges in Medicaid managed care. We encourage all plans to provide customized information and assistance to prevent disruptions in care from occurring. Meaning, network adequacy standards are not used to determine the availability of, or authorize care by, a particular type of provider for an individual enrollee. Comment: Several commenters suggested that the final rule should instruct states that their designations of specialists for purposes of 438.68(b), and any network adequacy standards, must be consistent with existing state laws regarding licensure and certification, as well as the Medicaid managed care nondiscrimination regulation which prohibits managed care plans from discriminating against providers based on their licensure or certification. Comment: Several commenters supported the proposal to require states to publicly identify any exempted plans along with the beginning date of their current exemption period on their website or in the annual EQR technical support. We explained how it was important to continue ensuring that such payment arrangements under paragraph (c)(1)(iii) are consistent with states' and our goals and objectives for directed payments under Medicaid managed care contracts. Response: We do not believe that providing states with the option to use a different quantitative standard than time and distance will add provider burden or negatively impact health outcomes for children and underserved populations. Third, the Medicaid contract must have been in effect for at least 2 consecutive years before the effective date of the exemption and during those 2 years, the MCO must have been subject to the Medicaid EQR during those 2 years and been found to have performed acceptably with respect to the quality, timeliness, and access to health care services it provides to Medicaid beneficiaries. If the state requires a managed care plan to apply increases or other adjustments to those state plan approved rates, it is not an arrangement described in paragraph (c)(1)(iii)(A), and therefore, paragraph (c)(2)(ii) would apply and require prior written approval. We inadvertently did not include a provision in 457.1270 that states may choose to establish sanctions for PCCMs and PCCM entities as specified in 438.700(a). Although we are not finalizing a list of specifically prohibited rate development practices (as proposed at 438.4(d)), it is still our view that these rate development practices generally increase Federal costs and vary with the rate of FFP, and as such, are generally prohibited under 438.4(b)(1) as finalized in this rule. Response: While we agree that standardization and comparability are important considerations, we are not able to define disability status for the purposes of other programs. Since we are not finalizing 438.4(d), we are finalizing this proposed standard as part of the new text in 438.4(b)(1). We believe that this concept includes risk mitigation strategies and other arrangements that protect the state or the MCO, PIHP, or PAHP against the risk that the assumptions used in the initial development of capitation rates are different from actual experience. Commenters stated that the changes would provide states and plans more flexibility while continuing to promote better coordination of benefits for dually eligible individuals and reducing burden on the providers who serve them. The following is a summary of the public comments we received on our Start Printed Page 72824proposal to amend 457.1207 and our responses to them. The proposed parameters and guardrails carefully strike a balance between state flexibility and program integrity and we are finalizing them, with some modifications as discussed in response to other comments. To include pass-through payments in the managed care contract(s) and capitation rates(s) under new paragraph (d)(6), we proposed that the state would have to calculate and demonstrate that the aggregate amount of the pass-through payments for each rating period of the pass-through payment transition period was less than or equal to the amounts calculated as described in proposed paragraph (d)(6)(iii)(A), (B), or (C) for the relevant provider type. States that elect to adopt rate ranges must comply with 438.4(c) as amended effective July 1, 2021 for Medicaid managed care rating periods starting on or after July 1, 2021. To address states' requests to continue making supplemental payments for certain services and assist states with transitioning some or all services or eligible populations from a FFS delivery system into a managed care delivery system, we proposed to add a new 438.6(d)(6) that would allow states to make pass-through payments under new managed care contracts during a specified transition period if certain criteria are met. In the proposed rule, we provided the following four basic steps for making the calculation: In the proposed rule, we provided the following formula to help illustrate the aggregate amount of pass-through payments for each rating period of the pass-through payment transition period for each applicable provider type: In the proposed rule, we also provided an example to help demonstrate how the calculation would be performed. Our policy on this issue has not changed. Response: We do not agree with commenters that we should permit automatic renewals of payment arrangements under 438.6(c). Comment: A few commenters disagreed that the