[Medicaid] Medicaid Managed Care and Supporting Regulations (CMS-10855)

This collection of information request is associated with our September 26, 2024 (89 FR 79020) final rule (CMS-2434-F; RIN 0938-AU28). We intend to fold the following collection of information requirements and burden estimates under CMS-10108 (OMB 0938-0920). However, there are a number of conflicting activities that make this impractical at this time. To address those conflicts, as a stop gap measure we are proposing to submit the collection of information requirements and burden estimates under CMS-10855 (OMB 0938-1445). When ready we will be folding them to their proper place under CMS-10108 (OMB 0938-0920). Most Medicaid beneficiaries receive either all or part of their health care benefits through Medicaid managed care programs, including their prescription drug benefits. Because of the specialized nature of the prescription drug benefit, many of the Medicaid managed care plans (MCOs, PIHPS, or PAHPS) either own, or contract with, PBMs to administer the pharmacy benefit. In § 438.3(s), Medicaid MCOs, PIHPs, and PAHPs that provide coverage of covered outpatient drugs (CODs) would be required to structure any contract that it has with any subcontractor (e.g., PBM) for the delivery or administration of the COD benefit so that the subcontractor is required to report separately the amounts related to the incurred claims described in § 438.8(e)(2) to the managed care plan. The provisions would ensure that medical loss ratios (MLRs) reported by MCOs, PIHPs and PAHPs that use subcontractors in the delivery of COD coverage would be more accurate and transparent. The separate payment requirements would help States and managed care plans better understand whether they are appropriately and efficiently paying for the delivery of CODs, a significant part of which is funded by the Federal Government.

The latest form for [Medicaid] Medicaid Managed Care and Supporting Regulations (CMS-10855) expires 2026-04-30 and can be found here.

States: Require plans to Structure their Subcontracts

Federal Enterprise Architecture: Health - Health Care Services