The CMS' new guidelines on reimbursement for Medicaid managed care organization (MCO) plans ignore suggestions made by states and health plans that the new guidelines won't help them.
The National Association of Medicaid Directors (NAMD) sent a letter to the CMS saying that before the agency finalized its guidelines, it should outline clear timelines for rate reviews and approvals, because delays have previously meant financial uncertainty for states.
“These delays can span years and can adversely impact contract approvals and modifications, waiver extensions and performance measurement,” the NAMD wrote. “The guide fails to remedy this longstanding concern, and could ultimately further delay approvals with excessive, unnecessary levels of detail required.”
But the CMS appears to not have addressed those issues, at least not in the most recent document that advises states on how to ensure that next year's payments are actuarially sound—meaning that they cover all medical and administrative costs, taxes and fees for which the health plan is responsible.
The 18-page document, like its proposed version, was posted under the radar, failing to be highlighted through traditional channels like the Federal Register or the Medicaid.gov home page.
A side-by-side comparison of the document and its initial draft appear to be nearly identical, with only slight modifications in wording and some added clarifying language.
“Not much in the final has changed from the draft, so our comments on that remain unchanged,” said Matt Salo, the NAMD's executive director.
States will still have to provide a letter from the certifying actuary confirming that their rates are sound and explaining how they were determined.
The CMS also stuck to its guns in regards to the amount of documentation needed, which again is likely to be a concern for states.
“The magnitude of this documentation is more akin to an audit process for rates, rather than a review of the rate development process,” the NAMD said in the letter. “This undermines the rationale for securing the services of professional actuaries to develop rates and certify them. It is also likely that the volume of information will only exacerbate the unrestricted follow-up questions that have impeded timely rate approvals to date.”
The association also pointed out that CMS' limited staff, “is unlikely to have the ability to thoroughly review the array of information and data required under the draft guide.”
The NAMD said that if the agency truly wants to ensure adequate rates, it should work with states and their actuaries to strike a reasonable balance on the level of documentation required, and ensure CMS oversight of a feasible rate-review process.
After seeing the final document, the Association for Community Affiliated Plans (ACAP) expressed concern that the CMS hasn't gone far enough to ensure transparency from the states.
“We recommend CMS require states to disclose, in a timely manner, sufficient information to permit plans to replicate the rate-setting methodology and underlying assumptions, and to establish an appeals process for plans related to actuarial soundness,” Meg Murray, CEO of the ACAP said.
The Medicaid Health Plans of America (MHPA) had similar worries. “We remain concerned that Medicaid MCOs will continue to face barriers in receiving the materials necessary to verify that rates are actuarially sound, and that the terms of the contract are sustainable, prior to contracts being signed,” an MHPA spokesman said.
Now that the guide has been finalized without provisions for transparency, the MHPA hopes that the CMS will write a final Medicaid managed-care rule that requires states to share documentation with Medicaid managed care organizations during the rate certification process.
“Failing to require that states share information and materials regarding rate development with both CMS and contracted plans, transparency issues will persist that may adversely affect the Medicaid program, health plans, and enrollees,” the MHPA spokesman added.
The CMS has said the guide comes in response to feedback from states saying they wanted to better understand what the CMS considers to be a sufficient rate for plans.
