CMS has issued guidance on the requirements for state Children's Health Insurance Programs (CHIP) contracting with managed care entities (MCE). Section 403 of the Children's Health Insurance Program Reauthorization Act (CHIPRA) (PubLNo 111-3) applies Medicaid managed care requirements to CHIP.
New requirements
Effective July 1, 2009, CHIP managed care programs must allow beneficiaries to disenroll without cause within 90 days of enrollment, and with cause at any time. Those who disenroll must be able to obtain services through another managed care entity (MCE) or an alternative delivery system. CHIP managed care programs must follow the requirements for provision of information, marketing, emergency care and grievance procedures. CHIP MCEs may not limit communications between health professional and patient about available or effective services whether or not the services are covered under the MCE's plan.
CHIP managed care programs also must meet the same requirements for solvency, adequacy of the network, and protection against balance billing, so that beneficiaries are never liable to the providers for an amount over the required copayment and any deductible. They must comply with maternity care and mental health parity requirements applicable to group insurance plans. The Medicaid MCE quality assurance and independent external review requirements apply to CHIP MCEs as well.
State obligations States must include the new contractual provisions in any contract with a CHIP MCE executed, renewed or amended on or after July 1, 2009.In addition to the requirements described above, the contracts must prohibit the MCE from contracting with or having more than 5 percent ownership by, anyone who has been excluded from participation in Medicare, Medicaid or any other federal program. They must develop intermediate sanctions to be used against MCEs that deny medically necessary, covered care, charge fees other than those permitted, discriminate among enrollees; misrepresent facts to enrollees or government officials ; or violate marketing rules. The sanctions must include civil money penalties, temporary management, allowing enrollees to terminate their enrollment without cause, suspension of new enrollment and suspension of payments to the MCE. Imposition of sanctions must trigger a right to administrative appeal for the MCE.
Additional guidance and a Notice of Proposed Rulemaking will be issued in the future.
CMS Letter to State Health Officials, No. SHO-09-008, Aug. 31, 2009, ¶53,121
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
Visit our News Library to read more news stories.
