In late April, the Centers for Medicare and Medicaid Services (CMS) issued two proposed rules for Medicaid and the Children’s Health Insurance Program (CHIP). The first rule — Ensuring Access to Medicaid Services — primarily addresses the fee-for-service (FFS) delivery system; the second — Managed Care Access, Finance, and Quality — addresses issues related to Medicaid managed care plans, which cover nearly three of four Medicaid beneficiaries. This post examines the new rules, which share a focus on improving health outcomes and health equity by ensuring access to care.
New Rate Transparency Requirements
Citing evidence on the relationship between provider payment rates and access to care, CMS proposes greater transparency on provider rates, including analyses that compare Medicaid and CHIP rates for certain services to Medicare rates for those services. Many states make their FFS rates public; these rules would require all states to do so in a simplified and uniform manner. To put rates into context, states would be required every other year to quantify how FFS rates for evaluation and management services for primary care, obstetrics/gynecology, and outpatient behavioral health compare to Medicare. For managed care, actual payment rates would not be shared publicly but each year, plans would provide the state with comparisons of their total Medicaid and CHIP payments for these service categories against what Medicare FFS would have paid. Both the FFS and managed care analyses would be public and account for rate variations based on provider type, geographical location, site of service, or age of the beneficiary (i.e., adults vs. children).
New Federal Standards for Measuring Access
CMS has proposed a new national standard to promote access in managed care, which augments existing state-designed standards that often consider travel time and distance to providers. The new standard would set maximum wait times for getting routine appointments for primary care, obstetrics/gynecology, and outpatient behavioral health services — plus at least one additional service selected by the state. As proposed, appointments would need to be provided within 10 business days for behavioral health and 15 business days for primary care and obstetrics/gynecology. States could also adopt standards for nonroutine visits, allow exceptions to the wait-time requirements, and/or apply more stringent standards than those proposed. CMS seeks comment on whether these wait-time standards should be extended to states with 100 percent FFS programs.
State and federal oversight of access to care is particularly important, given that neither enrollees nor providers can challenge the adequacy of provider rates in court, per the Supreme Court’s 2015 decision in Armstrong v. Exceptional Child Center. For this reason, the application of the proposed rules, should they be adopted, would require ongoing monitoring. This monitoring could include “secret shopper” surveys through which states could assess appointment wait times for managed care enrollees and verify information in provider directories.1 Plans that meet wait-time standards at least 90 percent of the time would be deemed compliant. If plan performance falls short — on this or another federal access standard — states would be required to devise “remedy plans.”
To deepen the engagement of enrollees and stakeholders and advance equity goals, the proposed regulations would bolster opportunities for public input at the state level. Annual “satisfaction” surveys of managed care enrollees would be required, along with revamped requirements for beneficiary and stakeholder advisory groups.
CMS will continue to review states’ payment rates for managed care plans annually when states submit contracts for approval but with the benefit of additional data from the new provider reimbursement analyses and monitoring surveys. Greater federal scrutiny on FFS rates would be triggered if states seek to reduce rates for any service in a manner that could significantly diminish access — for instance, by bringing rates below 80 percent of comparable Medicare rates. CMS retains authority to withhold federal payments for noncompliance.
Home- and Community-Based Access Standards and Oversight
CMS has proposed the first federal access standards tailored to home- and community-based services (HCBS), which now account for more than half of all Medicaid expenditures for long-term services and supports. Several of CMS’s proposals focus on a subset of home-based services (i.e., personal care, home health aide, and homemaker services). Because beneficiaries are highly dependent on direct care workers to provide these services, and because these services generally have no comparable Medicare analog, CMS proposes rate transparency requirements that differ from those outlined above for other services. States would be required to report their FFS payments in the form of a standardized hourly rate every other year, while managed care plans would annually compare total spending on these services to comparable payments under Medicaid FFS and report the results to the state, which would in turn publish the analysis.
In addition, home care agencies would be required to devote at least 80 percent of their Medicaid payment to compensation for the direct care workers who provide those services. New state advisory groups — made up of beneficiaries, family caregivers, agencies, and workers and their representatives — would be established to “advise and consult” on the adequacy of home care rates. Recommendations would be publicly reported and considered by CMS as part of its review. The regulations also propose state reporting of the time elapsed from when home care services are approved to when they are provided as well as information about wait lists for HCBS services.
These proposals hold the promise of bolstering access for millions of people who receive their health care through Medicaid and CHIP, but reform will not be easy. The proposals entail significant new responsibilities for states, health plans, and CMS. Public comments on these proposals — due by July 3 — are likely to be robust. Recognizing the new burdens inherent in these reforms, CMS anticipates providing extensive technical support and time to implement them. We will continue to closely monitor these proposals as they make their way through the regulatory process.