CMS 2016 Medicaid Managed Care Final Rule — 42 CFR Parts 430–456

Source: Centers for Medicare & Medicaid Services · Document date: 2016-05-06 · Type: regulation

Final rule modernizing Medicaid managed care regulations. Strengthened MCO program integrity requirements including mandatory SIU establishment (455.236), fraud referral obligations to state agencies, encounter data quality standards, and DHS oversight responsibilities. Basis for current MCO fraud detection regulatory framework.

Significance: Regulatory foundation for MCO fraud detection requirements. The gap between these requirements and Minnesota MCO practice is the central subject of the mco-oversight-gap investigation.

Tags: regulation, CMS, managed-care, 2016, final-rule, SIU