DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard 
Mail Stop S2-26-12  
Baltimore, Maryland  21244-1850 
CMCS Informational Bulletin 
 
DATE:  June 28, 2021 
 
FROM:  Anne Marie Costello, Acting Deputy Administrator and Director 
    Center for Medicaid and CHIP Services 
 
SUBJECT:  Medicaid and CHIP Managed Care Monitoring and Oversight Tools 
 
 
The purpose of this Center for Medicaid and CHIP Services (CMCS) Informational Bulletin 
(CIB) is to introduce a series of tools for states and the Centers for Medicare & Medicaid 
Services (CMS) to utilize to improve the monitoring and oversight of managed care in Medicaid 
and the Childrens Health Insurance Program (CHIP).  This CIB also provides guidance setting 
the content and format of  the Annual Managed Care Program Report required by CMS 
regulations at 42 CFR  438.66(e)(1)(i), and introduces additional resources and technical 
assistance toolkits that states can use to improve compliance with managed care standards and 
requirements.  The annual report is part of CMSs overall strategy to improve access to services 
by supporting Federal and state access monitoring for Medicaid beneficiaries within a managed 
care delivery system.  
 
Introduction 
Over the last decade, states have drastically increased their use of managed care to deliver 
Medicaid and CHIP benefits, becoming the dominant delivery system in both programs.  For 
example: 
 
  As of July 2018, 53.9 million individuals were enrolled in Medicaid managed care, which 
represents 69 percent of the total Medicaid enrollment. 
  In fiscal year 2018, total federal and state Medicaid managed care expenditures were 
$296 billion, which is approximately 50 percent of total Medicaid expenditures. 
  In 31 states, about 79 percent of CHIP children were enrolled in managed care.  
  Twenty-two states had Managed Long-Term Supports and Services (MLTSS) programs 
in operation as of July 1, 2018. 
 
The increased prevalence in the use of managed care delivery systems underscores the continued 
need for strong federal and state oversight of managed care in Medicaid and CHIP.  Over the last 
decade, CMS has engaged in numerous monitoring and oversight activities for Medicaid and 
CHIP managed care programs, and while these activities have been effective in assuring state 
compliance with specific regulatory and statutory requirements, CMS recognizes the need for 
additional tools to improve monitoring and oversight efforts.  Accordingly, CMS has begun to 
develop several state tools described below. 
 
 
 
  Page 2  CMCS Informational Bulletin 
 
Development of a Web-Based Reporting Portal for the Collection of Required Managed 
Care Reports 
The May 2016 Medicaid and CHIP managed care final rule strengthened the federal oversight of 
state managed care programs in several ways, one of which was to create new reporting 
requirements for states on their managed care programs and operations.  CMS is developing 
reporting templates for each of the following reports: the Annual Program Oversight Report 
required in 42 CFR  438.66(e), the Medical Loss Ratio (MLR) Summary Report required in 42 
CFR  438.74(a), and the Access Standards Report required in 42 CFR  438.207(d) and (e).  
CMS intends to develop these templates in a web-based reporting portal, thereby creating a 
single submission process and repository for all state reporting requirements related to managed 
care.   
 
The structured data captured by this system will allow CMS to generate and analyze state-
specific and nationwide data across the universe of managed care programs and requirements.  
This data analysis will allow CMS to identify areas of technical assistance and to target efforts to 
assist states in improving their managed care programs while also ensuring compliance with 
managed care statutes and regulations, such as ensuring access to care. 
 
Annual Managed Care Program Report 
CMS regulations at 42 CFR  438.66(e) require states to submit an Annual Managed Care 
Program Report.  Under the regulation, each state must submit to CMS, no later than 180 days 
after each contract year, a report on each managed care program administered by the state which 
will contain data from all involved plans.  The initial report is due after the contract year 
following the release of CMS guidance on the content and form of the report and would cover 
that contract year.  The information below and the template available on Medicaid.gov at 
https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-
monitoring-and-oversight-initiative/index.html with instructions serves as the CMS guidance on 
the content and format of the required report so the initial report will be due for contract years 
starting on or after [insert date] and due 180 days after the end of that contract year. 
 
