Form CMS-10108 Managed Care Program Annual Report (MCPAR) Template

The Managed Care Program Annual Report (MCPAR): A requirement of 42 CFR 438.66(e)
MCPAR Overview
Beginning on June 28, 2021, the Centers for Medicare and Medicaid Services (CMS) is requiring that, as part of its monitoring system for all Medicaid managed care
programs, 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, regardless of
the authority under which the program operates. (For purposes of the MCPAR, a program is defined by a specified set of benefits and eligibility criteria that is articulated in a
contract between the state and managed care plans, and that has associated rate cells.) The initial report will be due for the contract year beginning on or after June 28,
2021; reports are required annually thereafter and aligned with state contract cycles (42 CFR 438.68(e)(1)). (See the Glossary tab for a definition of "reporting year;" see
Instructions tab for example reporting timeframes.)
This document provides instructions for data collection and a template for states to use to submit the required information, hereafter referred to as the Managed Care
Program Annual Report (MCPAR). States must complete one MCPAR workbook (i.e., complete lettered sheets A-E in this excel file) for each managed care program
operating in the state during the year. Data should cover the 12-month period of the contract term during which the state is reporting information to CMS; this is referred to
as the "reporting year."
Completed forms should be submitted through an online portal that will be made available on or before June 27, 2022. Questions about this form may be directed to
[email protected]. This form, or the information contained therein, must also be posted on the state's website as required at 438.66(e)(3)(i), and
provided to the Medical Care Advisory Committee as required at 438.66(e)(i) and, if applicable, the MLTSS consultation group as required at 438.66(e)(iii).

MCPAR Template Organization
Consistent with 438.66(e), this template provides space for states to report indicators related to the following ten topics: (I) Program Characteristics and Enrollment; (II)
Financial Performance; (III) Encounter Data Reporting; (IV) Grievance, Appeals, and State Fair Hearings; (V) Availability, Accessibility, and Network adequacy; (VI) Quality
and Performance Measures; (VII) Sanctions and Corrective Action Plans; (VIII) Beneficiary Support System; and (IX) Program Integrity.
Data on each topic is organized by reporting level: state, program, plan, and other entity (i.e. beneficiary support system). Within this report, states will find data elements
with specific drop downs that CMS has pre-selected to standardize data across states, as well as places with instructions for states to report state-specific indicators or free
text. Tabs are organized as follows:
Tab topic:
Reporting instructions
A. Cover sheet and identifying information
B. State level, set indicators
C1. Program-level, set indicators
C2. Program-level, state-specific indicators: Availability, accessibility, and network adequacy
D1. Plan-level, set indicators
D2. Plan-level, state-specific indicators: Quality and Performance Measures
D3. Plan-level, state-specific indicators: Sanctions and Corrective Action Plans
E. BSS-entities, set indicators
Glossary
List of all indicators in the MCPAR, crosswalked to the tab on which they appear

Tab name
Instructions
A_COVER
B_STATE_set-indc
C1_PROG_set-indc
C2_PROG_free-indc_accs
D1_PLAN_set-indc
D2_PLAN_free-indc_qual
D3_PLAN_free-indc_sanc
E_BSS_set-indc
Glossary
Crosswalk

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0920 (Expires: June 30,2024). The time required to complete this information
collection is estimated to average 6 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Reporting Instructions
Item

Instruction or description

Inputting data

Enter information into tabs A-E, and only input values in BEIGE CELLS (white cells with black text provide explanatory text or calculated values). Key terms are
defined in the glossary.

Reporting timeframe

The State must submit MPCAR reports to CMS no later than 180 days after each contract year. The initial MCPAR report will be due after the contract year following
the release of CMS guidance on the content and form of the report (i.e. after release of this form) (42 CFR 438.68(e)(1). Example timeframe: If CMS releases
guidance on the MCPAR in the beginning 2021, states that have contracts on a calendar cycle (for example, states with contracts running from July, 2021 to June,
2022), would have their first required report due December 31, 2022. For states with calendar year contracts, the calendar year following release of the guidance would
be 2022, and their first reports would be due June 2023.  
For purposes of the MCPAR, a program is defined by a distinct set of benefits and eligibilty criteria that is articulated in a contract between the state and managed
care plans. "Programs" may also be differentiated from one another based on their associated rate cells.

Program definition
Exclusion of CHIP from
MCPAR
Preparing the first
MCPAR
Overlap with other state
reporting requirements

Separate CHIP enrollees and programs should not be reported in the MCPAR. Please use free text to flag any items for which the state is unable to remove
information about Separate CHIP from required reporting for Medicaid-only or Medicaid Expansion CHIP programs.
CMS acknowledges that states may need to update their contracts with plans to collect some information requested in the MCPAR and that states will need time to
create the first MCPAR report. CMS will be available to provide technical assistance to states to help prepare the MCPAR. Requests for technical assistance can be
submitted to [email protected].
CMS acknowledges that some of the indicators requested in the MCPAR are also reported to CMS through other means. For example, state EQRO reports include
measure validation results and measure rates for some or all measures collected by states, although measure rates may not be program specific and may not be
reported for all managed care programs operating in the state in a given year. States should consider leveraging existing reports and/or contractors (such as EQROs)
to populate the MCPAR. CMS will explore opportunities to align the MCPAR with other data collection efforts in future years.

1115 reports overlap

Per 42 CFR 438.66(e)(1)(ii), states that operate managed care programs under 1115(a) authority may reference 1115 reports required by its Special Terms and
Conditions (STCs) in lieu of entering an indicator into the MCPAR if the report includes the information required by the indicator including the same level
of detail (e.g. plan-level data). However, CMS has worked to ensure that most of the managed care reporting requirements in the MCPAR are not duplicated in
STCs; therefore, CMS anticipates few instances where the information required in 1115 quarterly and annual reports will directly overlap with what is required in the
MCPAR. If a state would like assistance in determining whether an existing 1115 reporting requirement can be deemed to satisfy requirements of the MCPAR, please
request technical assistance via [email protected].

Data lags

If the state does not have data available over the time period with which it is requested in the MCPAR, use the most recent data available and note the reporting period
that the data cover.

A. Cover sheet and identifying information
Item or entity
State name 

Instructions and definition
Enter the name of state submitting the report.
Enter the name and email address of the person or position to contact with
questions regarding information reported in the MCPAR. States that do not
wish to list a specific individual on the report are encouraged to use a
department or program-wide email address that will allow anyone with
questions to quickly reach someone who can provide answers.

Data format
Set value (select one)

Contact name
Contact email address
Date of report submission

Enter the email address of the individual filling out this document.
Enter the date on which this document is being submitted to CMS.

Free text
Free text
Date (MM/DD/YYYY)

Reporting period start date

Enter the start date of the reporting period represented in this document.

Date (MM/DD/YYYY)

Reporting period end date

Enter the end date of the reporting period represented in this document.

Date (MM/DD/YYYY)

Program name

Enter the name of the program for which the state is reporting data in the
MCPAR. For purposes of the MCPAR, a program is defined by a contract
between the state and a managed care plan (or group of plans), which
articulates a standard set of benefits, eligibility criteria, reporting
requirements, and has a set of rate cells specific to that program.

Free text

Plan 1
Plan 2
Plan 3
Plan 4
Plan 5
Plan 6
Plan 7
Plan 8
Plan 9
Plan 10
Plan 11
Plan 12
Plan 13
Plan 14
Plan 15
Plan 16
Plan 17
Plan 18
Plan 19
Plan 20
Plan 21

Enter the name of each plan that participates in the program for which the
state is reporting data. If the program contracts with fewer than 35 plans,
leave unused fields blank.

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Input data in beige cells in this column. These
values will autopopulate other tabs.
Response

Plan 22
Plan 23
Plan 24
Plan 25
Plan 26
Plan 27
Plan 28
Plan 29
Plan 30
Plan 31
Plan 32
Plan 33
Plan 34
Plan 35
BSS entity 1
BSS entity 2
BSS entity 3
BSS entity 4
BSS entity 5
BSS entity 6
BSS entity 7
BSS entity 8
BSS entity 9
BSS entity 10

Enter the names of the beneficiary support system (BSS) entities that
support enrollees in the program for which the state is reporting data. If the
program contracts with fewer than 10 BSS entities, leave unused fields
blank. If the program includes more than 10 BSS entities, states may
contact CMS for guidance.

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B. State-level indicators
#
Indicator
Instructions and definition
Data format
Topic I. Program Characteristics and Enrollment
Enter the total number of individuals enrolled in Medicaid as of the first day of
the last month of the reporting year. Include all FFS and managed care
Statewide Medicaid
Count
B.I.1
enrollees, and count each person only once, regardless of the delivery
enrollment
system(s) in which they are enrolled.
Enter the total, unduplicated number of individuals enrolled in any type of
Medicaid managed care as of the first day of the last month of the reporting
Statewide Medicaid
B.I.2
year. Include enrollees in all programs, and count each person only once,
Count
managed care enrollment
even if they are enrolled in more than one managed care program or more
than one managed care plan.
Topic III. Encounter Data Reporting

B.III.1

Data validation entity

Select the state agency/division or contractor) tasked with evaluating the
validity of encounter data submitted by MCPs. Encounter data validation
Set values (select
includes verifying the accuracy, completeness, timeliness, and/or
multiple) or use free text
consistency of encounter data records submitted to the state by Medicaid
for "other" response
managed care plans. Validation steps may include pre-acceptance edits and
post-acceptance analyses. (See Glossary defintion for more information.)

B.III.2

HIPAA compliance of
proprietary system(s) for
encounter data validation

If state selected “proprietary system(s)” in indicator B.III.1, indicate whether
the system(s) utilized are fully HIPAA compliant.

Set values (select one)

Topic X. Program Integrity

B.X.1

B.X.2
B.X.3

B.X.4

B.X.5

Describe service-specific or other focused PI activities that the state
conducted during the past year in this managed care program (such as
Payment risks between the analyses focused on use of long-term services and supports [LTSS] or
Free text
prescription drugs) or activities that focused on specific payment issues to
state and plans
identify, address, and prevent fraud, waste or abuse. Consider data analytics,
reviews of under/overutilization, and other activities.
Contract standard for
overpayments
Contract locations of
overpayment standard
Description of
overpayment contract
standard
State overpayment
reporting monitoring

Indicate whether the state allows plans to retain overpayments, requires the
return of overpayments, or has established a hybrid system.

Set values (select one)
Identify where the overpayment standard in indicator B.X.2 is located in plan
contracts, as required by 42 CFR 438.608(d)(1)(i).
Free text

Briefly describe the overpayment standard (for example, details on whether
the state allows plans to retain overpayments, requires the plans to return
overpayments, or administers a hybrid system) selected in indicator B.X.2

Free text

Describe how the state monitors plan performance in reporting overpayments
to the state. For example, does the state track compliance with this
requirement and/or timeliness of reporting?
Free text

Input data only in beige cells in this column
[STATE]

B.X.6

Describe how the state ensures timely and accurate reconciliation of
enrollment files between the state and plans to ensure appropriate payments
for enrollees experiencing a change in status (e.g., incarcerated, deceased,
Free text
switching plans).

Changes in provider
B.X.7.a circumstances: Part 1

Indicate if the state monitors whether plans report provider “for cause”
terminations in a timely manner under 42 CFR 438.608(a)(4).

