On April 22, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality final rule. CMS finalized several substantial updates to the Managed Care Rule with implications for state directed payments (SDPs), payment transparency, medical loss ratios (MLRs), wait time standards and in lieu of services (ILOS). Read on for key takeaways and our full analysis of the final rule.

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KEY TAKEAWAYS

CMS finalized several substantial updates to the Managed Care Rule, including the following:

• The final rule includes process and transparency-related changes to SDPs, including a requirement that SDP amounts for inpatient hospital services, outpatient hospital services, nursing facility services and qualified practitioner services at an academic medical center do not exceed the average commercial rate.
• The final rule creates new payment transparency for states by conducting a managed care provider payment rate analysis for certain services.
• The final rule includes requirements for clinical or quality improvement standards for provider incentive arrangements and for expense allocation reporting. The rule prohibits administrative costs from being included in reporting quality improvement activities.
• The final rule incorporates several requirements to measure and improve access to care, including establishing maximum appointment wait times, requiring secret shopper and enrollee experience surveys, and developing remedy plans for issues that are identified.
• The final rule requires that an ILOS be considered approvable as a service or setting through the Medicaid state plan or a Medicaid section 1915(c) waiver. The rule finalizes new reporting and standard requirements for ILOSs.