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CMS Finalizes 2017 Managed Care Rate-Setting Guide

The Centers for Medicare & Medicaid Services (CMS) has released its final 2017 Medicaid Managed Care Rate Development Guide, which give states information they need to develop actuarial rate certifications, such as benefit cost projections, pass-through payments, and risk mitigation strategies.

All Medicaid managed care rates for calendar year 2017 are subject to federal actuarial soundness requirements set by July 2016 final regulations for Medicaid and Children’s Health Insurance Program managed care. Medicaid managed care payment rates submitted for CMS review must be certified by an actuary, appropriate for the covered population and services for the effective period, and developed in accordance with generally accepted actuarial practices and principles.

CMS will use these principles to ensure managed care plans meet the requirements:

  • Payment rates are reasonable and comply with applicable laws for Medicaid managed care;
  • The payment rate development process complies with applicable Medicaid laws, including eligibility, benefits, financing, waiver or demonstration project requirements, and program integrity; and
  • Documentation sufficiently shows that the development process meets generally accepted actuarial practices and principles.

If you have questions or concerns, please contact Erin O’Malley, director of policy, at eomalley@essentialhospitals.org or 202.585.0127.

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About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.