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GAO Finds Gaps in CMS Review of Managed Care Rates

Cheryl Clark, for HealthLeaders Media, August 9, 2010

"Variation in a number of CMS regional office practices contributed to these gaps and other inconsistencies in the agency's oversight of states' rate setting," the GAO says.

"For example, regional offices varied in the extent to which they tracked state compliance with the actuarial soundness requirements, their interpretations of how extensive a review of a state's rate setting was needed, and their determinations regarding sufficient evidence for meeting the actuarial soundness requirement.

Spokesman for America's Health Insurance Plans, Robert Zirkelbach, says his organization "agrees that there needs to be more uniformity and consistency with how actuarial soundness is done across the country."

CMS, he adds, "must assure that health plans have enough money in reserves to be able to pay the healthcare claims of their policy holders and to ensure that the coverage families rely on is going to be there when they need it."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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