allowed amount is already in the public domain in the form of EOBs because EOBs are not public documents. Response: Persons with disabilities, including vision impairments, make up a significant proportion of the Medicaid population. Response: We are finalizing the amendments to 438.1270. We use the term framework to encompass all of the critical components of a QRS, which include, but are not necessarily limited to, the selected performance measures and methodology. That final rule prevented increases in pass-through payments and the addition of new pass-through payments beyond those in place when the pass-through payment transition periods were established in the 2016 final Medicaid managed care regulations. We considered proposing changes to the regulation at 438.6(e) but, after careful review, did not do so because of our belief that the underlying analysis regarding the transfer of risk that underpinned the policy in the 2016 final rule was appropriate. We proposed paragraphs (d)(6)(iii)(A) through (C) to address the maximum aggregate pass-through payment amounts permitted to be directed to hospitals, nursing facilities, and physicians for each rating period of the specified 3-year pass-through payment transition period; that is, we proposed three paragraphs to identify the maximum aggregate amount of the pass-through payments for each rating period of the 3-year pass-through payment transition period that the state can require the managed care plan to make to ensure that pass-through payments under proposed 438.6(d)(6) are less than or equal to the payment amounts attributed to and actually paid as FFS supplemental payments to hospitals, nursing facilities, or physicians, respectively, during the 12-month period immediately 2 years prior to the first rating period of the pass-through payment transition period for each applicable provider type. Therefore, we are not projecting a specific fiscal impact to state or Federal governments, or the Medicaid program, as we expect the net financial impact of this provision to be budget neutral. We originally proposed 438.4(d)(1) in conjunction with our proposed revisions to 438.4(b)(1) to provide specificity regarding the rate development practices that we believed increased Federal costs and varied with the rate of FFP; however, based on public comments, we agree with commenters that there could be legitimate and actuarially sound reasons for varying pricing assumptions between rate cells that are (and must be) independent of differing levels of FFP, and that there could be valid actuarial reasons for an actuary to vary rating components that would be supported by actuarial experience and data. While it might be theoretically possible for a state to design and mandate a particular provider payment arrangement that does not consider access to care as part of setting the provider payment, there are other regulatory requirements (such as required quantitative network adequacy standards) in part 438 that ensure that states consider access to care in contracting with managed care plans. 3. Response: We understand that commenters would like us to include additional provider types under 438.6(d)(6)(iii) (such as by replacing the term physician as used in 438.6(d)(6)(iii)(C) to the more general and broader term provider) to recognize additional health care providers; however, we decline to make these modifications. ++ The circumstances under which an appeal process can be expedited and how to request it. The following requirements and burden will be submitted to OMB for approval under control number 0938-1148 (CMS-10398 #52). Response: We appreciate the value of making such data available to plans. Response: We disagree with commenters that pass-through payments, beyond those payments permitted under a pass-through payment transition period, should be permissible under Medicaid managed care. While we have no data on the number of adverse benefit notices that are sent due to denials of unclean claims, we believe that at least one unclean claim may be generated for half of all enrollees (37,389,908); thus, this proposal could reduce paper, toner, and postage costs for some managed care plans. No public comments were received on this provision. Discharge planning should result in a written document, a discharge plan. (e) Managed care quality strategy. We explained that while we understood that value-based purchasing payment arrangements or those tied to larger delivery system reform efforts can be more complex and may take longer for a state to implement, we believed that more traditional payment arrangements and fee schedules permitted under paragraph (c)(1)(iii) should continue to be reviewed and evaluated on an annual basis by both states and us. Secretary, Department of Health and Human Services. In the January 18, 2017 Federal Register (82 FR 5415), we published the Medicaid Program; The Use of New or Increased Pass-Through Payments in Medicaid Managed Care Delivery Systems final rule (the 2017 pass-through payments final rule) that made changes to the pass-through payment transition periods and the maximum Start Printed Page 72755amount of pass-through payments permitted annually during the transition periods under Medicaid managed care contract(s) and rate certification(s). legal research should verify their results against an official edition of (1) The State must ensure that its contracted