Changes in beneficiary
circumstances

B.X.7.b
B.X.7.c

B.X.8a

B.X.8b
B.X.9a

B.X.9b

B.X.10

Changes in provider
circumstances: Part 2
Changes in provider
circumstances: Part 3

Set values (select one)

If the state monitors whether plans report provider “for cause” terminations in
a timely manner in indicator B.X.7.a, indicate whether the state uses a metric
or indicator to assess plan reporting performance.
Set values (select one)
If the state uses a metric or indicator to assess plan reporting performance in
indicator B.X.7.b, describe the metric or indicator that the state uses.
Free text

Consistent with the requirements at 42 CFR 455.436 and 438.602, the State
must confirm the identity and determine the exclusion status of the MCO,
Federal database checks: PIHP, PAHP, PCCM or PCCM entity, any subcontractor, as well as any
Part 1
person with an ownership or control interest, or who is an agent or managing
employee of the MCO, PIHP, PAHP, PCCM or PCCM entity through routine
checks of Federal databases. In the course of the state's federal database
checks, did the state find any person or entity excluded?
Set values (select one)
If in the course of the state's federal database checks the state found any
person or entity excluded, please summarize the instances and whether the
Federal database checks:
entity was notified as required in 438.602(d). Report actions taken, such as
Part 2
plan-level sanctions and corrective actions in Tab D3 as applicable. Enter
N/A if not applicable.
Free text
Website posting of 5
percent or more ownership
control [Y/N]
Website posting of 5
percent or more ownership
control [link]
Periodic audits [link]

Report whether the state posts on its website the names of individuals and
entities with 5% or more ownership or control interest in MCOs, PIHPs,
PAHPs, PCCMs and PCCM entities and subcontractors following §455.104
and required by 42 CFR 438.602(g)(3).
Set values (select one)
If the state posts on its website the names of the plan individuals with 5% or
more ownership or control, under 42 CFR 602(g)(3), provide a link to the
website. Enter N/A if not applicable.
Free text
If the state conducted any audits during the contract year to determine the
accuracy, truthfulness, and completeness of the encounter and financial data
submitted by the plans under 42 CFR 438.602(e), provide the link(s) to the
audit results.
Free text

C1. Program-level, set indicators
#
Indicator
Instructions and definition
Topic I. Program Characteristics and Enrollment
Enter the title and date of the contract between the state and plans
C1.I.1
Program contract
participating in the managed care program.
Enter the hyperlink to the model contract or landing page for executed
C1.I.2
Contract URL
contracts for the program being reported in the MCPAR.

Data format
Free Text
Free Text (hyperlink)

Program type

Select the type of MCPs that contract with the state to provide the services
covered under the program. Select one of the allowed values.

C1.I.4.a

Special program benefits

CMS is interested in knowing whether one or more of the following four
special benefit types are covered by the managed care program: (1)
behavioral health, (2) long-term services and supports, (3) dental, and (4)
transportation, or (5) none of the above. Select one or more of the allowed
Set values (select
values. (Note: Only list the benefit type if it is a covered service as specified multiple)
in a contract between the state and managed care plans participating in the
program. Benefits available to eligible program enrollees via fee-for-service
should not be listed here.)

C1.I.4.b

Variation in special
benefits

Please note any variation in the availability of special benefits within the
program (e.g. by service area or population). Enter "N/A" if not applicable.

C1.I.3

Enter the total number of individuals enrolled in the managed care program
as of the first day of the last month of the reporting year. 
Provide a brief explanation of any major changes to the population enrolled
Changes to enrollment or
in or benefits provided by the managed care program during the reporting
C1.I.6
benefits 
year.
Topic III. Encounter Data Reporting
Federal regulations require that states, through their contracts with MCPs,
collect and maintain sufficient enrollee encounter data to identify the provider
C1.III.1
Uses of encounter data
who delivers any item(s) or service(s) to enrollees (42 CFR 438.242(c)(1)).
Select purposes for which the state uses encounter data collected from
managed care plans (MCPs).

C1.I.5

Program enrollment

Set values (select
one)

Free text
Count
Free text

Set values (select
multiple) or use free
text for "other"
response

C1.III.2

Criteria/ measures used
to evaluate MCP
performance

Federal regulations also require that states validate that submitted enrollee
encounter data they receive is a complete and accurate representation of the
services provided to enrollees under the contract between the state and the
MCO, PIHP, or PAHP. 42 CFR 438.242(d). Select types of measures used
by the state to evaluate managed care plan performance in encounter data
submission and correction.

Set values (select
multiple) or use free
text for "other"
response

C1.III.3

Encounter data
performance criteria
contract language

Enter reference(s) to the contract section(s) that describe the criteria by
which managed care plan performance on encounter data submission and
correction will be measured. Use contract section references, not page
numbers.

Free text

C1.III.4

Financial penalties
contract language

Enter reference to the contract section that describes the types of failures to
meet encounter data submission standards for which states may impose
Free text
financial sanction(s) related to encounter data quality.
Use contract section references, not page numbers.

Input data only in beige cells in this column
[Program]

Incentives for encounter Describe the types of incentives that may be awarded to managed care
data quality
plans for encounter data quality
Barriers to
Describe any barriers to collecting and/or validating managed care plan
C1.III.6
collecting/validating
encounter data that the state has experienced during the reporting period.
encounter data
Topic IV. Grievance, Appeals, and State Fair Hearings
C1.III.5

C1.IV.1

C1.IV.2

C1.IV.3

State's definition of
"critical incident," as used
for reporting purposes in
its MLTSS program

If this report is being completed for a managed care program that covers
LTSS, provide the definition that the state uses for "critical incidents" within
the managed care program. If the managed care program does not cover
LTSS, the state should respond "N/A."
Per 42 CFR §438.408(b)(2), states must establish a timeframe for timely
resolution of standard appeals that is no longer than 30 calendar days from
State definition of "timely" the day the MCO, PIHP or PAHP receives the appeal. Describe the state's
definition of timely resolution for standard appeals in the managed care
resolution for standard
appeals
program.

Free text
Free text

Free text or N/A

Free text

Per 42 CFR §438.408(b)(3), states must establish a timeframe for timely
State definition of "timely" resolution of expedited appeals that is no longer than 72 hours after the
resolution for expedited
MCO, PIHP or PAHP receives the appeal. Describe in the state's definition of
timely resolution for expedited appeals in the managed care program.
appeals
Free text

Per 42 CFR §438.408(b)(1), states must establish a timeframe for timely
resolution of grievances that is no longer than 90 calendar days from the day
State definition of "timely" the MCO, PIHP or PAHP receives the grievance. Describe the state's
resolution for grievances definition of timely resolution for grievances in the managed care program.
Free text
Topic V. Availability, Accessibility, and Network Adequacy
Gaps/challenges in
Describe any challenges to maintaining adequate networks and meeting
C1.V.1
Free text
network adequacy
standards. What are the state’s biggest challenges?
C1.IV.4

C1.V.2

State response to gaps in
Describe how the state works with MCPs to address these gaps.
network adequacy

Topic IX. Beneficiary Support System (BSS)
Indentify the website and/or email address that beneficiaries use to seek
C1.IX.1 BSS website
assistance from the BSS through electronic means.

C1.IX.2

C1.IX.3

BSS auxiliary aids and
services

BSS LTSS program data

State evaluation of BSS
entity performance
Topic X. Program Integrity

C1.IX.4

Free text

Free text

42 CFR 438.71 requires that the beneficiary support system be accessible in
multiple ways including phone, Internet, in-person, and via auxiliary aids and
Free text
services when requested. Describe how BSS entities offer services in a
manner that is accessible to all beneficiaries who need their services,
including beneficiaries with disabilities, as required by 42 CFR 438.71(b)(2)).
Describe how BSS entities assist the state with identifying, remediating, and
resolving systemic issues based on a review of LTSS program data such as
Free text
grievances and appeals or critical incident data, as required by 42 CFR
438.71(d)(4).
Describe steps taken by the state to evaluate the quality, effectiveness, and
Free text
efficiency of the BSS entities' performance.

C1.X.3

Prohibited affiliation
disclosure

Did any plans disclose prohibited affiliations? If the state took action, as
required under 42 CFR 438.610(d), please enter interventions on Tab D3
Sanctions and Corrective Action Plans.

Set values (select
one)

C2. Program-level, state-specific indicators: Availability, accessibility, and network adequacy

Context: Revisions to the Medicaid managed care regulations in 2016 and 2020 built on existing requirements that managed care plans maintain provider networks sufficient to ensure adequate access to covered services by: (1) requiring states to develop quantitative network adequacy standards for at least eight specified provider
types if covered under the contract, and to make these standards available online; (2) strengthening network adequacy monitoring requirements; and (3) addressing the needs of people with long-term care service needs (42 CFR 438.66; 42 CFR 438.68). 42 CFR 438.66(e) specifies that the MCPAR must provide information on
and an assessment of the availability and accessibility of covered services within the MCO, PHIP, or PAHP contracts, including network adequacy standards for each managed care program.
Instructions: Describe the measures the state uses to monitor availability, accessibility, and network adequacy. Report at the program level, with each indicator on a separate row. Select drop downs or enter information in the beige cells in columns B-I >>
Domain or standard type
Data format:

Set values (select one)

Topic V. Availability, Accessibility, and Network Adequacy
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Standard
Free text

Standard type

Provider type

Applicable region(s)

Population

Monitoring methods

Set values (select one) or use free Set values (select one) or use free Set values (select one) or use free Set values (select one) or use free Set values (allow multiple) or use
text for "other" response
text for "other" response
text for "other" response
text for "other" response
free text for "other" response

Frequency of oversight
methods
Set values (select one) or use free
text for "other" response

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D1. Plan-level, set indicators
Instructions and definition
#
Indicator
Topic I: Program Characteristics and Enrollm ent
D1.I.1

Plan enrollment

D1.I.2

Plan share of Medicaid

D1.I.3

Plan share of any Medicaid
managed care

Topic II. Financial Perform ance

D1.II.1a

Medical Loss Ratio (MLR):
Aggregate value

D1.II.1b

Aggregate MLR value: Level of
aggregation

D1.II.2

Population specific MLR
description

MLR reporting period
discrepancies
Topic III. Encounter Data
D1.II.3

Enter total number of individuals enrolled in each plan as of the first day of the last month of
the reporting year  
Sum of enrollment in the plan (w ithin the specific program) as a percentage of total Medicaid
enrollment in the state
• Numerator: Plan enrollment (indicator D1.I.1)
D
i t St t id M di id
ll
t (i di t B I 1)
Sum of enrollment in a given plan (regardless of program) as a percentage of total Medicaid
enrollment in any type of managed care. 
• Numerator: Plan enrollment (indicator D1.I.1)
• Denominator: Statew ide Medicaid managed care enrollment (indicator B I 2)
Per 42 CFR 438.66(e)(2)(i), the Managed Care Program Annual Report must provide
information on the Financial performance of each MCO, PIHP, and PAHP, including MLR
experience. Indicate below in D1.II.1b the level of aggregation of the reported MLR. If MLR
data are not available for this reporting period due to data lags, enter the MLR calculated for
the most recently available reporting period and indicate the reporting period in item D1.II.4
below . See glossary for the regulatory definition of MLR.
As permitted under 42 CFR 438.8(i), states are allow ed to aggregate data for reporting
purposes across programs and populations. Select the aggregation level that best describes
th MLR b i
t d i i di t D1 II 1 f
h l
If the state requires plans to submit separate MLR calculations for specific populations
served w ithin this program, for example, MLTSS or Group VIII expansion enrollees, describe
the populations here. If the state does not require this, w rite "N/A." See glossary for the
regulatory definition of MLR
If the data reported in item D1.II.1a covers a different time period than the MCPAR report, use
this space to note the start and end date for that data

