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MEDICAID MANAGED CARE


Enrollment Statistics

Children's Hospice Solicitation - June 8, 2000

Descriptions of State Programs

Programs for All Inclusive Care for the Elderly (PACE)

Final Rules

Rate Setting for Risk-Based Contracts

  • Federal Regulatory Requirements [42 CFR 438.6(c)] (PDF 21KB)
    • These are the regulations implementing section 1903(m)(2)(A)(iii) of the Social Security Act requiring payments in risk contracts to be made on an actuarially sound basis.

  • Checklist—Financial Documentation for At-Risk Capitated Contracts Rate Setting (7/22/03) (PDF 432KB)
    • This is a tool used by CMS Regional Offices in their review and approval of rates in risk-based Medicaid managed care contracts.

  • Draft Health Practice Note 2004-1, Actuarial Certification of Rates for Medicaid Managed Care Programs, by the American Academy of Actuaries Medicaid Rate Certification Work Group -- www.actuary.org/pdf/practnotes/health_medicaid_july04.pdf

    This link will connect you to the draft Practice Note that was developed by an work group of actuaries who are familiar with rate setting issues in Medicaid managed care programs from various perspectives. It is intended to provide guidance to actuaries in certifying rates and rate ranges in risk contracts. As a draft document, this Practice Note is subject to change.

  • A Guide for Implementing a Health-Based Risk-Adjusted Payment System for Medicaid Managed Care Programs (ZIP 2.5MB) --A Guide for States – There are a total of 35 files, totaling over 2,460 KB. The pages are in a variety of formats including Power Point, Microsoft Word and Excel. Please be advised that individual files can be very large and may take considerable time to download or to print.

  • Financial Attachment (PDF 105KB)
    • This site contains "A Guide to Implementing a Health-Based Risk-Adjusted Payment System for Medicaid Managed Care Programs." This guide was developed by the Center for Health Program Development and Management at the University of Maryland, Baltimore County, and the Actuarial Research Corporation under contract with the Centers for Medicare and Medicaid Services (CMS). CMS is making this information available as a general resource on health-based risk adjustment and examples of how such payment systems can be implemented by State Medicaid agencies.

      However. CMS neither requires health-based risk adjustment, nor endorses any particular method or model of health-based risk adjustment in Medicaid managed care payment systems.

Quality

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Waivers and Demonstrations

CMS Guidelines on Key Approaches to the Use of Managed Care Systems for Persons With Special Health Care Needs.

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Last Modified on Thursday, September 16, 2004