MCOs, PIHPs, and PAHPs comply with the provisions of 438.402(a), (b), and (c)(2) and (3) of this chapter with regard to the establishment and operation of a grievances and appeals system. This requirement is redesignated as 438.334(c)(1)(iii), in this final rule. We explained that our proposed change would clarify the corrective action plan timeline for states to achieve compliance with the base data standard; that is, states would have the rating year for which the corrective action period request was made, plus 2 years following that rating year to develop rates using the required base data. Therefore, as long as the Federal requirements are met for risk adjustment, we agree that such mechanisms can be appropriately applied outside of the certified rate range (meaning, applied to the rates after calculation of the rate range), consistent with existing Federal regulations and our analysis in the 2016 final rule. Given that states are required to also display a provider's cultural and linguistic capabilitieswhich is far more descriptive than a yes/no indicator about trainingin their FFS directories, we believe that they will select clear, consistent, and meaningful ways to display the information and ensure that their managed care plans do so as well. the current document as it appeared on Public Inspection on Commenters recommended that CMS require states to consult with managed care plans prior to implementing state directed payments. Response: We do not agree with commenters that further revisions are needed to address the role of supplemental payments in the Medicaid program; we believe that our policies Start Printed Page 72778finalized in this final rule, specifically to define the term supplemental payments for purposes of part 438, including 438.6, and to adopt (in 438.6(d)(6)) a period for pass-through payments to be used for states transitioning new services or new populations to Medicaid managed care, demonstrate that CMS understands the role of supplemental payments in the Medicaid program. Our proposed revisions only correct technical errors from the 2016 final rule and we did not propose to reconsider our alignment with regulations in the private market. Regarding the acceptable criteria for paying managed care plans at different points within the rate range, which must be documented in the rate certification documents under 438.4(c)(1)(iv), we confirm that such criteria could include state negotiations with managed care plans or a competitive bidding process, as long as states document in the rate certification how the negotiations or the competitive bidding process produced different points within the rate range. Therefore, we are finalizing a revision to 438.7(c)(3) to include the language during the rating period as part of the standard for using the 1.5 percent adjustment. Medicare would generate the crossover consistent with the COBAs in place. Unlike Medicaid, CHIP is not an entitlement program and therefore the right to benefits pending appeal is not available to CHIP beneficiaries. Comment: Several commenters opposed the proposed change and stated that these types of denials should continue to be treated as adverse benefit determinations that trigger notice requirements. As finalized, 438.340(b)(6) enables states to do so. We also defined risk corridor in 438.6(a) as a risk-sharing mechanism in which states and MCOs, PIHPs, or PAHPs may share in profits and losses under the contract outside of a predetermined threshold amount. Second, we proposed to add paragraphs (h)(3)(i)(A) and (B) which would reflect, respectively, that monthly updates are required if a plan does not offer a mobile enabled directory and that only quarterly updates would be required for plans that do offer a mobile enabled directory. We note that there is no regulation in part 438 that authorizes denial of Medicaid-covered services for an enrollee who is eligible for those services based on the enrollee's eligibility as well for Medicare. In the capitated model, CMS and the state will pay each health plan a prospective capitation payment. The following summarizes the public comments received on our proposal to revise 438.4(b)(1) and add 438.4(d) and our responses to those comments. Under 438.818, states must submit all enrollee encounter data to CMS; 438.242(c) requires states to require Medicaid managed care plans to submit to the state the same encounter data that must be submitted in their T-MSIS submissions to us. By limiting the carve out from the definition of adverse benefits determination to situations where the denial is because the claim does not meet the definition of clean claim, we believe we struck the appropriate balance between reducing burden and confusion for enrollees and maintaining an important enrollee protection. As finalized, paragraph (b)(1) includes clarifications about the MAC QRS framework, including performance measures, a subset of minimum mandatory measures, and methodology; timing of CMS's consultation with states and other stakeholders; clarifications to the listed examples of the content of the MAC QRS; and a technical correction to the citation to the Medicare Advantage 5-Star Quality Rating System. When we reviewed and analyzed the May 6, 2016 final rule, we concluded that states will have other mechanisms to build in the amounts currently provided through pass-through payments in approvable ways, such