Requiring Medicaid managed care plans to be included in Medicaid RAC programs

Section 1902(a)(42) of the Social Security Act (42 U.S.C. 1396a(a)(42)) is amended— (1) in subparagraph (A), by striking and at the end; (2) in subparagraph (B)(ii)— (A) in subclause (III), by striking and at the end; and (B) by adding at the end the following new subclause: (V) such program is carried out in a robust manner likely to identify and recoup or prevent a substantial portion of overpayments and specifically includes a review of claims paid by medicaid managed care organizations (as defined in section 1903(m)(1)(A)), prepaid inpatient health plans (as defined in section 1903(m)(9)(D)(iii)(I)), and prepaid ambulatory health plans (as defined in section 1903(m)(9)(D)(iii)(II));; and (3) by adding at the end the following new subparagraph: (C) not later than January 1, 2028, the State shall provide assurances satisfactory to the Secretary that the State has an adequate process for ensuring that any contract with a medicaid managed care organization (as defined in section 1903(m)(1)(A)), prepaid inpatient health plan (as defined in section 1903(m)(9)(D)(iii)(I)), or prepaid ambulatory health plan (as defined in section 1903(m)(9)(D)(iii)(II)), and a State shall include provisions under which such an organization or health plan— (i) shall either— (I) elect to engage in a period of payment integrity review by designating a period (not to exceed the lesser of 18 months after payment for a claim or the term of the contract with the managed care organization) during which the organization or health plan shall be permitted to engage in efforts to identify underpayments and overpayments and recoup overpayments under the State plan and under any waiver of the State plan with respect to all services for which payment is made to the organization or health plan under such plan or waiver; or (II) agree to permit a Medicaid recovery audit contractor (as described in subparagraph (B)) engaged by the State to engage in such payment integrity review; and (ii) shall agree to— (I) cooperate with any Medicaid recovery audit contractor (as so described) engaged by the State to identify any such underpayments and overpayments and recoup any overpayments under the State plan and under any waiver of the State plan (after the expiration of the period designated under clause (i)(I), if the organization or health plan has elected such a period); and (II) coordinate such recovery audit efforts in the same manner described in subparagraph (B)(ii)(IV)(cc); and.