Last month, the Centers for Medicaid & CHIP Services (CMCS) issued a Center Informational Bulletin, “Medicaid and CHIP Managed Care Monitoring and Oversight Tools.” Among other items, this CIB discusses the Managed Care Program Annual Reports that state Medicaid agencies are required to submit to CMS. MCPARs are each state’s accounting of how each of their MCOs performed during the previous contract year. They include MCO-specific data on, among other things, enrollment, medical loss ratios, the timeliness of encounter data reporting, appeals of denials of care, quality metrics, and sanctions imposed. These data are collected on a standardized reporting template that allows for comparison of performance among MCOs (and their parent companies) and among states.
If MCPARs were publicly available, they could be a tool for advocates to hold MCOs, the state agencies, and CMS accountable for performance. Unfortunately, they are not. Despite a requirement that state Medicaid agencies post their MCPARs, only five currently do so: Arkansas, Louisiana, Mississippi, Ohio, and Pennsylvania. And despite an explicit commitment in a July 2022 CIB to post the MCPARs on Medicaid.gov, CMCS has not yet posted any of the MCPARs it has collected. Last month’s CIB—an ideal opportunity for CMCS to reaffirm its support for MCPAR transparency—is silent on the matter.
How did we get to this point? The saga begins in May of 2016 with the issuance of the Medicaid managed care rule, a comprehensive overhaul of the rules under which states and the MCOs with which they contract operate. Included in the rule was a requirement that state Medicaid agencies report to CMS each year on the performance of each MCO, post the report on the agency’s website, and provide it to the state Medical Care Advisory Committee. The initial report was not due until after the release of CMS guidance on the content and form of the report.
Fast forward through the Trump administration to June 2021, when CMCS issued the first of three CIBs on managed care monitoring and oversight. CMS announced that, as part of its “overall strategy to improve access to services,” it would be requiring states to submit the annual managed care program reports called for in its 2016 regulations. CMS provided a standardized reporting template and a schedule for submission of the MCPARs, which recognized that states use different 12-month contracting periods. Thus, for the first full cycle of MCPARs, the first tranche would be due on December 27, 2022, for the MCO contract year July 1, 2021 through June 30, 2022. The last tranche for the cycle would be due September 27, 2023, for the MCO contract year April 1, 2022 to March 31, 2023.
A year later CMCS issued a second CIB that announced the availability of a web-based portal to allow states to submit their MCPARs (and other required reports) electronically and reminded the states of the schedule for submission. Under the heading “Public Availability of Reports,” the CIB stated: “CMS will make all reports submitted through [the web-based portal] 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 on request.”
(The bracketed term “web-based portal” is a placeholder for the preposterous initialism “MDCT-MCR.” Don’t ask).
This shout-out for transparency was cause for cautious optimism, at least in some quarters. All states contracting with MCOs, and all the MCOs with which they contract, were on notice that standardized, MCO-specific performance data would be collected and made publicly available on an annual basis. This would give the MCOs (and their parent companies) an incentive to improve their performance so they would not look worse than their competitors. It would also give state Medicaid officials an incentive to improve the performance of the MCOs with which they contract so that their managed care programs would not look worse than those in neighboring states. And the better MCOs perform, the better Medicaid works for children and families and other beneficiaries.
The CIB recognizes the importance of the MCPAR data to improving MCO performance:
“The structured data captured by this system will allow CMS to generate and analyze State-specific and nationwide data across all managed care programs and requirements. CMS will use these data to identify areas that need improvement and target technical assistance to help States improve their managed care programs and comply with managed care statutory and regulatory requirements.” (Emphasis added).
But it also assumes that performance improvement can be achieved through what are, in effect, private conversations between CMS and the states, with little or no involvement by the public. And therein lies the rub.
Conversations between federal and state officials are a necessary part of any effective Medicaid oversight, but they are not sufficient to the task of ensuring that all MCOs work well for their enrollees in every state. Medicaid managed care, now operating through over 280 MCOs in 41 states (including D.C.) is simply too large and too complicated, with too many moving parts, for federal regulators to track by themselves. Monitoring this massive enterprise is a job for a village—advocates, providers, researchers, people covered by Medicaid and the media, as well as state and federal officials and policymakers.
The village can’t do its job without MCPAR transparency. All that would take is a new page on Medicaid.gov populated with each state’s MCPAR(s) as received within, say, 30 days of receipt. (Some states have more than one managed care “program,” requiring separate MCPARs for each). That would provide all stakeholders with one-stop shopping for this information, eliminating the need for fruitless scans of state agency websites or the filing of state Public Records Act requests to extricate the MCPARs.
CMCS may have concerns about the quality of the data some states report. Given the experience with annual state reporting on CHIP, this concern is not unreasonable. But without transparency, there will be little reason for states to submit accurate and complete MCPARs. Knowing that their reports will be posted to an easily accessible federal website where their responses can readily be compared with those of other states will give state Medicaid agencies an incentive to get their data submissions right.
In the case of states that post their MCPARs on their agency websites, posting the MCPARs on Medicaid.gov would be redundant. For those states, Medicaid.gov could link directly to those states’ reports on their websites. This would eliminate duplicate posting without compromising transparency at the federal level. And, to the extent it encourages more states to post their MCPARs on their own websites so that their citizens don’t have to go to Medicaid.gov in order to learn about the performance of the MCOs in their states, this solution could promote transparency at the state level as well.
Standing up a new webpage on Medicaid.gov and populating it with MCPARs (or links to MCPARs on state agency websites) shouldn’t be that difficult. The MCPARs are already being prepared and submitted; all that remains is to post them as received. The cost and administrative burden on CMCS would be minimal, while the potential for greater accountability of individual MCOs would be substantial. In short, we’re wishing CMCS a transparent New Year.
