Congress has three weeks to finalize an omnibus spending package. There are a number of issues that are expected to come up, including market stabilization and drug pricing, among other issues. There’s also activity at the state level on Medicaid waivers and work requirements. We cover this and more in this week’s preview, which you can find here.

As states attempt to control increasing healthcare costs, many Medicaid programs are seeking approval from the Centers for Medicare & Medicaid Services (CMS) to implement Medicaid managed care programs.  In 2013, nearly 68 percent of Medicaid beneficiaries were enrolled in some form of managed care, and this percentage is only expected to increase through 2016.

Federal regulations appearing at 42 CFR § 438.6(a) require that CMS review and approve all state Medicaid managed care contracts.  In an effort to increase transparency, CMS recently released its State Guide to CMS Criteria for Managed Care Contract Review and Approval (State Guide), outlining the standards and criteria used by the applicable CMS Regional Office to review state Medicaid contracts with managed care entities.  Specifically, this State Guide lists over 350 criteria or contract requirements, organized into 11 categories, that the Regional Office staff will specifically look for in approving state contracts.  For each criterion, CMS provides the statutory or regulatory reference and which type of managed care entity it applies to.

Historically, CMS Regional Offices review and approve state managed care contracts against a current version of the “CMS Checklist for Managed Care Contract Approval (checklist).”  Prior OIG Reports have found that CMS Regional Office staff failed to consistently utilize the entire checklist prior to approving contracts.  The new State Guide appears to update, clarify, and better organize many of the same requirements in the checklist, which will likely prove beneficial for states, CMS, and managed care plans in developing and reviewing contracts.

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