Data form at

Input plan level data in beige cells in these columns >>
[Plan 1]
[Plan 2]

[Plan 3]

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

[Plan 9]

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

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Count
Percentage (calculated)
Note: No data entry
required; this cell is
t
l t d
Percentage (calculated)
Note: No data entry
required; this cell is
autopopulated

Percentage

Set values (select one) or
use free text for "other"

Free text
Free text

D.1.III.1

Definition of timely encounter data
Describe the state's standard for timely encounter data submissions.
submissions

D1.III.2

Share of encounter data
submissions that met state’s
timely submission requirements

Enter the percentage of the plan’s encounter data file submissions (submitted during the
reporting period) that met state requirements for timely submission. If the state has not yet
received any encounter data file submissions for the entire contract period w hen it submits
this report, the state should enter here the percentage of encounter data submissions that
w ere compliant out of the file submissions it has received from the managed care plan for the
reporting period

Percentage

D1.III.3

Share of encounter data
submissions that w ere HIPAA
compliant

Enter the percentage of the plan’s encounter data submissions (submitted during the
reporting period) that met state requirements for HIPAA compliance. If the state has not yet
received encounter data submissions for the entire contract period w hen it submits this
report, enter here percentage of encounter data submissions that w ere compliant out of the
proportion received from the managed care plan for the reporting period.

Percentage

Free text

Topic IV. Grievance, Appeals, and State Fair Hearings
Subtopic: Appeals

D1.IV.1

Appeals resolved (at the plan
level)

D1.IV.2

Active appeals

D1.IV.3

Appeals filed on behalf of LTSS
users

D1.IV.4

Number of critical incidents filed
during the reporting period by (or
on behalf of) an LTSS user w ho
previously filed an appeal

D1.IV.5a

Standard appeals for w hich
timely resolution w as provided

D1.IV.5b

Expedited appeals for w hich
timely resolution w as provided

D1.IV.6a

Appeals related to denial of
authorization or limited
authorization of a service

D1.IV.6b

Appeals related to reduction,
suspension, or termination of a
previously authorized service

Enter the total number of appeals resolved as of the first day of the last month of the
reporting year. An appeal is "resolved" at the plan level w hen the plan has issued a decision,
regardless of w hether the decision w as w holly or partially favorable or adverse to the
beneficiary, and regardless of w hether the beneficiary (or the beneficiary's representative)
chooses to file a request for a State Fair Hearing or External Medical Review .
Enter the total number of appeals still pending or in process (not yet resolved) as of the first
day of the last month of the reporting year
Enter the total number of appeals filed during the reporting year by or on behalf of LTSS
users. An LTSS user is an enrollee w ho received at least one LTSS service at any point
during the reporting year (regardless of w hether the enrollee w as actively receiving LTSS at
the time that the appeal w as filed) If not applicable w rite "N/A "

Count

Count
Count

For managed care plans that cover LTSS, enter the number of critical incidents filed w ithin
the reporting period by (or on behalf of) LTSS users w ho previously filed appeals in the
reporting year. The appeal and critical incident do not have to have been "related" to the same
issue - they only need to have been filed by (or on behalf of) the same enrollee. Neither the
critical incident nor the appeal need to have been filed in relation to delivery of LTSS - they
may have been filed for any reason, related to any service received (or desired) by an LTSS
user. If the managed care plan does not cover LTSS, the state should w rite "N/A" in this
Count
field. Additionally, if the state already submitted this data for the reporting year via the CMS
readiness review appeal and grievance report (because the managed care program or plan
w ere new or serving new populations during the reporting year), and the readiness review
tool w as submitted for at least 6 months of the reporting year, the state can w rite "N/A" in
this field. To calculate this number, states or managed care plans should first identify the
LTSS users for w hom critical incidents w ere filed during the reporting year, then determine
w hether those enrollees had filed an appeal during the reporting year, and w hether the filing
of the appeal preceded the filing of the critical incident.
Enter the total number of standard appeals for w hich timely resolution w as provided by plan
during the reporting period. (See 42 CFR §438.408(b)(2) for requirements related to timely
l ti
f t d d
l )
Enter the total number of expedited appeals for w hich timely resolution w as provided by plan
during the reporting period. (See 42 CFR §438.408(b)(3) for requirements related to timely
resolution of standard appeals )
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's denial of authorization for a service not yet rendered or limited
authorization of a service. (Appeals related to denial of payment for a service already
d d h ld b
t d i i di t D1 IV 6 )
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's reduction, suspension, or termination of a previously authorized service.

Count
Count

Count

Count

D1.IV.6c

Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to payment denial related to the plan's denial, in w hole or in part, of payment for a service that w as already
d d

Count

D1.IV.6d

Appeals related to service
timeliness

Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's failure to provide services in a timely manner (as defined by the state).

Count

D1.IV.6e

Appeals related to lack of timely
plan response to an appeal or
grievance

D1.IV.6f

Appeals related to plan denial of
an enrollee's right to request outof-netw ork care

D1.IV.6g

Appeals related to denial of an
enrollee's request to dispute
financial liability

Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's failure to act w ithin the timeframes provided at 42 CFR §438.408(b)(1)
and (2) regarding the standard resolution of grievances and appeals
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's denial of an enrollee's request to exercise their right, under 42 CFR
§438.52(b)(2)(ii), to obtain services outside the netw ork (only applicable to residents of rural
ith l
MCO)
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to the plan's denial of an enrollee's request to dispute a financial liability.

Num ber of appeals resolved during the reporting period related to the follow ing services:
(A single appeal may be related to multiple service types and may therefore be counted in multiple categories below.)
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to general inpatient care, including diagnostic and laboratory services. Please do not
Appeals related to general
D1.IV.7a
include appeals related to inpatient behavioral health services – those should be included in
inpatient services
indicator D1.IV.7c. If the managed care plan does not cover general inpatient services, enter
"N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to general outpatient care, including diagnostic and laboratory services. Please do not
Appeals related to general
D1.IV.7b
include appeals related to outpatient behavioral health services – those should be included in
outpatient services
indicator D1.IV.7d. If the managed care plan does not cover general outpatient services, enter
"N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to inpatient
D1.IV.7c
related to inpatient mental health and/or substance use services. If the managed care plan
behavioral health services
d
t
i
ti t b h i l h lth
i
t "N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to outpatient
D1.IV.7d
related to outpatient mental health and/or substance use services. If the managed care plan
behavioral health services
d
t
t ti t b h i l h lth
i
t "N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to covered
D1.IV.7e
related to outpatient prescription drugs covered by the managed care plan. If the managed
outpatient prescription drugs
care plan does not cover oupatient prescription drugs enter "N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to skilled nursing
D1.IV.7f
related to SNF services. If the managed care plan does not cover skilled nursing services,
facility (SNF) services
t "N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to long-term
related to institutional LTSS or LTSS provided through home and community-based (HCBS)
D1.IV.7g
services and supports (LTSS)
services, including personal care and self-directed services. If the managed care plan does
not cover LTSS services enter "N/A"
Enter the total number of appeals resolved by the plan during the reporting year that w ere
Appeals related to dental
D1.IV.7h
related to dental services. If the managed care plan does not cover dental services, enter
services
"N/A"
Appeals related to nonEnter the total number of appeals resolved by the plan during the reporting year that w ere
D1.IV.7i
emergency medical transportation
related to NEMT. If the managed care plan does not cover NEMT, enter "N/A".
(NEMT)
D1.IV.7j

Appeals related to other service
types

Enter the total number of appeals resolved by the plan during the reporting year that w ere
related to services that do not fit into one of the categories listed above. If the managed care
plan does not cover services other than those in items D1.IV.7a-i, enter "N/A".

Count

Count

Count
(none)

Count

Count

Count
Count
Count
Count

Count

Count
Count

Count

Subtopic: State Fair Hearings and External Medical Review s By Originating Plan
D1.IV.8a

State Fair Hearing requests

Enter the total number of requests for a State Fair Hearing filed during the reporting year by
or on behalf of enrollees from the plan that issued the adverse benefit determination.

Count

D1.IV.8b

State Fair Hearings resulting in a
favorable decision for the
enrollee

Enter the total number of State Fair Hearing decisions rendered during the reporting year that
w ere partially or fully favorable to the enrollee.

Count

D1.IV.8c

State Fair Hearings resulting in an Enter the total number of State Fair Hearing decisions rendered during the reporting year that
adverse decision for the enrollee w ere adverse for the enrollee.

Count

D1.IV.8d

State Fair Hearings retracted
prior to reaching a decision

D1.IV.9a

External Medical Review s
resulting in a favorable decision
for the enrollee

D1.IV.9b

External Medical Review s
resulting in an adverse decision
for the enrollee

Enter the total number of State Fair Hearing decisions retracted (by the enrollee or the
representative w ho filed a State Fair Hearing request on behalf of the enrollee) prior to
hi
d i i
External medical review is defined and described at 42 CFR §438.402(c)(i)(B). If your state
does not offer an external medical review process, please enter "N/A". If your state does
offer an external medical review process, provide the total number of external medical
review decisions rendered during the reporting year that w ere partially or fully favorable to
th
ll
External medical review is defined and described at 42 CFR §438.402(c)(i)(B). If your state
does not offer an external medical review process, please enter "N/A". If your state does
offer an external medical review process, enter the total number of external medical review
decisions rendered during the reporting year that w ere adverse to the enrollee.

Count

Count or N/A

Count or N/A

Subtopic: Grievances
D1.IV.10

Grievances resolved

D1.IV.11

Active grievances

D1.IV.12

Grievances filed on behalf of
LTSS users

Enter the total number of grievances resolved by the plan during the reporting year. A
grievance is "resolved" w hen it has reached completion and been closed by the plan
Enter the total number of grievances still pending or in process (not yet resolved) as of the
first day of the last month of the reporting year
Enter the total number of grievances filed during the reporting year by or on behalf of LTSS
users. An LTSS user is an enrollee w ho received at least one LTSS service at any point
during the reporting year (regardless of w hether the enrollee w as actively receiving LTSS at
th ti
th t th
i
fil d)

D1.IV.13

Number of critical incidents filed
during the reporting period by (or
on behalf of) an LTSS user w ho
previously filed a grievance

For managed care plans that cover LTSS, enter the number of critical incidents filed w ithin
the reporting period by (or on behalf of) LTSS users w ho previously filed grievances in the
reporting year. The grievance and critical incident do not have to have been "related" to the
same issue - they only need to have been filed by (or on behalf of) the same enrollee.
Neither the critical incident nor the grievance need to have been filed in relation to delivery of
LTSS - they may have been filed for any reason, related to any service received (or desired)
by an LTSS user. If the managed care plan does not cover LTSS, the state should enter
"N/A" in this field. Additionally, if the state already submitted this data for the reporting year
via the CMS readiness review appeal and grievance report (because the managed care
program or plan w ere new or serving new populations during the reporting year), and the
readiness review tool w as submitted for at least 6 months of the reporting year, the state
can enter "N/A" in this field. To calculate this number, states or managed care plans should
first identify the LTSS users for w hom critical incidents w ere filed during the reporting year,
then determine w hether those enrollees had filed an appeal during the reporting year, and
w hether the filing of the appeal preceded the filing of the critical incident.