as approaches consistent with 438.6(c). The standard critical to obtaining services cuts to the heart of the role of Medicaid managed care plans: The provision of services to enrollees. The requirements for populating fields in T-MSIS are documented in a data dictionary and accompanying guidance issued by CMS. We proposed to amend 438.7(c)(3) to clarify the scope of permissible changes to the capitation rate per rate cell and the need for a contract modification and rate certification. In the 2016 final rule, when we originally finalized 438.7(c)(3), we described the final rule as providing the ability for the state to adjust the actuarially sound capitation rate during the rating period by +/1.5 percent (81 FR 27568). In order to publish additional guidance needed to implement this requirement, we are delaying the effective date of this provision until the first contract rating period beginning on or after July 1, 2021. Some commenters stated that this proposal violates section 1557 of the PPACA, which prohibits discrimination on the basis of race, color, national origin, sex, age, and disability. 22. At the same time, we agree with commenters who are concerned that having no definition will impede identification of individuals with disabling conditions, provision of appropriate services and utilization of robust quality measurement to drive improvements in care. Notwithstanding the restrictions on pass-through payments in paragraphs (d)(1), (3), and (5) of this section, a State may require the MCO, PIHP, or PAHP to make pass-through payments to network providers that are hospitals, nursing facilities, or physicians under the contract, for each rating period of the transition period for up to 3 years, when Medicaid populations or services are initially transitioning from a fee-for-service (FFS) delivery system to a managed care delivery system, provided the following requirements are met: (i) The services will be covered for the first time under a managed care contract and were previously provided in a FFS delivery system prior to the first rating period of the transition period. Risk-sharing mechanisms may not be added or modified after the start of the rating period. These proposed revisions were intended to better balance the goal of facilitating inter-state comparisons of plan performance and reducing plan burden through standardization with the need for state flexibility and the practical challenges inherent in producing comparable ratings across heterogeneous states. We further explained that the regulation did not prohibit the state from having different capitation rates per rate cell based on differences in the projected risk of populations under the contract or based on different payment rates to providers that were required by Federal law (for example, section 1932(h) of the Act). The revision to 438.3(t) that we are finalizing here maintains a process in which providers only bill once (to Medicare), because the regulation only applies when the state enters into a COBA but allows greater state flexibility in how that claim is routed from Medicare to Medicaid and Medicaid managed care plans. In 438.242(b)(3) of the final rule, we required that all contracts between a state and an MCO, PIHP, or PAHP provide for the submission by the managed care plan of all enrollee encounter data that the state is required to submit to us under 438.818. Response: We note that capitation rates, including permissible rate ranges under 438.4(c), must comply with all rate setting requirements in 438.4, 438.5, 438.6, and 438.7. (1) The State must ensure that its contracted MCOs, PIHPs, and PAHPs comply with the provisions at 438.404(a) and (b)(1), (2), and (5) of this chapter (regarding the content of the notice of an adverse benefit determination). (d) Managed care quality rating system. Response: We use the term mobile-enabled to mean a mobile website or a mobile application; we defer to states and managed care plans to determine whether a mobile website or application is most appropriate for each applicable managed care program and managed care plan, provided that the end result is that the provider directory is mobile-enabled as explained here. However, since publication of the 2016 final rule, we have found that some states have applied new or modified risk-sharing mechanisms retrospectively; for example, some states have sought approval to change rates, or revise a medical loss ratio (MLR) requirement, after the claims experience for a rating period became known to the state and the managed care plan. A few commenters suggested including Healthcare Effectiveness Data and Information Set (HEDIS) measures. These payment arrangements will continue to be reviewed on a periodic basis. Response: We believe that provider education is critical whenever a state implements changes to how crossover claims are routed to the Medicaid managed care plan responsible for processing them. The term adverse benefit determination was proposed and finalized in the 2016 final rule as a replacement for the term action, which had been defined with the same definition in the 2002 rule. After consideration of the public comments and for the reasons outlined in the proposed rule and our responses to comments, we are finalizing the amendments to 457.1270 as proposed with slight modification. Because 438.364 applies to CHIP through an existing cross reference in 