CMS has issued two new proposed rules to improve transparency, health care access and quality of care in Medicaid and the Children’s Health Insurance Program. The proposed rules would create national standards for certain appointment wait times and help states implement a rating system for enrollees to compare CHIP and Medicaid plans.
The Ensuring Access to Medicaid Services proposed rule and Managed Care Access, Finance, and Quality proposed rule would:1,2
- Establish national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees, and strengthen state monitoring and reporting requirements related to access and network adequacy for Medicaid or CHIP managed care plans.
- Require states to conduct independent “secret shopper” surveys of Medicaid or CHIP managed care plans to make sure appointment wait time standards are met and provider directories are accurate.
- Require disclosure of provider payment rates in Medicaid fee-for-service and managed care plans.
- Increase transparency for setting Medicaid payment rates for home and community-based services, and require that at least 80% of Medicaid payments for personal care, homemaker and home health aide services be spent on payment for direct care workers and not on administrative overhead or profit.
- Strengthen how states use state Medical Care Advisory Committees to ensure they are utilizing these committees optimally to realize a more effective and efficient Medicaid program informed by the experiences of beneficiaries, their caretakers and other stakeholders.
- Require states to conduct enrollee experience surveys in Medicaid managed care every year for each plan.
- Establish a framework for states to implement a Medicaid or CHIP quality rating system for enrollees to compare Medicaid or CHIP managed care plans based on quality of care, access to providers, covered benefits and drugs, cost and other plan performance indicators.
- Create timeliness-of-access measures for home and community-based services and strengthen safeguards to ensure beneficiary health and welfare and promote health equity.
Ensuring enrollees can find an in-network provider and access care and coverage in a timely manner is a key priority for the Biden-Harris administration, CMS said. The agency notes that nearly 1 in 4 Americans and more than half of the country’s children are covered by Medicaid. More than 70% of people with Medicaid or CHIP coverage are enrolled in managed care plans.3
“Having health care coverage is fundamental to reducing health disparities, but it must go hand-in-hand with timely access to services,” said CMS Administrator Chiquita Brooks-LaSure. “Connecting those priorities lies at the heart of these proposed rules.”3
The Association for Community Affiliated Plans said it supports the proposed rules but suggested certain changes.4 For example, “these measures should reflect differences in populations served by different plans,” said ACAP CEO Margaret Murray. They also “need to take into account the pressures posed by the health care workforce shortages we see around the country.”
Both proposed rules can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection. Public comments are due July 3, 2023.
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- Frieden, J. CMS proposed rules aim to increase Medicaid and CHIP access, transparency. MedPage Today. April 27, 2023. https://www.medpagetoday.com/practicemanagement/reimbursement/104238
- Morse, S. CMS proposes national standards for Medicaid and CHIP. Healthcare Finance. April 27, 2023. https://www.healthcarefinancenews.com/news/cms-proposes-national-standards-medicaid-and-chip
- The Biden-Harris Administration proposes new standards to help ensure access to quality health care in Medicaid and CHIP. CMS. April 27, 2023. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-proposes-new-standards-help-ensure-access-quality-health-care-medicaid
- Bailey, V. CMS proposes transparency, access standards for Medicaid managed care. HealthPayerIntelligence. April 28, 2023. https://healthpayerintelligence.com/news/cms-proposes-transparency-access-standards-for-medicaid-managed-care