D1.IV.14

Number of grievances for w hich
timely resolution w as provided

Enter the number of grievances for w hich timely resolution w as provided by plan during the
reporting period. (See 42 CFR §438.408(b)(1) for requirements related to the timely resolution
of grievances )

Num ber of grievances resolved by plan during the reporting period related to the follow ing services:
(A single grievance may be related to multiple service types and may therefore be counted in multiple categories below.)
Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to general inpatient care, including diagnostic and laboratory services. Please do not
D1.IV.15a Grievances related to general
include grievances related to inpatient behavioral health services – those should be included
inpatient services
in indicator D1.IV.15c. If the managed care plan does not cover this type of service, enter
"N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to general outpatient care, including diagnostic and laboratory services. Please do not
D1.IV.15b Grievances related to general
include grievances related to outpatient behavioral health services – those should be included
outpatient services
in indicator D1.IV.15d. If the managed care plan does not cover this type of service, enter
"N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
D1.IV.15c Grievances related to inpatient
related to inpatient mental health and/or substance use services. If the managed care plan
behavioral health services
d
t
thi t
f
i
t "N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
D1.IV.15d Grievances related to outpatient
related to outpatient mental health and/or substance use services. If the managed care plan
behavioral health services
d
t
thi t
f
i
t "N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
D1.IV.15e Grievances related to coverage
related to outpatient prescription drugs covered by the managed care plan. If the managed
of outpatient prescription drugs
care plan does not cover this type of service enter "N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
D1.IV.15f Grievances related to skilled
related to SNF services. If the managed care plan does not cover this type of service, enter
nursing facility (SNF) services
"N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to institutional LTSS or LTSS provided through home and community-based (HCBS)
D1.IV.15g Grievances related to long-term
services and supports (LTSS)
services, including personal care and self-directed services. If the managed care plan does
not cover this type of service enter "N/A"
Enter the total number of grievances resolved by the plan during the reporting year that w ere
D1.IV.15h Grievances related to dental
related to dental services. If the managed care plan does not cover this type of service,
services
t "N/A"
Grievances related to nonD1.IV.15i emergency medical transportation Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to NEMT. If the managed care plan does not cover this type of service, enter "N/A".
(NEMT)
D1.IV.15j

Grievances related to other
service types

Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to services that do not fit into one of the categories listed above. If the managed care
plan does not cover services other than those in items D1.IV.15a-i, enter "N/A".

Num ber of grievances resolved by plan during the reporting period related to the follow ing reasons:
(A single grievance may be related to multiple reasons and may therefore be counted in multiple categories below.)

Count
Count
Count

Count

Count
(none)

Count

Count

Count
Count
Count
Count

Count

Count
Count

Count

(none)

D1.IV.16a Grievances related to plan or
provider customer service

Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to plan or provider customer service. Customer service grievances include complaints
about interactions w ith the plan's Member Services department, provider offices or facilities,
plan marketing agents, or any other plan or provider representatives.

Count

Grievances related to plan or
D1.IV.16b provider care management/case
management

Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to plan or provider care management/case management. Care management/case
management grievances include complaints about the timeliness of an assessment or
complaints about the plan or provider care or case management process.

Count

D1.IV.16c

Grievances related to access to
care/services from plan or
provider

Enter the total number of grievances resolved by the plan during the reporting year that w ere
Count
related to access to care. Access to care grievances include complaints about difficulties
finding qualified in-netw ork providers, excessive travel or w ait times, or other access issues.

D1.IV.16d Grievances related to quality of
care

Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to quality of care. Quality of care grievances include complaints about the
effectiveness, efficiency, equity, patient-centeredness, safety, and/or acceptability of care
provided by a provider or the plan

Count

D1.IV.16e Grievances related to plan
communications

Enter the total number of grievances resolved by the plan during the reporting year that w ere
related to plan communications. Plan communication grievances include grievances related to
the clarity or accuracy of enrollee materials or other plan communications or to an enrollee's
access to or the accessibility of enrollee materials or plan communications.

Count

Grievances related to payment or
billing issues

Enter the total number of grievances resolved during the reporting period that w ere filed for a
reason related to payment or billing issues

Count

D1.IV.16g Grievances related to suspected
fraud

Enter the total number of grievances resolved during the reporting year that w ere related to
suspected fraud. Suspected fraud grievances include suspected cases of financial/payment
fraud perpetuated by a provider, payer, or other entity. Note: grievances reported in this row
should only include grievances submitted to the managed care plan, not grievances submitted
to another entity, such as a state Ombudsman or Office of the Inspector General.

Count

D1.IV.16h Grievances related to abuse,
neglect or exploitation

Enter the total number of grievances resolved during the reporting year that w ere related to
abuse, neglect or exploitation. Abuse/neglect/exploitation grievances include cases involving
potential or actual patient harm

Count

D1.IV.16f

D1.IV.16i

D1.IV.16j

Grievances related to lack of
timely plan response to a service
authorization or appeal request
(including requests to expedite or
extend appeals)
Grievances related to plan denial
of request for an expedited
appeal

Grievances filed for other
reasons
Topic X. Program Integrity
D1.IV.16k

D1.X.1

Dedicated program integrity staff

D1.X.2

Count of opened program
integrity investigations

D1.X.3

Ratio of opened program integrity
investigations

D1.X.4

Count of resolved program
integrity investigations
Ratio of resolved program
integrity investigations

D1.X.5

D1.X.6

Referral path for program
integrity referrals to the state

Enter the total number of grievances resolved during the reporting year that w ere filed due to
a lack of timely plan response to a service authorization or appeal request (including requests Count
to expedite or extend appeals).
Enter the total number of grievances resolved during the reporting year that w ere related to
the plan's denial of an enrollee's request for an expedited appeal. (Per 42 CFR
§438.408(b)(3), states must establish a timeframe for timely resolution of expedited appeals
Count
that is no longer than 72 hours after the MCO, PIHP or PAHP receives the appeal. If a plan
denies a request for an expedited appeal, the enrollee or their representative have the right to
fil
i
)
Enter the total number of grievances resolved during the reporting period that w ere filed for a Count
reason other than the reasons listed above
Report the number of dedicated program integrity staff for routine internal monitoring and
compliance risks as required under 42 CFR 438 608(a)(1)(vii)

Count

Enter the count of program integrity investigations opened by the plan in the past year.

Count

Enter the ratio of program integrity investigations opened by the plan in the past year per
1,000 beneficiaries enrolled in the plan on the first day of the last month of the reporting year.

Ratio

Enter the count of program integrity investigations resolved by the plan in the past year.

Count

Enter the ratio of program integrity investigations resolved by the plan in the past year per
1 000 beneficiaries enrolled in the plan at the beginning of the reporting year
Select the referral path that the plan uses to make program integrity referrals to the state:
· If the plan makes referrals to the Medicaid Fraud Control Unit (MFCU) only.
· If the plan makes referrals to the State Medicaid Agency (SMA) and MFCU concurrently.
· If the plan makes some referrals to the SMA and others directly to the MFCU

Ratio

Set value (select one)

D1.X.7

Count of program integrity
referrals to the state

Enter the count of program integrity referrals that the plan made to the state in the past year
using the referral path selected in indicator D1.X.6
· If the plan makes referrals to the MFCU only, enter the count of referrals made.
Count
· If the plan makes referrals to the SMA and MFCU concurrently, enter the count of
unduplicated referrals.
· If the plan makes some referrals to the SMA and others directly to the MFCU, enter the count
of referrals made to the SMA and the MFCU in aggregate

D1.X.8

Ratio of program integrity
referrals to the state

Enter the ratio of program integrity referrals listed in indicator D1.X.7 made to the state in the
past year per 1,000 beneficiaries, using the plan's total enrollment as of the first day of the
last month of the reporting year (reported in indicator D1.I.1) as the denominator.

D1.X.9

Summarize the plan’s latest annual overpayment recovery report submitted to the state as
required under 42 CFR 438.608(d)(3). Include, for example, the follow ing information:
Plan overpayment reporting to the · The date of the report (rating period or calendar year).
state
· The dollar amount of overpayments recovered.
· The ratio of the dollar amount of overpayments recovered as a percent of premium revenue
as defined in MLR reporting under 438.8(f)(2).

Free text

D1.X.10

Changes in beneficiary
circumstances

Set values (select one)

Select the frequency the plan reports changes in beneficiary circumstances to the state.

Ratio

D2. Plan-level, state-specific indicators: Quality and Performance Measures
Context: Per 42 CFR 438.66(e)(2)(v ii), the Managed Care Program Annual Report must prov ide inf ormation on and an assessment of the operation of the managed care program including ev aluation of MCO, PIHP, or
PAHP perf ormance on quality measures, including as applicable, consumer report card, surv ey s, or other reasonable measures of perf ormance.
Describe the measures the state uses to monitor quality and perf ormance by selecting drop downs or entering inf ormation in the beige cells in columns A-G. Consider measures in each of the f ollowing eight domains: (1)
Primary care access and prev entiv e care, (2) Maternal and perinatal health, (3) Care of acute and chronic conditions, (4) Behav ioral health care, (5) Dental and oral health serv ices, (6) Health plan enrollee experience of
care, (7) Long-term serv ices and supports, and (8) Other. Report one row per measure. Note: if no measures are reported in a particular domain, list "N/A" under that domain. If the state does not hav e data av ailable ov er
the time period with which it is requested in the MCPAR use the most recent data av ailable and note the reporting period that the data cov er
Measure
reporting
If measure reporting is
(programMeasure set
Measure description
Domain
NQF #
Measure name
cross-program, list which
specific or
programs
cross-

Input plan-lev el measure v alues in beige cells in these columns >>

[Plan 1]

[Plan 2]

[Plan 3]

[Plan 4]

[Plan 5]

[Plan 6]

[Plan 7]

[Plan 8]

[Plan 9]

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

[Plan 10]

[Plan 11]

[Plan 12]

[Plan 13]

[Plan 14]

[Plan 15]

[Plan 16]

[Plan 17]

[Plan 18]

[Plan 19]

[Plan 20]

[Plan 21]

[Plan 22]

[Plan 23]

[Plan 24]

[Plan 25]

[Plan 26]

[Plan 27]

[Plan 28]

[Plan 29]

[Plan 30]

[Plan 31]

[Plan 32]

[Plan 33]

[Plan 34]

[Plan 35]

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

Free text

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program)

Set v alues (select one) or use f ree
text f or "other" response

Free
text

Topic VII. Quality and Performance Measures
Primary care access and
ti
M t
l d
i t l h lth
Care of acute and chronic
diti
Behav ioral health care
Dental and oral health serv ices
Health plan enrollee experience of
care
Long term serv ices and supports
Other (f ree text specif y )

Free text

Set v alues
(select one)

Free text

Set v alues (select
one) or use f ree
text f or "other"
response

Free text. For measures that are not part of standardized
national measure sets (i.e. state-specif ic measures), states
should prov ide a description of the measure (f or example,
numerator and denominator)

D3. Plan-level, state-specific indicators: Sanctions and Corrective Action Plans
Context: 42 CFR 438.66(e)(2)(viii) specifies that the MCPAR include the results of any sanctions or corrective action plans imposed by the State or other formal or informal intervention with a contracted MCO, PIHP, PAHP, or PCCM entity to improve performance.
Describe sanctions and corrective action plans that the state has issued to the plan by selecting drop downs or entering information in the beige cells in columns A-J. Report all known actions across the following domains: sanctions, administrative penalties, corrective action plans, other.
Use one row per action.

