On Nov. 9, the Centers for Medicare and Medicaid Services (CMS) released the final rule “Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care” (CMS 2408-F), which finalizes changes to Medicaid and CHIP managed care plan requirements alongside other alterations. In January 2019, NADP filed comments on the proposed rule, voicing support for changes in tagline requirements, grievance/appeals support, and asking for a carve-out for dental benefits in the existing MMC medical loss ratio reporting requirements. Both the information reporting requirements and grievance changes were finalized; however, the rule keeps the existing MLR framework in place.

Issues discussed in NADP Comments on Proposed Rule

Section 438.8: Medical Loss Ratios (p.87, p.39 preamble notes)

The final rule makes a single technical correction to the existing MLR reporting framework that originated in the Medicaid “mega rule” of 2016, allowing plans to add fraud prevention services to the numerator of their MLR calculation.

In comments on the proposed rule, NADP asked CMS to revisit the inclusion of dental benefits in MLR reporting requirements, citing industry standards, cost to plans of reporting, and the lack of such a requirement for dental plans on exchanges.

CMS did not alter their language on the MLR section for the final rule, leaving the existing framework intact.  

Section 438.10: Information Requirements (p.87, p.40 preamble notes)

The final rule adopts the “conspicuously visible” standard of 45 CFR 92.8(f)(1) for taglines, which was implemented in final rule “Nondiscrimination in Health and Health Education Programs or Activities: Delegation of Authority“, a change from the existing requirement that taglines be printed in at least size 18 font. The rule also would require plans to only update their paper provider directories quarterly if there is a mobile enabled provider directory available that is updated at least every 30 days.

NADP commented in support of both these changes, citing the relief of administrative burden on plans. 

Sections 438.400, 438.402, 438.406, 438.408: Grievances and Appeals (p.89)

The final rule would add language that a denial of payment for a service because it did not meet the definition of a clean claim (§ 447.45(b)) is not an adverse benefit determination, and therefore notice requirements would not be triggered.

The rule also removes the requirement that enrollees submit a written, signed appeal after an oral appeal is completed, and that an enrollee may request a state fair hearing no less than 90 calendar days and no more than 120 days from a plan’s notice of resolution. 

NADP commented in support of these changes in the proposed rule, again sighting the relief of administrative burdens on plans.

Other Changes

Section 438.4 Actuarial Soundness Requirements (p.84)

Under the final rule, states may develop their own rate range requirements, as opposed to the existing requirement that each individual rate paid per rate cell. The top upper bound of the rate range must be less than or equal to (lower range bound*1.05) and must comply with “generally accepted actuarial principles and practices.” Further clarification was added in the press release:

  • The rate range provisions with a modification to permit states to move rate cells a de minimis amount (+/- 1 percent) within the 5 percent rate range to address minor program changes during the rating period without the need to submit a revised rate certification. This provision will take effect with rating periods beginning on or after July 1, 2021.
  • The provisions specifying that differences in the assumptions, methodologies, or factors used to develop capitation rates for covered populations must be based on valid rate development standards that represent actual cost differences in providing covered services to the covered populations and that any differences in the assumptions, methodologies, or factors used must not vary with the rate of federal financial participation associated with the covered populations in a manner that increases federal costs.

NADP did not comment on the actuarial soundness requirements in the proposed rule.

Section 438.68 Network Adequacy (p.88)

The final rule eliminates the requirement that states set time and distance standards, substituting in its place a more general requirement that states set “quantitative network adequacy standards” for the range of providers (including pediatric dental).

NADP did not comment on the network adequacy requirements in the proposed rule.

Please see the links below for more information, including NADP’s write ups of the proposed rule, our advocacy, and the CMS fact sheet on the final rule.


Final Rule Full Text

CMS Fact Sheet

CMS Press Release

NADP Letter on Proposed Rule

Please contact Government Relations Analyst Owen Urech with any comments or questions on the rule.

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