During the development of this report template, CMS consulted with states and other 
stakeholders on the content and form of the report.  The final report template includes changes 
made to address comments and concerns from those entities. 
 
Timing of the Report 
The chart below clarifies the reporting period and due date of the first Annual Managed Care 
Program Report for each state, based on the contract year of each managed care program. 
 
Contract Year of the  Contract Period of First  First Report Due 
Managed Care Program  Report 
July through June  7/1/2021  6/30/2022  December 27, 2022 
September through August  9/1/2021  8/31/2022  February 27, 2023 
October through September  10/1/2021  9/30/2022  March 29, 2023 
January through December  1/1/2022  12/31/2022  June 29, 2023 
February through January  2/1/2022  1/31/2023  July 30, 2023 
April through March  4/1/2022  3/31/2023  September 27, 2023 
 
  Page 3  CMCS Informational Bulletin 
 
Content of the Report 
Every state must submit a report for each managed care program administered by the state, 
including behavioral health plans and managed LTSS plans.  As defined by the regulation, the 
report will collect information in the following categories: 
 
1.  Program enrollment and service area expansions** 
2.  Financial performance 
3.  Encounter data reporting 
4.  Grievances, appeals, and state fair hearings 
5.  Availability, accessibility, and network adequacy 
6.  Delegated entities 
7.  Quality and performance measures 
8.  Sanctions and corrective action plans** 
9.  Beneficiary support system (BSS) 
10. Program integrity 
 
All 10 categories apply to Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans 
(PIHPs), and Prepaid Ambulatory Health Plans (PAHPs).  Only those categories marked by ** 
apply to Primary Care Case Management (PCCM) entities.  Each of the above categories have 
data indicators (data elements) that are organized by and will be reported at state, program, or 
plan levels for ease of data entry.  The excel workbook is available on Medicaid.gov at 
https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-
monitoring-and-oversight-initiative/index.html and provides the exact indicators that will be 
required, along with instructions on how to complete each field. 
 
Form of the Report 
The report will be collected electronically through a web-based submission portal.  This portal 
will collect exactly the information that is included in the excel workbook.  As presented in the 
workbook, each indicator will require a response in a specified format based on the indicator.  
The formats include selections for a drop down list, numerical counts, free text, percentages, and 
dates.  CMS will make the web-based portal available to states at least 6 months prior to the date 
the first reports are due, no later than June 27, 2022.   
 
Technical Assistance on Completing the Report 
CMS strongly encourages states to review the attached excel workbook version of the report over 
the next few months and begin planning any changes to state data gathering or processes that will 
need to be implemented to complete the report.  States could also use the excel version to collect 
information from individual managed care plans to facilitate data collection.  As states are 
reviewing the tool or planning their data collection, CMS is available to provide one on one 
technical assistance.  Please contact your CMCS managed care state lead or complete the 
Medicaid Managed Care  State Technical Assistance Request Form to request technical 
assistance. 
 
Appeals and Grievances Data Collection Pilot 
As required by 42 CFR  438.66(a) and (b), all states must have a monitoring system for all 
managed care programs, including, among other things, appeals and grievances systems.  In 
 
  Page 4  CMCS Informational Bulletin 
 
addition, CMS regulations at 42 CFR  438.66(d) require each state to conduct a readiness 
review of each MCO, PIHP, PAHP, or PCCM entity with which it contracts to assess the ability 
of each entity to perform satisfactorily in several areas, including appeals and grievances. 
 
CMS believes that appeals and grievances data can provide critical insight into the performance 
of a managed care program and managed care plans, especially during the first year of 
implementation.  Such data could quickly reveal areas of weakness in a program or plan, and 
identifying those early will allow states to remedy the issue before plan members are 
disadvantaged or critical incidents occur. 
 