Domain
Intervention type
Set values (select one)
Set values (select one) or use free
or use free text for
text for "other" response
"other" response
Topic VIII. Sanctions and Corrective Action Plans

Intervention topic
Set values (select
multiple) or use free text
for "other" response

Plan name
Set values (select one)
Note: list will autopopulate with
plan names listed on the cover

Reason for intervention

Instances (#) of
noncompliance

Amount

Date assessed

Remediation date
non-compliance
was corrected

Free text

Count

Dollar

Date
(MM/DD/YYYY)

Date
(MM/DD/YYYY)

Has plan had CAP or
had an intervention for
similar reasons within
the previous two years
Set values (select one)

E. Beneficiary support system (BSS) entities, set indicators
Context: Per 42 CFR 438.66(e)(2)(ix), the Managed Care Program Annual Report must provide information on and an assessment of
the operation of the managed care program including activities and performance of the beneficiary support system. Information on how
BSS entities support program-level functions is reported in tab C1, Topic IX.
#
Indicator
Topic IX. Beneficiary Support System

Instructions and definition

Data format

E.IX.1

BSS entity type

Select type of entity contracted to perform each BSS activity specified at 42
CFR 438.71(b).

Set values (select
multiple) or use
free text for
"other" response

E.IX.2

BSS entity role

Select roles that the contracted BSS entity performs, specified at 42 CFR
438.71(b).

Set values (select
multiple) or use
free text for
"other" response

Input data in the beige cells in these columns >>
[BSS Entity 1]
[BSS Entity 2]
[BSS Entity 3]

[BSS Entity 4]

[BSS Entity 5]

[BSS Entity 6]

[BSS Entity 7]

[BSS Entity 8]

[BSS Entity 9]

[BSS Entity 10]

Glossary

This tab defines key terms used in the workbook. DO NOT INPUT INFORMATION INTO THIS TAB.
Term
Beneficiary Support
System

Acronym
BSS

Definition/ specification
As defined at 42 CFR 438.71, a BSS provides support to beneficiaries both prior to and after enrollment in a MCO, PIHP, PAHP, PCCM or PCCM entity. The BSS must
provide at a minimum: (i) Choice counseling for all beneficiaries, (ii) Assistance for enrollees in understanding managed care. (iii) Assistance as specified for enrollees who
use, or express a desire to receive, LTSS in paragraph (d) of this section. (2) The beneficiary support system must perform outreach to beneficiaries and/or authorized
representatives and be accessible in multiple ways including phone, Internet, in-person, and via auxiliary aids and services when requested....(d) Functions specific to LTSS
activities: (1) An access point for complaints and concerns about plan enrollment, access to covered services, and other related matters. (2) Education on enrollees'
grievance and appeal rights; the State fair hearing process; enrollee rights and responsibilities; and additional resources outside of the MCO, PIHP or PAHP. (3) Assistance,
upon request, in navigating the plan grievance and appeal process, as well as appealing adverse benefit determinations by a plan to a State fair hearing. (4) Review and
oversight of LTSS program data to provide guidance to the State Medicaid Agency on identification, remediation and resolution of systemic issues.

Corrective action plan

CAP

A corrective action plan is a step by step plan of action that is developed to achieve targeted outcomes for resolution of identified errors in an effort to: (1) identify the most
cost-effective actions that can be implemented to correct error causes; (2) develop and implement a plan of action to improve processes or methods so that outcomes are
more effective and efficient; (3) achieve measureable improvement in the highest priority areas; and (4) eliminate repeated deficient practices.

Critical incident

--

CMS uses the term "critical incident" to refer to events that adversely impact enrollee health and welfare and the achievement of quality outcomes identified in the
person centered plan. However, the exact definition of "critical incident" and the categories that managed care plans are required to report is defined by each state.

Encounter data validation --

LTSS user

--

Managed care
organization

MCO

Managed care plan
Managed care program

MCP
--

Managed long-term
services and supports
Medical Loss Ratio

MLTSS
MLR

Non-emergency medical NEMT
transportation
Premium deficiency
PDR
reserve
Prepaid ambulatory
PAHP
health plan
Prepaid inpatient health
plan

PIHP

Primary care case
management

PCCM

The act of verifying the accuracy, completeness, timeliness, and/or consistency of encounter data records submitted to the state by Medicaid managed care plans. Validation
steps may include pre-acceptance edits and post-acceptance analyses. See the 2019 State Toolkit for Validating Medicaid Encounter Data for examples of intrafield,
interfield, interfile and intersource validation tests that states can use to evaluate encounter data quality. The toolkit is available at:
https://www.medicaid.gov/medicaid/downloads/ed-validation-toolkit.pdf.
An LTSS user is an enrollee who received at least one LTSS service at any point during the reporting year (regardless of whether the enrollee was actively receiving LTSS
at the time that the grievance was filed).
Consistent with 42 CFR 438.2, Managed care organization (MCO) means an entity that has, or is seeking to qualify for, a comprehensive risk contract under this part, and
that is (1) A Federally qualified HMO that meets the advance directives requirements of subpart I of part 489 of this chapter; or (2) Any public or private entity that meets the
advance directives requirements and is determined by the Secretary to also meet the following conditions: (i) Makes the services it provides to its Medicaid enrollees as
accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid beneficiaries within the area served by the entity, (ii) Meets the
solvency standards of § 438.116.
Consistent with 42 CFR 438.66, this document uses the term “managed care plan” to refer to MCO, PIHP, PAHP, and PCCM entities
Consistent with 42 CFR 438.2, Managed care program means a managed care delivery system operated by a State as authorized under sections 1915(a), 1915(b), 1932(a),
or 1115(a) of the Act. For purposes of the MCPAR, a program is defined by a specified set of benefits and eligibilty criteria that is articulated in a contract between the state
and managed care plans, and that has associated rate cells.
Managed Long Term Services and Supports (MLTSS) refers to the delivery of long term services and supports through capitated Medicaid managed care programs.
As specified under 42 CFR 438.8(d)-(h), MLR is the sum of an MCP’s incurred claims, quality expenditures, and fraud prevention expenditures divided by its adjusted
premium revenue. The MCP’s adjusted premium revenue is its aggregated premium revenue minus taxes, licensing, and regulatory fees. For states that mandate minimum
MLR values for MCPs, minimum values must be at least 85 percent under 42 CFR 438.8(c).
Medicaid agencies are reqired to ensure necessary transportation for beneficiaries to and from providers. For situations that do not involve an immediate threat to the life or
health of an individual, this requirement is usually called “non-emergency medical transportation,” or NEMT.
Premium deficiency reserve (PDR) indicates whether future premiums plus current reserves are enough to cover future claim payments and expenses for the remainder of a
contract period.
Consistent with 42 CFR 438.2, Prepaid ambulatory health plan (PAHP) means an entity that (1) Provides services to enrollees under contract with the State, and on the
basis of capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Does not provide or arrange for, and is not otherwise responsible
for the provision of any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract.
Consistent with 42 CFR 438.2, Prepaid inpatient health plan (PIHP) means an entity that (1) Provides services to enrollees under contract with the State, and on the basis of
capitation payments, or other payment arrangements that do not use State plan payment rates; (2) Provides, arranges for, or otherwise has responsibility for the provision of
any inpatient hospital or institutional services for its enrollees; and (3) Does not have a comprehensive risk contract.
Consistent with 42 CFR 438.2, Primary care case management means a system under which: (1) A primary care case manager (PCCM) contracts with the State to furnish
case management services (which include the location, coordination and monitoring of primary health care services) to Medicaid beneficiaries; or (2) A PCCM entity
contracts with the State to provide a defined set of functions.

Primary care case
management entity

PCCM entity Consistent with 42 CFR 438.2, Primary care case management entity (PCCM entity) means an organization that provides any of the following functions, in addition to primary
care case management services, for the State: (1) Provision of intensive telephonic or face-to-face case management, including operation of a nurse triage advice line; (2)
Development of enrollee care plans; (3) Execution of contracts with and/or oversight responsibilities for the activities of FFS providers in the FFS program; (4) Provision of
payments to FFS providers on behalf of the State; (5) Provision of enrollee outreach and education activities; (6) Operation of a customer service call center; (7) Review of
provider claims, utilization and practice patterns to conduct provider profiling and/or practice improvement; (8) Implementation of quality improvement activities including
administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers; (9) Coordination with behavioral health
systems/providers; (10) Coordination with long-term services and supports systems/providers.

Reporting period
/Reporting year
Risk-based capital

--

The 12-month period of the contract term (i.e. the contract year) for which the state is reporting information to CMS. Reporting year may also correspond to “rating period.”

RBC

Risk-based capital (RBC) measures the percentage of the required minimum capital that the MCP is holding. The MCP’s minimum capital is calculated using a standard
formula that measures the risk of insolvency.
Sanctions are enforcement actions taken against a managed care plans. Such actions include monetary and other forms of remedies, such as suspending all or part of new
member enrollments, and suspending or terminating all or part of the contract.

Sanction

Crosswalk of MCPAR indicators by tab
A
Cover
sheet
Set
Indicator type* 
Tab identifier 

Reporting level 
#

n/a
n/a
n/a
n/a
n/a
I

Indicator

Instructions and definition

Identifying information on the state, program, plan, and BSS being reported

C2

D1

Set

Free

Set

X
X

B.I.1

Statewide Medicaid enrollment

B.I.2

Statewide Medicaid managed care
enrollment

Enter the total, unduplicated number of individuals enrolled in any type of Medicaid
managed care as of the first day of the last month of the reporting year. Include enrollees
in all programs, and count each person only once, even if they are enrolled in more than
one managed care program or more than one managed care plan.

C1.I.1

Program contract

C1.I.2

Contract URL

C1.I.3

Program type

C1.I.4.a

Special program benefits

C1.I.4.b

Variation in special benefits

C1.I.5

Program enrollment

C1.I.6

Changes to enrollment or benefits 

D1.I.1

Plan enrollment

Count

X

X

X

Free Text

X

Free Text (hyperlink)

X

Set values (select one)

X

Set values (select multiple)

X

Free text

X

Count

X

Free text

X

X

Count

X

Percentage (calculated)
Note: No data entry required; this cell
is autopopulated

X

Percentage (calculated)
Note: No data entry required; this cell
is autopopulated

X

D1.I.2

Plan share of Medicaid

D1.I.3

Plan share of any Medicaid managed
care

II

Financial Performance

D1.II.1a

Per 42 CFR 438.66(e)(2)(i), the Managed Care Program Annual Report must provide
information on the Financial performance of each MCO, PIHP, and PAHP, including MLR
Medical Loss Ratio (MLR): Aggregate experience. Indicate below in D1.II.1b the level of aggregation of the reported MLR. If
Percentage
value
MLR data are not available for this reporting period due to data lags, enter the MLR
calculated for the most recently available reporting period and indicate the reporting period
in item D1.II.4 below. See glossary for the regulatory definition of MLR.