457.1250(a), separate CHIPs must also come into compliance with the requirements of 438.364 for external quality reports submitted on or after July 1, 2021. We did not receive comments on this technical correction to 438.364(d) and, for the reasons noted here and in the proposed rule, are finalizing it as proposed. for better understanding how a document is structured but Regulations at 438.334(c)(2)(i) and (c)(3) and 438.340(c)(1)(i) require that the state seek input from the MCAC in developing a state alternative QRS and managed care quality strategy. An enrollee may request a State external review in accordance with the terms of subpart K of this part after receiving notice under paragraph (e) of this section that the adverse benefit decision is upheld by the MCO, PIHP, or PAHP. The final rule will require an evaluation of any differences in the assumptions, methodologies, or factors used to develop capitation rates for MCOs, PIHPs, and PAHPs that increase Federal costs and vary with the rate of FFP associated with the covered populations. These retroactive adjustments must be certified by an actuary in a revised rate certification and submitted as a contract amendment to be approved by CMS. American Printing House for the Blind, Inc. Print Document Guidelines. The program is jointly funded by. Another commenter recommended that printed directories for an entire service region of a managed care plan should only be required annually. At 438.4(c)(2)(iv)(A) through (C), we are finalizing the list of information that must be posted on the state's website required by 438.10(c)(3): (A) The upper and lower bounds of each rate cell; (B) a description of all assumptions that vary between the upper and lower bounds of each rate cell, including for the assumptions that vary, the specific assumptions used for the upper and lower bounds of each rate cell; and (C) a description of the data and methodologies that vary between the upper and lower bounds of each rate cell, including for the data and methodologies that vary, the specific data and methodologies used for the upper and lower bounds of each rate cell. The PPACA amendment to section 1903(m)(2)(A)(xi) of the Act specifies that the obligation for an MCO to report patient encounter data was, for contract years after January 1, 2010, to the state in a timeframe and level of detail specified by the Secretary. Comment: Some commenters submitted technical recommendations about the rate range option, including that the calculation of the rate range should exclude risk adjustments and pass-through payments, that states should be able to apply or adjust risk adjustment mechanisms outside of setting the certified rate range, that the calculation of rate ranges should not reflect incentive payments for managed care plans, and that state budget factors should not influence the calculation of rates within the rate range. Additionally, the allowed and paid amounts of claims are routinely included on explanation of benefits provided to enrollees; thus making this information already publicly available. However, we erroneously finalized 438.8(k)(1)(iii) as proposed instead of referencing the updated finalized regulatory language in 438.8(e)(4). Comment: Commenters opposed the proposed technical clarification and recommended that CMS reconsider our alignment with regulations in the private market at 45 CFR part 158. Response: As we noted in our response to comments received in the 2016 final rule (81 FR 27760), the mandatory Medicaid standards regarding advance directives described in 438.3(j) and 422.128 do not apply to CHIP and we do not believe that they should. Response: We appreciate the comments in support of our proposal to clarify that states have the authority to designate specialists to which network adequacy standards will apply under 438.68(b)(1). Regardless of which methodology a state chooses to implement, it should not have any effect on providers, who should be able to submit their claims once and have it routed to the appropriate MCO, PIHP, or PAHP for adjudication. (N.D. Tex. http://www.aph.org/research/design-guidelines/. We remind states and managed care plans that they will be held accountable for compliance with 438.10(d)(2) through (6) and with ensuring that all necessary steps are taken to adequately accommodate enrollees and potential enrollees that request information in large print or that request other formats or auxiliary aids and services. We also requested that states provide quantitative data to help us quantify the benefits and risks associated with the proposal. The estimates are based on commonly available prices for bulk paper and toner purchases and bulk postage rates. Response: Finalizing the elimination of the requirement for a written appeal to be submitted in follow up to an oral appeal in 438.402(c)(3) and 438.406(b)(3), does not eliminate the option for enrollees to submit appeals in writing. To address the commenter's concern about when states indicate multiple denials on the state's remittance advice, we are clarifying our intent by finalizing 438.3(t) with additional text specifying that the state's remittance advice must inform the provider that the claim was not denied by the state but was redirected to a managed care plan for adjudication.
Slane Whiskey Vs Jameson Taste,
Osu Spring Break 2023,
2023 State Income Tax Nexus For Telecommuters,
Articles T