To that end, CMS has developed a standard appeals and grievances data collection tool to be 
used for the first year of implementation as a second part of a readiness review.  Through the 
CMCS Managed Care Technical Advisory Group, CMS consulted with states during the 
development of the tool, and incorporated state feedback into the final tool.  Over the next 12 to 
18 months, CMS will pilot the tool with states that are completing their readiness review process 
within that timeframe.  Based on the results of the pilot, the tool will be edited as necessary.  
Once final, the tool will be incorporated into the web-based reporting portal described above and 
become a regular part of the readiness review process. 
 
Technical Assistance Toolkits to Improve State Compliance and Oversight 
CMS is also developing a series of technical assistance toolkits to assist states in complying with 
various managed care standards and regulations, and to help improve state monitoring and 
oversight of their managed care programs.  The topics will include: 
 
  Behavioral Health Access* 
  Managed Long-Term Services and Supports 
  Managing Plan Transitions 
  Provider Screening and Enrollment 
  Managed Care Quality Strategies* 
  Program Integrity 
  Tribal Protections in Medicaid and CHIP Managed Care 
 
*See more detail below 
 
Tools to Assist States in Managed Care Monitoring and Oversight 
As part of the strategy described above, CMS is making the following resources and tools 
available to states: 
 
Behavioral Health (BH) Access Toolkit 
Recent increases in substance use disorders, as well as repercussions of the COVID-19 
pandemic, have underscored the importance of behavioral health services that treat substance use 
and mental health disorders.  Medicaid plays a critical role in the financing and delivery of 
behavioral health services.  In 2015, Medicaid was the primary source of health coverage for 26 
percent of adults with serious mental illness and 17 percent of adults with substance use 
disorders.  State Medicaid agencies have increasingly covered behavioral health services through 
comprehensive managed care plans rather than paying for them on a fee-for-service (FFS) basis 
 
  Page 5  CMCS Informational Bulletin 
 
or covering them through limited-benefit managed care plans, sometimes called behavioral 
health organizations.  The expanded role that Medicaid managed care plans play in delivering 
behavioral health servicesand the greater demand for such services among Medicaid 
beneficiariesraises the importance of access to these critical services through robust provider 
networks.  This toolkit aims to help state Medicaid agencies and the managed care plans with 
which they contract meet the network adequacy requirements for behavioral health care 
providers.  Numerous state Medicaid agencies have developed innovative approaches to 
strengthen their behavioral health workforce and improve access to services within Medicaid 
managed care.  This toolkit highlights promising practices and strategies implemented by state 
Medicaid agencies and managed care plans and is available on Medicaid.gov at 
https://www.medicaid.gov/medicaid/managed-care/guidance/medicaid-and-chip-managed-care-
monitoring-and-oversight-initiative/index.html. 
 
Quality Strategy Toolkit 
Under regulations at 42 CFR  438.340(a) and 457.1240(e), CMS requires state Medicaid and 
CHIP agencies that contract with MCOs, PIHPs, PAHPs, and certain PCCM entities to develop 
and maintain a Medicaid and CHIP quality strategy to assess and improve the quality of health 
care and services provided by managed care plans.  To support states in implementing managed 
care quality strategy requirements, CMS has developed the Medicaid and CHIP Quality Strategy 
Toolkit.  CMS recommends that states use this toolkit as a part of their quality strategy 
development, revision, and submission processes to ensure that their quality strategies address 
regulatory requirements and leverage best practices.  This toolkit describes quality strategy 
regulatory requirements and provides considerations for states to improve their quality strategy 
and is available on Medicaid.gov at https://www.medicaid.gov/medicaid/managed-
care/guidance/medicaid-and-chip-managed-care-monitoring-and-oversight-initiative/index.html..  
 
Closing 
CMS is committed to strengthening the monitoring and oversight of Medicaid and CHIP 
managed care programs.  To do so, the agency is developing a series of reporting templates and 
technical assistance toolkits described above.  CMS looks forward to engaging and collaborating 
with states on the implementation of these tools and anticipates issuing additional tools 
periodically over the next two years to improve its monitoring and oversight activities. 
 
If you have any questions or need additional information, please contact John Giles, Director, 
Division of Managed Care Plans at 410-786-5545 or John.Giles1@cms.hhs.gov.