D1.II.1b

Aggregate MLR value: Level of
aggregation

X

Set values (select one) or use free text
for "other" response

D2

D3

Plan-level

X
X
X
X

Enter the total number of individuals enrolled in Medicaid as of the first day of the last
month of the reporting year. Include all FFS and managed care enrollees, and count each Count
person only once, regardless of the delivery system(s) in which they are enrolled.

As permitted under 42 CFR 438.8(i), states are allowed to aggregate data for reporting
purposes across programs and populations. Select the aggregation level that best
describes the MLR being reported in indicator D1.II.1a for each plan.

C1

Program-level

Data format

Point of contact and email address
(see Tab A)
Date of report submission
(see Tab A)
Reporting period start and end date
(see Tab A)
Name of the state, program, plans,
(see Tab A)
and BSS entities being reported on
Program Characteristics and Enrollment**

Enter the title and date of the contract between the state and plans participating in the
managed care program.
Enter the hyperlink to the model contract or landing page for executed contracts for the
program being reported in the MCPAR.
Select the type of MCPs that contract with the state to provide the services covered under
the program. Select one of the allowed values.
CMS is interested in knowing whether one or more of the following four special benefit
types are covered by the managed care program: (1) behavioral health, (2) long-term
services and supports, (3) dental, and (4) transportation, or (5) none of the above. Select
one or more of the allowed values. (Note: Only list the benefit type if it is a covered
service as specified in a contract between the state and managed care plans participating
in the program. Benefits available to eligible program enrollees via fee-for-service should
not be listed here.)
Please note any variation in the availability of special benefits within the program (e.g. by
service area or population). Enter "N/A" if not applicable.
Enter the total number of individuals enrolled in the managed care program as of the first
day of the last month of the reporting year. 
Provide a brief explanation of any major changes to the population enrolled in or benefits
provided by the managed care program during the reporting year.
Enter total number of individuals enrolled in each plan as of the first day of the last month
of the reporting year. 
Sum of enrollment in the plan (within the specific program) as a percentage of total
Medicaid enrollment in the state
• Numerator: Plan enrollment (indicator D1.I.1)
• Denominator: Statewide Medicaid enrollment (indicator B.I.1)
Sum of enrollment in a given plan (regardless of program) as a percentage of total
Medicaid enrollment in any type of managed care. 
• Numerator: Plan enrollment (indicator D1.I.1)
• Denominator: Statewide Medicaid managed care enrollment (indicator B.I.2)

B
Statelevel
Set

X

X

Free

E
BSSlevel
Set

D1.II.2

Population specific MLR description

If the state requires plans to submit separate MLR calculations for specific populations
served within this program, for example, MLTSS or Group VIII expansion enrollees,
describe the populations here. If the state does not require this, write "N/A." See glossary
for the regulatory definition of MLR.
If the data reported in items D1.II.1a covers a different time period than the MCPAR
report, use this space to note the start and end date for that data.

Free text

X

D1.II.3

MLR reporting period discrepancies

III

Encounter Data Reporting

B.III.1

Data validation entity

B.III.2

HIPAA compliance of proprietary
If state selected “proprietary system(s)” in indicator B.III.1, indicate whether the system(s)
system(s) for encounter data validation utilized are fully HIPAA compliant.

C1.III.1

Uses of encounter data

Federal regulations require that states, through their contracts with MCPs, collect and
maintain sufficient enrollee encounter data to identify the provider who delivers any item(s) Set values (select multiple) or use free
text for "other" response
or service(s) to enrollees (42 CFR 438.242(c)(1)). Select purposes for which the state
uses encounter data collected from managed care plans (MCPs).

X

C1.III.2

Criteria/ measures used to evaluate
MCP performance

Federal regulations also require that states validate that submitted enrollee encounter
data they receive is a complete and accurate representation of the services provided to
enrollees under the contract between the state and the MCO, PIHP, or PAHP. 42 CFR
438.242(d). Select types of measures used by the state to evaluate managed care plan
performance in encounter data submission and correction.

Set values (select multiple) or use free
text for "other" response

X

C1.III.3

Encounter data performance criteria
contract language

Free text

X

C1.III.4

Financial penalties contract language

Free text

X

Free text

X

Free text

X

C1.III.5
C1.III.6
D.1.III.1

Incentives for encounter data quality
Barriers to collecting/validating
encounter data
Definition of timely encounter data
submissions

Free text

Select the state agency/division or contractor) tasked with evaluating the validity of
encounter data submitted by MCPs. Encounter data validation includes verifying the
Set values (select multiple) or use free
accuracy, completeness, timeliness, and/or consistency of encounter data records
submitted to the state by Medicaid managed care plans. Validation steps may include pre- text for "other" response
acceptance edits and post-acceptance analyses. (See Glossary defintion for more
information.)

Enter reference(s) to the contract section(s) that describe the criteria by which managed
care plan performance on encounter data submission and correction will be measured.
Use contract section references, not page numbers.
Enter reference to the contract section that describes the types of failures to meet
encounter data submission standards for which states may impose financial sanction(s)
related to encounter data quality.
Use contract section references, not page numbers.
Describe the types of incentives that may be awarded to managed care plans for
encounter data quality
Describe any barriers to collecting and/or validating managed care plan encounter data
that the state has experienced during the reporting period.
Describe the state's standard for timely encounter data submissions.

Set values (select one)

X
X

X

X

X

Free text

X

D1.III.2

Share of encounter data submissions
that met state’s timely submission
requirements

Enter the percentage of the plan’s encounter data file submissions (submitted during the
reporting period) that met state requirements for timely submission. If the state has not yet
received any encounter data file submissions for the entire contract period when it submits
Percentage
this report, the state should enter here the percentage of encounter data submissions that
were compliant out of the file submissions it has received from the managed care plan for
the reporting period.

D1.III.3

Share of encounter data submissions
that were HIPAA compliant

Enter the percentage of the plan’s encounter data submissions (submitted during the
reporting period) that met state requirements for HIPAA compliance. If the state has not
yet received encounter data submissions for the entire contract period when it submits this Percentage
report, enter here percentage of encounter data submissions that were compliant out of
the proportion received from the managed care plan for the reporting period.

IV

Grievance, Appeals, and State Fair Hearings

X

C1.IV.1

State's definition of "critical incident,"
as used for reporting purposes in its
MLTSS program

X

C1.IV.2

C1.IV.3

State definition of "timely" resolution
for standard appeals

State definition of "timely" resolution
for expedited appeals

If this report is being completed for a managed care program that covers LTSS, provide
the definition that the state uses for "critical incidents" within the managed care program. If
the managed care program does not cover LTSS, the state should respond "N/A."
Free text or N/A
Per 42 CFR §438.408(b)(2), states must establish a timeframe for timely resolution of
standard appeals that is no longer than 30 calendar days from the day the MCO, PIHP or
PAHP receives the appeal. Describe the state's definition of timely resolution for standard
appeals in the managed care program.
Free text
Per 42 CFR §438.408(b)(3), states must establish a timeframe for timely resolution of
expedited appeals that is no longer than 72 hours after the MCO, PIHP or PAHP receives
the appeal. Describe in the state's definition of timely resolution for expedited appeals in
the managed care program.
Free text

X

X

X

X

X

X

C1.IV.4

State definition of "timely" resolution
for grievances

Per 42 CFR §438.408(b)(1), states must establish a timeframe for timely resolution of
grievances that is no longer than 90 calendar days from the day the MCO, PIHP or PAHP
receives the grievance. Describe the state's definition of timely resolution for grievances in
the managed care program.
Free text

X

Subtopic: Appeals

D1.IV.1

D1.IV.2
D1.IV.3

D1.IV.4

D1.IV.5a
D1.IV.5b

D1.IV.6a

D1.IV.6b
D1.IV.6c
D1.IV.6d

Enter the total number of appeals resolved as of the first day of the last month of the
reporting year. An appeal is "resolved" at the plan level when the plan has issued a
decision, regardless of whether the decision was wholly or partially favorable or adverse
Appeals resolved (at the plan level)
to the beneficiary, and regardless of whether the beneficiary (or the beneficiary's
representative) chooses to file a request for a State Fair Hearing or External Medical
Review.
Enter the total number of appeals still pending or in process (not yet resolved) as of the
Active appeals
first day of the last month of the reporting year.
Enter the total number of appeals filed during the reporting year by or on behalf of LTSS
users. An LTSS user is an enrollee who received at least one LTSS service at any point
Appeals filed on behalf of LTSS users
during the reporting year (regardless of whether the enrollee was actively receiving LTSS
at the time that the appeal was filed). If not applicable, write "N/A."

Count

X

Count

X

Count

X

For managed care plans that cover LTSS, enter the number of critical incidents filed within
the reporting period by (or on behalf of) LTSS users who previously filed appeals in the
reporting year. The appeal and critical incident do not have to have been "related" to the
same issue - they only need to have been filed by (or on behalf of) the same enrollee.
Neither the critical incident nor the appeal need to have been filed in relation to delivery of
LTSS - they may have been filed for any reason, related to any service received (or
Number of critical incidents filed during desired) by an LTSS user. If the managed care plan does not cover LTSS, the state
the reporting period by (or on behalf of) should write "N/A" in this field. Additionally, if the state already submitted this data for the
Count or N/A
an LTSS user who previously filed an reporting year via the CMS readiness review appeal and grievance report (because the
appeal
managed care program or plan were new or serving new populations during the reporting
year), and the readiness review tool was submitted for at least 6 months of the reporting
year, the state can write "N/A" in this field. To calculate this number, states or managed
care plans should first identify the LTSS users for whom critical incidents were filed during
the reporting year, then determine whether those enrollees had filed an appeal during the
reporting year, and whether the filing of the appeal preceded the filing of the critical
incident.
Enter the total number of standard appeals for which timely resolution was provided by
plan during the reporting period. (See 42 CFR §438.408(b)(2) for requirements related to
timely resolution of standard appeals.)
Enter the total number of expedited appeals for which timely resolution was provided by
Expedited appeals for which timely
plan during the reporting period. (See 42 CFR §438.408(b)(3) for requirements related to
resolution was provided
timely resolution of standard appeals.)
Enter the total number of appeals resolved by the plan during the reporting year that were
Appeals related to denial of
related to the plan's denial of authorization for a service not yet rendered or limited
authorization or limited authorization of
authorization of a service. (Appeals related to denial of payment for a service already
a service
rendered should be counted in indicator D1.IV.6c)
Appeals related to reduction,
Enter the total number of appeals resolved by the plan during the reporting year that were
suspension, or termination of a
related to the plan's reduction, suspension, or termination of a previously authorized
previously authorized service
service.
Enter the total number of appeals resolved by the plan during the reporting year that were
Appeals related to payment denial
related to the plan's denial, in whole or in part, of payment for a service that was already
rendered.
Enter the total number of appeals resolved by the plan during the reporting year that were
Appeals related to service timeliness related to the plan's failure to provide services in a timely manner (as defined by the
state).
Standard appeals for which timely
resolution was provided

X

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

D1.IV.6e

Appeals related to lack of timely plan
response to an appeal or grievance

Enter the total number of appeals resolved by the plan during the reporting year that were
Count
related to the plan's failure to act within the timeframes provided at 42 CFR
§438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals.

