It’s Unanimous: CMS Needs to Bring More Transparency to Medicaid Managed Care

Last week, MACPAC Commissioners voted to recommend that the Centers for Medicare & Medicaid Services post all state Managed Care Program Annual Reports (MCPARs) to the CMS website. The vote was unanimous: 17-0.  The recommendation will be included in MACPAC’s March 2024 Report to Congress. At first glance, this may seem unremarkable, but on further examination, it could augur the beginning of a new chapter in the evolution of Medicaid managed care—one in which transparency brings greater accountability of individual managed care organizations (MCOs) for their performance, and greater accountability of state Medicaid agencies and CMS for their monitoring and oversight.

But before we get too carried away, let’s unpack what just happened.  As students of Medicaid acronyms well know, MACPAC—aka the Medicaid and CHIP Access and Payment Commission—is a nonpartisan agency established by Congress to provide it with information and policy analysis independent from that available from CMS or the White House.  MACPAC has 17 commissioners appointed by the Comptroller General, who heads up the Government Accountability Organization (GAO).  MACPAC holds public meetings and submits reports to Congress every March 15 and June 15 containing recommendations for improving the Medicaid and CHIP programs.

As Medicaid acronyms go, MCPAR is far more obscure than MACPAC.  In part this is because the Managed Care Program Annual Reports are, with a few exceptions, not accessible to the public on state Medicaid agency websites or on the CMS website  (As of December 2023, only six states posted their MCPARs: Arkansas, Louisiana, Mississippi, Ohio, Pennsylvania,  and Tennessee).  The MCPARs contain information on how each of the MCOs with which the state contracts performed during the previous contract year, including medical loss ratios, quality metrics, and sanctions imposed.  The standardized reporting template (in the form of an excel workbook) allows for comparison of performance among MCOs (and their parent companies ) and among states.

States are required to submit MCPARs to CMS within 180 days after the end of each MCO contract year. To date, states have submitted MCPARs to CMS for the first reporting cycle, which includes the contract year July 1, 2021 through June 30, 2022 as well as the contract year January 1, 2022 through December 31, 2022.  The MCPARs for the second reporting cycle, beginning with contract period July 1, 2022 through June 30, 2023, should now be in.  CMS has not yet posted any of the MCPARs it has received.

Over the past year, one of the issues on MACPAC’s agenda has been denials and appeals in Medicaid managed care.  The MACPAC staff analysis resulted in seven recommendations, ranging from Congress requiring states to establish independent, external medical review of prior authorization denials to CMS posting the MCPARs on its website “in a timely manner following states’ submissions to CMS.”  These were presented to the commissioners at their January 25 meeting.

The MACPAC commissioners, by design, bring a wide range of perspectives to their task. They include former CMS managers, former state Medicaid and CHIP agency directors, MCO executives, and Medicaid consultants to state agencies and MCOs (the list includes CCF’s own Tricia Brooks).  They are perfectly capable of disagreeing, as they did in the case of the recommendation relating to external medical review, which 3 commissioners voted against and 1 abstained.  On the recommendation that CMS post the MCPARs, however, there was no disagreement.

Their rationale for the recommendation was straightforward: “Currently there is little transparency on MCO approvals and denials of services, limiting what is known about beneficiary access to medically necessary care.”  Leveraging the MCPARs by posting them “would bring greater oversight and accountability to managed care programs and provide beneficiaries with key information on denials and appeals.”  This seems more than sufficient, but if you need additional arguments for posting; you can read them here.

By March, CMS will have the MACPAC’s recommendations on appeals and denials formally before it.  CMS is not under any obligation to implement MACPAC’s recommendations. (Famously, the Trump administration CMS ignored a 2018 MACPAC letter requesting a pause in the Arkansas work reporting requirements waiver to stem the massive coverage losses).  But there’s no reason for CMS not to take up the recommendation. For that matter, it doesn’t need to wait for the March report to be published.

All of this is not to say that the current version of MCPAR could not be improved.  As the MACPAC recommendations on reporting of appeals and denials indicate, there is room for CMS to collect and post even better performance data on individual MCOs (for example, Child Core Set metrics). But one step at a time.  CMS should get the MCPARs it has already collected up on its website so that everyone interested can take a look.  Then we’ll see what transparency can do.

Editor’s Note: On the same day this blog posted, CMCS added the following to its Medicaid and CHIP Managed Care Reporting page: “MCPAR reports submitted to CMS in 2022 and 2023 are available upon request. Please email your request to CMS Managed Care TA,”

Andy Schneider is a Research Professor at the Georgetown University McCourt School of Public Policy.