If the phrase “transparency in Medicaid managed care” sounds like an oxymoron, that’s because in many states it is. Finding information on the performance of individual Medicaid managed care organizations (MCOs) for children and families and other Medicaid beneficiaries on state Medicaid agency websites can be challenging. This is more than unfortunate because in the large majority of Medicaid programs, most beneficiaries are enrolled in MCOs, and the companies’ performance matters a lot! But in many states, the only people who know whether an MCO is delivering the services that beneficiaries need and to which they are entitled are the MCOs themselves and the state officials who oversee them.

The CMS Medicaid website is also not a source of MCO-specific information. Fortunately, this may be changing. CMS has recently taken some actions that suggest that going forward, it will be placing more emphasis on transparency of MCO-specific performance information. A skeptic might argue that this wouldn’t be hard given the current dearth of publicly available MCO-specific performance data. But that skeptic would not appreciate the difficulty of changing the deeply rooted culture of opacity surrounding Medicaid managed care at the individual MCO, industry, state, and federal levels alike.

Our saga starts in May 2016 with the issuance of the Medicaid Managed Care Rule. Among many other things, the rule required states contracting with MCOs to report annually to CMS on their managed care programs, network adequacy, and access, and medical loss ratios (MLRs).  Implementation of these reporting requirements, like many other provisions in the rule, was phased in.

In June 2017, one month before the first  implementation dates, CMS, under Administrator Seema Verma, issued guidance to states announcing that it would use its “enforcement discretion” to allow states to postpone compliance with “new and potentially burdensome requirements” of the managed care rule except for a few provisions with “significant federal fiscal implications.” The agency did not post information on which states benefited from its “enforcement discretion” or which requirements those states were able to postpone compliance with (and for how long). CMS did not issue any guidance to states specifying how they should comply with the annual reporting requirements and made no efforts to share the information, if any, they gathered through this reporting.

Fast forward to July 2021. Now under new management, CMS notified states that it had developed a standard reporting template for the Annual Managed Care Program Report. The annual report, CMS said, was part of its “overall strategy to improve access to services by supporting Federal and state access monitoring for Medicaid beneficiaries within a managed care delivery system.” Early this month, CMS announced the availability of standard reporting templates for the network adequacy and MLR reports. Standardized reporting means all states will be reporting the same data elements, allowing apples-to-apples comparisons of states and of individual MCOs within and across states.

Crucially, the guidance makes clear that “CMS will make all reports … available after CMS has completed an initial review of the reports. Once a Medicaid.gov page is established for the reports, CMS will announce its availability. Until that time, reports will be made available upon request.” This has the potential to make MCO-specific performance information available to advocates in otherwise opaque states in 2023 (exact due dates for the states and for different reports vary).

The standard data elements in the three reporting templates will not enable advocates to compare the performance of individual MCOs for children and families. For example, states will not have to provide the number of children enrolled in each MCO, report on the EPSDT screens and treatment services each MCO’s enrollees receive, or break down any enrollment or service information by race or ethnicity.  Nonetheless, the templates, in the form of Excel workbooks, do request some information that will be useful to understanding the performance of individual MCOs for their enrollees generally, which in turn may be an indicator of their performance for children and families. Here’s a brief, incomplete summary of what will be available from each report.

• Managed Care Program Annual Report. The standard reporting template, which can be found here, includes MCO-specific (“plan-level”) data in three buckets: (1) program characteristics (such as the MCO’s share of total Medicaid enrollment in the state, state Fair Hearing decisions that were partially or fully favorable to the enrollee, etc. ); (2) results of quality measures (such as the MCO’s performance on the state’s measures for primary care access/preventive care and for maternal/perinatal health, etc.); and (3) sanctions (such as the number of instances of non-compliance in the reporting year, the dollar amount of each sanction (if any) applied, etc.). The due dates for this report are tied to state contracting years. The first round of reports is due December 27, 2022 from those states with a July 1, 2021 through June 30, 2022 contract year.
• Network Adequacy and Access Report. States are required to start using the standard reporting template for these reports after October 1, 2022. In addition to submitting these reports to CMS, state Medicaid agencies will have to post them on their websites. The template, which is available here, includes MCO-specific information on compliance with the state’s network adequacy standards and its availability of services standards (such as the results of the state’s analyses of whether the MCO complies with the state’s network adequacy and availability of services standards and, if the state cannot assure the MCO’s compliance, what the MCO will do to achieve compliance and how the state will monitor the MCO’s progress, etc.).
• Medical Loss Ratio (MLR) Report. The standard reporting template for this report, found here, is not as comprehensive as the MLR reports that each MCO is required to submit to their state Medicaid agency each year. It requires states to provide, for each MCO, the MLR numerator, denominator, and MLR percentage, which is helpful for constructing a national database. But the components of each of those numbers, like non-claims costs or amounts spent on activities that improve health quality, are optional. Unless states elect to provide those figures, advocates interested in an MCO’s financial performance will have to request the Annual MLR Report that the MCO is required to submit to the state Medicaid agency each year. States are required to start using the standard reporting template after October 1, 2022.

Developing standardized reporting templates that request MCO-specific information is one thing. Getting states to provide that information is another. The reports that a state submits will only be as useful as the information that the state actually provides on the reports, and how accurate that information is. Still, the fact of the matter is that CMS is requesting that states start providing some MCO-specific performance information and has pledged to make that information public.  For fans of transparency, that in and of itself is a cause for celebration. Not a dance-to-the-music, party-all-night event, but certainly party-horn-emoji worthy.