Medicaid final rules improve care access for managed care, FFS beneficiaries
The rules address payment rates, care quality, and home- and community-based services in Medicaid managed care and fee-for-service plans.
Source: CMS Logo
- CMS has finalized policies to improve access to Medicaid and the Children’s Health Insurance Program (CHIP) managed care and boost coverage quality.
The Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule and the Ensuring Access to Medicaid Services Final Rule address state payments, medical loss ratios, home- and community-based services (HCBS) payments, and more.
Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule
This rule aims to increase access to Medicaid and CHIP managed care plans. CMS established maximum appointment wait time standards, including 15 business days for routine primary care and obstetric/gynecological services and 10 business days for outpatient mental health and substance use disorder services.
States must use an independent entity to conduct annual secret shopper surveys that validate managed care plans’ compliance with appointment wait time standards and provider directory accuracy. States must also conduct yearly enrollee experience surveys for managed care plans and implement remedy plans for any plan that does not meet access standards.
The policies will require states to submit an annual payment analysis comparing managed care plan payment rates for certain services as a proportion of Medicare payment rates and comparing payment rates for community-based services to those of the state’s Medicaid plan.
The rule also addressed state-directed payments, removing barriers to help states use these payments to implement value-based purchasing payment arrangements and included non-network providers in state-directed payments. Provider payment levels for state-directed payments for inpatient and outpatient hospital services, nursing facility services, and professional services at an academic medical center cannot exceed the average commercial rate.
Medicaid managed care plans must submit actual expenditures and revenues for state-directed payments as a part of their medical loss ratio reports to states, and states must provide medical loss ratios for each managed care plan. In addition, managed care plans must report any identified or recovered overpayments to states within 30 calendar days.
The final rule specified the scope of in lieu of services and settings (ILOSs) to better address health-related social needs by stating they can be used as immediate or longer-term substitutes for a covered service or setting under the state plan.
CMS stated that Medicaid and CHIP Quality Rating System (MAC QRS) websites must be established as a one-stop shop where beneficiaries can access information about Medicaid and CHIP eligibility and managed care, compare managed care plans based on quality, and select plans that best meet their needs. The rule also established the CMS framework, state requirements for the MAC QRS, and the process by which measures will be updated.
Ensuring Access to Medicaid Services Final Rule
The rule renamed states’ Medical Care Advisory Committees to Medicaid Advisory Committees (MACs) and required states to establish a Beneficiary Advisory Council (BAC) that includes Medicaid beneficiaries, their families, and caregivers. A quarter of MAC members must be drawn from the BAC and states must make information about MAC and BAC activities publicly available.
The rule also strengthened oversight of person-centered service planning in HCBS, required states to meet nationwide incident management system standards for monitoring HCBS programs, and required states to establish a grievance system for HCBS delivered through fee-for-service (FFS).
In three years, states must report on their readiness to collect data on the share of Medicaid payments for homemaker, home health aide, personal care, and habilitation services spent on compensation to the direct care workers providing these services, with plans to report the data in four years. In six years, states must ensure a minimum of 80 percent of Medicaid payments for these services are spent on compensation for direct care workers.
The rule requires states to publish all FFS Medicaid fee schedule payment rates on a publicly available and accessible website and compare FFS payment rates for primary care, obstetrical and gynecological care, and outpatient mental health and substance use disorder services to Medicare rates, publishing the results every two years.
States must also establish an advisory group for direct care workers, beneficiaries, and other interested parties to meet at least every two years to consult payment rates paid to direct care workers.
