REFORM- CMS proposes national standards for Medicaid and CHIP


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[MM Curator Summary]: CMS thinks it will open up the black boxes of provider pricing and the true depth of the network access problem with this new rule. Cute.




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The proposed rules would establish wait times and require states to disclose provider payment rates in fee-for-service and managed care.


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The Centers for Medicare and Medicaid is proposing new standards and requirements for Medicaid or CHIP services, including ones for in-home and community-based services

Among other standards, the proposed rule would establish national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees and require disclosure of provider payment rates in both fee-for-service and managed care.

CMS on Thursday unveiled the two notices of proposed rulemaking: Ensuring Access to Medicaid Services (Access NPRM); and Managed Care Access, Finance, and Quality (Managed Care NPRM).If adopted as proposed, the rules would establish historic national standards for access to care, regardless of whether that care is provided through managed care plans or directly by states through fee-for-service, CMS said. Over 70% of people with Medicaid or CHIP coverage are enrolled in managed care plans.


Together, the Access NPRM and Managed Care NPRM include new and updated proposed requirements for states and managed care plans that would establish tangible, consistent access standards, and a consistent way to transparently review and assess Medicaid payment rates across states, CMS said. 

The rules propose:

  • Transparency for Medicaid payment rates to providers, including hourly rates and compensation for certain home care and other direct care workers. 
  • Standards to allow enrollees to compare plans based on quality and access to providers through the state’s website. 
  • To establish national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees; stronger state monitoring and reporting requirements related to access and network adequacy.
  • To require states to conduct independent secret shopper surveys of Medicaid or CHIP managed care plans to verify compliance with appointment wait time standards and to identify where provider directories are inaccurate.
  • To create new payment transparency requirements for states by requiring disclosure of provider payment rates in both fee-for-service and managed care, with the goal of greater insight into how Medicaid payment levels affect access to care.
  • To establish additional transparency and interested party engagement requirements for setting Medicaid payment rates for home and community-based services (HCBS), as well as a requirement that at least 80% percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for direct care workers (as opposed to administrative overhead or profit).
  • Create timeliness-of-access measures for HCBS and strengthen safeguards to ensure beneficiary health and welfare as well as promote health equity. 
  • Strengthen how states use state Medical Care Advisory Committees, through which stakeholders provide guidance to state Medicaid agencies about health and medical care services, to ensure all states are using these committees optimally to realize a more effective and efficient Medicaid program that is informed by the experiences of Medicaid beneficiaries, their caretakers and other interested parties.
  • Require states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan to gather input directly from enrollees.
  • Establish a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” 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. 


Medicaid is the single largest health coverage program in the United States, covering nearly one in four Americans and over half of all children in the country.

Medicaid and CHIP provide benefits with little to no out-of-pocket costs for over 92 million people. Many of those enrolled in Medicaid or CHIP come from underserved communities whose populations have disproportionately higher uninsured rates, and who often experience chronic health issues. 


“The Biden-Harris Administration has made clear where we stand: we believe all Americans deserve the peace of mind that having health care coverage brings,” said HHS Secretary Xavier Becerra. “We are proposing important actions to remove barriers to care, engage consumers, and improve access to services for all children and families enrolled in these critical programs. One in four Americans and over half of all children in the country are enrolled in Medicaid or CHIP – and the Biden-Harris Administration is committed to protecting and strengthening these programs for future generations.” 

“Having healthcare coverage is fundamental to reducing health disparities, but it must go hand-in-hand with timely access to services. Connecting those priorities lies at the heart of these proposed rules,” said CMS Administrator Chiquita Brooks-LaSure. “With the provisions we’ve outlined, we’re poised to bring Medicaid or CHIP coverage and access together in unprecedented ways – a key priority that’s long overdue for eligible program participants who still face barriers connecting to care.” 


Twitter: @SusanJMorse
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