Managed-care guide directs state rate-setting for new Medicaid populations


The Centers for Medicare & Medicaid Services just released a 2015 Managed Care Rate Setting Consultation Guide to help states that expanded Medicaid.

The first section of the guide applies to all Medicaid managed care capitation rates, while the second section addresses setting rates for the new adult population in Medicaid managed-care plans.

Building on last year's guide to add transparency, it describes information that CMS expects states to provide when developing the actuarial rate certifications. This information will be the focus of CMS's review of capitation rates and may be helpful in conversations with actuaries and managed care organizations, according to an announcement.

The guide expands on the required information even for states that covered the new adult eligibility groups in 2014. 

"Capitation rates for the new adult eligibility groups may appropriately vary for a number of reasons, but those reasons must be documented and justified in the certification. The capitation rates may not vary only due to differences in the applicable federal medical assistance percentages (FMAPs). … variations in available data, utilization, benefit packages or provider networks may need to be taken into account when developing these capitation rates," the announcement states.

States must describe any changes in rates from the previous certification, and also should describe the risk mitigation strategy for rates for the new adult eligibility group, it says.

Three million new consumers are now insured due to Medicaid expansion, with 10 states--California, Colorado, Florida, Kentucky, Maryland, Massachusetts, New York, Oregon, Washington and West Virginia--driving 80 percent of that enrollment, according to an analysis from Avalere Health.

But 17 states that did not expand Medicaid added more than 550,000 people to the rolls through last-minute efforts to sign up eligible residents.

To learn more:
- read the announcement (.pdf)

Related Articles:
Nonexpansion states saw boost in Medicaid enrollment
CMS: Medicaid eligibility tops 1.46M people
Report: 20% enrollment boost for Medicaid plans
What states matter most to exchange enrollment, Medicaid expansion?
10 states drive Medicaid enrollment