X

D1.IV.6f

Appeals related to plan denial of an
enrollee's right to request out-ofnetwork care

Enter the total number of appeals resolved by the plan during the reporting year that were
related to the plan's denial of an enrollee's request to exercise their right, under 42 CFR
Count
§438.52(b)(2)(ii), to obtain services outside the network (only applicable to residents of
rural areas with only one MCO)

X

Appeals related to denial of an
Enter the total number of appeals resolved by the plan during the reporting year that were
Count
enrollee's request to dispute financial
related to the plan's denial of an enrollee's request to dispute a financial liability.
liability
pp
g
p
gp
g
(A single appeal may be related to multiple service types and may therefore be counted in multiple categories below.)

D1.IV.6g

X
X

Enter the total number of appeals resolved by the plan during the reporting year that were
related to general inpatient care, including diagnostic and laboratory services. Please do
Count
not include appeals related to inpatient behavioral health services – those should be
included in indicator D1.IV.7c. If the managed care plan does not cover general inpatient
services, enter "N/A".
Enter the total number of appeals resolved by the plan during the reporting year that were
related to general outpatient care, including diagnostic and laboratory services. Please do
Count
not include appeals related to outpatient behavioral health services – those should be
included in indicator D1.IV.7d. If the managed care plan does not cover general outpatient
services, enter "N/A".

D1.IV.7a

Appeals related to general inpatient
services

D1.IV.7b

Appeals related to general outpatient
services

D1.IV.7c

Enter the total number of appeals resolved by the plan during the reporting year that were
Appeals related to inpatient behavioral
related to inpatient mental health and/or substance use services. If the managed care plan Count
health services
does not cover inpatient behavioral health services, enter "N/A".

X

D1.IV.7d

Appeals related to outpatient
behavioral health services

Enter the total number of appeals resolved by the plan during the reporting year that were
Count
related to outpatient mental health and/or substance use services. If the managed care
plan does not cover outpatient behavioral health services, enter "N/A".

X

D1.IV.7e

Appeals related to covered outpatient
prescription drugs

Enter the total number of appeals resolved by the plan during the reporting year that were
related to outpatient prescription drugs covered by the managed care plan. If the managed Count
care plan does not cover oupatient prescription drugs, enter "N/A".

X

D1.IV.7f

Appeals related to skilled nursing
facility (SNF) services

D1.IV.7g

Appeals related to long-term services
and supports (LTSS)

D1.IV.7h

Appeals related to dental services

D1.IV.7i

Appeals related to non-emergency
medical transportation (NEMT)

Enter the total number of appeals resolved by the plan during the reporting year that were
Count
related to NEMT. If the managed care plan does not cover NEMT, enter "N/A".

X

D1.IV.7j

Enter the total number of appeals resolved by the plan during the reporting year that were
Count
Appeals related to other service types related to services that do not fit into one of the categories listed above. If the managed
care plan does not cover services other than those in items D1.IV.7a-i, enter "N/A".

X

Subtopic: State Fair Hearings and External Medical Reviews By Originating Plan

X

D1.IV.8a
D1.IV.8b
D1.IV.8c

State Fair Hearing requests
State Fair Hearings resulting in a
favorable decision for the enrollee
State Fair Hearings resulting in an
adverse decision for the enrollee

D1.IV.8d

State Fair Hearings retracted prior to
reaching a decision

D1.IV.9a

External Medical Reviews resulting in
a favorable decision for the enrollee

D1.IV.9b

External Medical Reviews resulting in
an adverse decision for the enrollee

Enter the total number of appeals resolved by the plan during the reporting year that were
related to SNF services. If the managed care plan does not cover skilled nursing services, Count
enter "N/A".
Enter the total number of appeals resolved by the plan during the reporting year that were
related to institutional LTSS or LTSS provided through home and community-based
Count
(HCBS) services, including personal care and self-directed services. If the managed care
plan does not cover LTSS services, enter "N/A".
Enter the total number of appeals resolved by the plan during the reporting year that were
related to dental services. If the managed care plan does not cover dental services, enter Count
"N/A".

Enter the total number of requests for a State Fair Hearing filed during the reporting year
by or on behalf of enrollees from the plan that issued the adverse benefit determination.

Grievances resolved

X

X

X

X

Count

X

Count

X

Count

X

Count

X

Count or N/A

X

External medical review is defined and described at 42 CFR §438.402(c)(i)(B). If your
state does not offer an external medical review process, please enter N/A. If your state
Count or N/A
does offer an external medical review process, enter the total number of external medical
review decisions rendered during the reporting year that were adverse to the enrollee.

X

Enter the total number of State Fair Hearing decisions rendered during the reporting year
that were partially or fully favorable to the enrollee.
Enter the total number of State Fair Hearing decisions rendered during the reporting year
that were adverse for the enrollee.
Enter the total number of State Fair Hearing decisions retracted (by the enrollee or the
representative who filed a State Fair Hearing request on behalf of the enrollee) prior to
reaching a decision
External medical review is defined and described at 42 CFR §438.402(c)(i)(B). If your
state does not offer an external medical review process, please enter N/A. If your state
does offer an external medical review process, provide the total number of external
medical review decisions rendered during the reporting year that were partially or fully
favorable to the enrollee.

X

Subtopic: Grievances
D1.IV.10

X

Enter the total number of grievances resolved by the plan during the reporting year. A
grievance is "resolved" when it has reached completion and been closed by the plan.

Count

X

Enter the total number of grievances still pending or in process (not yet resolved) as of the
Count
first day of the last month of the reporting year.
Enter the total number of grievances filed during the reporting year by or on behalf of
LTSS users. An LTSS user is an enrollee who received at least one LTSS service at any
Count
point during the reporting year (regardless of whether the enrollee was actively receiving
LTSS at the time that the grievance was filed).

D1.IV.11

Active grievances

D1.IV.12

Grievances filed on behalf of LTSS
users

D1.IV.13

For managed care plans that cover LTSS, enter the number of critical incidents filed within
the reporting period by (or on behalf of) LTSS users who previously filed grievances in the
reporting year. The grievance and critical incident do not have to have been "related" to
the same issue - they only need to have been filed by (or on behalf of) the same enrollee.
Neither the critical incident nor the grievance need to have been filed in relation to delivery
of LTSS - they may have been filed for any reason, related to any service received (or
Number of critical incidents filed during desired) by an LTSS user. If the managed care plan does not cover LTSS, the state
the reporting period by (or on behalf of) should enter "N/A" in this field. Additionally, if the state already submitted this data for the
Count
an LTSS user who previously filed a
reporting year via the CMS readiness review appeal and grievance report (because the
grievance
managed care program or plan were new or serving new populations during the reporting
year), and the readiness review tool was submitted for at least 6 months of the reporting
year, the state can enter "N/A" in this field. To calculate this number, states or managed
care plans should first identify the LTSS users for whom critical incidents were filed during
the reporting year, then determine whether those enrollees had filed an appeal during the
reporting year, and whether the filing of the appeal preceded the filing of the critical
incident.

Enter the number of grievances for which timely resolution was provided by plan during
Number of grievances for which timely
the reporting period. (See 42 CFR §438.408(b)(1) for requirements related to the timely
resolution was provided
ofggrievances.)
g
yp
g resolution
p
p
g
(A single grievance may be related to multiple service types and may therefore be counted in multiple categories below.)
Enter the total number of grievances resolved by the plan during the reporting year that
were related to general inpatient care, including diagnostic and laboratory services.
Grievances related to general inpatient
D1.IV.15a
Please do not include grievances related to inpatient behavioral health services – those
services
should be included in indicator D1.IV.15c. If the managed care plan does not cover this
type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
were related to general outpatient care, including diagnostic and laboratory services.
Grievances related to general
D1.IV.15b
Please do not include grievances related to outpatient behavioral health services – those
outpatient services
should be included in indicator D1.IV.15d. If the managed care plan does not cover this
type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to inpatient
D1.IV.15c
were related to inpatient mental health and/or substance use services. If the managed
behavioral health services
care plan does not cover this type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to outpatient
D1.IV.15d
were related to outpatient mental health and/or substance use services. If the managed
behavioral health services
care plan does not cover this type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to coverage of
D1.IV.15e
were related to outpatient prescription drugs covered by the managed care plan. If the
outpatient prescription drugs
managed care plan does not cover this type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to skilled nursing
D1.IV.15f
were related to SNF services. If the managed care plan does not cover this type of
facility (SNF) services
service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to long-term
were related to institutional LTSS or LTSS provided through home and community-based
D1.IV.15g
services and supports (LTSS)
(HCBS) services, including personal care and self-directed services. If the managed care
plan does not cover this type of service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
D1.IV.15h Grievances related to dental services were related to dental services. If the managed care plan does not cover this type of
service, enter "N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to non-emergency
D1.IV.15i
were related to NEMT. If the managed care plan does not cover this type of service, enter
medical transportation (NEMT)
"N/A".
Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to other service
were related to services that do not fit into one of the categories listed above. If the
D1.IV.15j
types
managed care plan does not cover services other than those in items D1.IV.15a-i, enter
g
yp
g "N/A".p
gp
g
(A single grievance may be related to multiple reasons and may therefore be counted in multiple categories below.)
D1.IV.14

X
X

X

Count

X

(none)

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

Count

X

(none)

X

D1.IV.16a

Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to plan or provider were related to plan or provider customer service. Customer service grievances include
customer service
complaints about interactions with the plan's Member Services department, provider
offices or facilities, plan marketing agents, or any other plan or provider representatives.

Count

X

D1.IV.16b

Enter the total number of grievances resolved by the plan during the reporting year that
Grievances related to plan or provider were related to plan or provider care management/case management. Care
Count
care management/case management management/case management grievances include complaints about the timeliness of an
assessment or complaints about the plan or provider care or case management process.

X

D1.IV.16c

Grievances related to access to
care/services from plan or provider

D1.IV.16d Grievances related to quality of care

D1.IV.16e

Grievances related to plan
communications

Enter the total number of grievances resolved by the plan during the reporting year that
were related to access to care. Access to care grievances include complaints about
Count
difficulties finding qualified in-network providers, excessive travel or wait times, or other
access issues.
Enter the total number of grievances resolved by the plan during the reporting year that
were related to quality of care. Quality of care grievances include complaints about the
Count
effectiveness, efficiency, equity, patient-centeredness, safety, and/or acceptability of care
provided by a provider or the plan.

X

Enter the total number of grievances resolved by the plan during the reporting year that
were related to plan communications. Plan communication grievances include grievances
Count
related to the clarity or accuracy of enrollee materials or other plan communications or to
an enrollee's access to or the accessibility of enrollee materials or plan communications.

Enter the total number of grievances resolved during the reporting period that were filed
Count
for a reason related to payment or billing issues.
Enter the total number of grievances resolved during the reporting year that were related
to suspected fraud. Suspected fraud grievances include suspected cases of
financial/payment fraud perpetuated by a provider, payer, or other entity. Note: grievances
Count
D1.IV.16g Grievances related to suspected fraud
reported in this row should only include grievances submitted to the managed care plan,
not grievances submitted to another entity, such as a state Ombudsman or Office of the
Inspector General.
Enter the total number of grievances resolved during the reporting year that were related
Grievances related to abuse, neglect
D1.IV.16h
Count
to abuse, neglect or exploitation. Abuse/neglect/exploitation grievances include cases
or exploitation
involving potential or actual patient harm.
Grievances related to lack of timely
Enter the total number of grievances resolved during the reporting year that were filed due
plan response to a service
Count
D1.IV.16i authorization or appeal request
to a lack of timely plan response to a service authorization or appeal request (including
requests to expedite or extend appeals).
(including requests to expedite or
extend appeals)
Enter the total number of grievances resolved during the reporting year that were related
to the plan's denial of an enrollee's request for an expedited appeal. (Per 42 CFR
Grievances related to plan denial of
§438.408(b)(3), states must establish a timeframe for timely resolution of expedited
D1.IV.16j
Count
request for an expedited appeal
appeals that is no longer than 72 hours after the MCO, PIHP or PAHP receives the
appeal. If a plan denies a request for an expedited appeal, the enrollee or their
representative have the right to file a grievance.)
Enter the total number of grievances resolved during the reporting period that were filed
Count
D1.IV.16k Grievances filed for other reasons
for a reason other than the reasons listed above.
V
Availability, Accessibility, and Network adequacy
Describe any challenges to maintaining adequate networks and meeting standards. What
C1.V.1
Gaps/challenges in network adequacy
Free text
are the state’s biggest challenges?
State response to gaps in network
C1.V.2
Describe how the state works with MCPs to address these gaps.
Free text
adequacy
State-specific measures used to
C2
monitor availability, accessibility, and (see Tab C2)
network adequacy.
VII
Quality and Performance Measures
D1.IV.16f

X

X

Grievances related to payment or
billing issues

X

X

X

X

X

X
X

X

X
X
X
X

D2

VIII
D4
IX
n/a

State-specific measures used to
monitor quality and performance
across eight domains:
(1) Primary care access and
preventive care,
(2) Maternal and perinatal health,
(3) Care of acute and chronic
conditions,
(4) Behavioral health care,
(5) Dental and oral health services,
(6) Health plan enrollee experience of
care,
(7) Long-term services and supports,
and
(8) Other.
Sanctions and Corrective Action
Plans**
List of sanctions, administrative
penalties, and corrective action plans
that the state has issued to plans.
Beneficiary Support System (BSS)
Name of the BSS entities being
reported on

C1.IX.1

BSS website

C1.IX.2

BSS auxiliary aids and services

C1.IX.3

BSS LTSS program data

C1.IX.4

X

(see Tab D2)

X
X

(see Tab D4)
X
(see Tab A)
Indentify the website and/or email address that beneficiaries use to seek assistance from
the BSS through electronic means.
42 CFR 438.71 requires that the beneficiary support system be accessible in multiple
ways including phone, Internet, in-person, and via auxiliary aids and services when
requested. Describe how BSS entities offer services in a manner that is accessible to all
beneficiaries who need their services, including beneficiaries with disabilities, as required
by 42 CFR 438.71(b)(2)).

Free text

X

X

Free text

X

Free text

X

Describe how BSS entities assist the state with identifying, remediating, and resolving
systemic issues based on a review of LTSS program data such as grievances and
appeals or critical incident data, as required by 42 CFR 438.71(d)(4).

Free text

X

State evaluation of BSS entity
performance

Describe steps taken by the state to evaluate the quality, effectiveness, and efficiency of
the BSS entities' performance.

Free text

X

E.IX.1

BSS entity type

Select type of entity contracted to perform each BSS activity specified at 42 CFR
438.71(b).

Set values (select multiple) or use free
text for "other" response

E.IX.2

BSS entity role

Select roles that the contracted BSS entity performs, specified at 42 CFR 438.71(b).

Set values (select multiple) or use free
text for "other" response

X

Program Integrity

B.X.1

Payment risks between the state and
plans

Describe service-specific or other focused PI activities that the state conducted during the
past year in this managed care program (such as analyses focused on use of long-term
services and supports [LTSS] or prescription drugs) or activities that focused on specific
Free text
payment issues to identify, address, and prevent fraud, waste or abuse. Consider data
analytics, reviews of under/overutilization, and other activities.

X

Contract standard for overpayments

Indicate whether the state allows plans to retain overpayments, requires the return of
overpayments, or has established a hybrid system.

X

Contract locations of overpayment
standard

Identify where the overpayment standard in indicator B.X.2 is located in plan contracts, as
required by 42 CFR 438.608(d)(1)(i).
Free text

X

Description of overpayment contract
standard

Briefly describe the overpayment standard (for example, details on whether the state
allows plans to retain overpayments, requires the plans to return overpayments, or
administers a hybrid system) selected in indicator B.X.2

X

State overpayment reporting
monitoring

Describe how the state monitors plan performance in reporting overpayments to the state.
For example, does the state track compliance with this requirement and/or timeliness of
reporting?
Free text

X

Describe how the state ensures timely and accurate reconciliation of enrollment files
Changes in beneficiary circumstances between the state and plans to ensure appropriate payments for enrollees experiencing a
change in status (e.g., incarcerated, deceased, switching plans).
Free text

X

B.X.2
B.X.3

B.X.4

B.X.5

B.X.6

X
X
X

Set values (select one)

X

X

Free text

X

X

B.X.7.a

B.X.7.b
B.X.7.c

Changes in provider circumstances:
Part 1

Indicate if the state monitors whether plans report provider “for cause” terminations in a
timely manner under 42 CFR 438.608(a)(4).

Changes in provider circumstances:
Part 2

If the state monitors whether plans report provider “for cause” terminations in a timely
manner in indicator B.X.7.a, indicate whether the state uses a metric or indicator to assess
plan reporting performance.
Set values (select one)
If the state uses a metric or indicator to assess plan reporting performance in indicator
B.X.7.b, describe the metric or indicator that the state uses.
Free text

Changes in provider circumstances:
Part 3

Federal database checks: Part 1
B.X.8a
Federal database checks: Part 2
B.X.8b
B.X.9a

Website posting of 5 percent or more
ownership control [Y/N]

B.X.9b

Website posting of 5 percent or more
ownership control [link]

B.X.10

Periodic audits [link]

C1.X.3

Prohibited affiliation disclosure

D1.X.1

Dedicated program integrity staff

D1.X.2

Count of opened program integrity
investigations

Consistent with the requirements at 42 CFR 455.436 and 438.602, the State must
confirm the identity and determine the exclusion status of the MCO, PIHP, PAHP, PCCM
or PCCM entity, any subcontractor, as well as any person with an ownership or control
interest, or who is an agent or managing employee of the MCO, PIHP, PAHP, PCCM or
PCCM entity through routine checks of Federal databases. In the course of the state's
federal database checks, did the state find any person or entity excluded?

Set values (select one)

X
X

X
Set values (select one)

If in the course of the state's federal database checks the state found any person or entity
excluded, please summarize the instances and whether the entity was notified as required
in 438.602(d). Report actions taken, such as plan-level sanctions and corrective actions in
Tab D3 as applicable. Enter N/A if not applicable.
Free text
Report whether the state posts on its website the names of individuals and entities with
5% or more ownership or control interest in MCOs, PIHPs, PAHPs, PCCMs and PCCM
entities and subcontractors following §455.104 and required by 42 CFR 438.602(g)(3).
If the state posts on its website the names of the plan individuals with 5% or more
ownership or control, under 42 CFR 602(g)(3), provide a link to the website. Enter N/A if
not applicable.

X

X

X
Set values (select one)
Free text

If the state conducted any audits during the contract year to determine the accuracy,
truthfulness, and completeness of the encounter and financial data submitted by the plans Free text
under 42 CFR 438.602(e), provide the link(s) to the audit results.
Did any plans disclose prohibited affiliations? Y/N. If the state took action, as required
under 42 CFR 438.610(d), please enter interventions on Tab D3 Sanctions and Corrective
Action Plans.
Set values (select one)
Report the number of dedicated program integrity staff for routine internal monitoring and
Count
compliance risks as required under 42 CFR 438.608(a)(1)(vii).

X

X

X
X

Enter the count of program integrity investigations opened by the plan in the past year.

Count

X

Enter the ratio of program integrity investigations opened by the plan in the past year per
1,000 beneficiaries enrolled in the plan on the first day of the last month of the reporting
year.

Ratio

X

Enter the count of program integrity investigations resolved by the plan in the past year.

Count

X

D1.X.3

Ratio of opened program integrity
investigations

D1.X.4

Count of resolved program integrity
investigations

D1.X.5

Ratio of resolved program integrity
investigations

Enter the ratio of program integrity investigations resolved by the plan in the past year per
Ratio
1,000 beneficiaries enrolled in the plan at the beginning of the reporting year.

X

D1.X.6

Referral path for program integrity
referrals to the state

Select the referral path that the plan uses to make program integrity referrals to the state:
· If the plan makes referrals to the Medicaid Fraud Control Unit (MFCU) only.
Set value (select one)
· If the plan makes referrals to the State Medicaid Agency (SMA) and MFCU concurrently.
· If the plan makes some referrals to the SMA and others directly to the MFCU.

X

D1.X.7

Count of program integrity referrals to
the state

Enter the count of program integrity referrals that the plan made to the state in the past
year using the referral path selected in indicator D1.X.6
· If the plan makes referrals to the MFCU only, enter the count of referrals made.
· If the plan makes referrals to the SMA and MFCU concurrently, enter the count of
unduplicated referrals.
· If the plan makes some referrals to the SMA and others directly to the MFCU, enter the
count of referrals made to the SMA and the MFCU in aggregate.

X

D1.X.8

Ratio of program integrity referrals to
the state

Enter the ratio of program integrity referrals listed in indicator D1.X.7 made to the state in
the past year per 1,000 beneficiaries, using the plan's total enrollment as of the first day of Ratio
the last month of the reporting year (reported in indicator D1.I.1) as the denominator.

Count

X

Summarize the plan’s latest annual overpayment recovery report submitted to the state as
required under 42 CFR 438.608(d)(3). Include, for example, the following information:
· The date of the report (rating period or calendar year).
Free text
· The dollar amount of overpayments recovered.
· The ratio of the dollar amount of overpayments recovered as a percent of premium
revenue as defined in MLR reporting under 438.8(f)(2).

D1.X.9

Plan overpayment reporting to the
state

D1.X.10

Changes in beneficiary circumstances Select the frequency the plan reports changes in beneficiary circumstances to the state.

Set values (select one)

X

X

* Standardized or pre-set indicators cover specific information that CMS would like reported consistently across all programs and plans (for example, enrollment count). State-specific or free indicators cover information that will vary based on what a
state collects from its plans (for example, access measures).
** Denotes sections that are required for PCCM entities, per 438.66(e)(2).