In late April, the federal Centers for Medicare & Medicaid Services (CMS) released two proposed rules that could significantly reshape the Medicaid regulatory landscape regarding managed care and access to care. With these proposed policy changes, CMS seeks to improve access to care, improve quality and health outcomes, and better address health equity issues in the Medicaid, CHIP, and home & community based service (HCBS) waiver programs.
Together, the proposed rules establish new standards and processes by which states would document that payment rates – across the Medicaid fee-for-service and managed care delivery systems and in HCBS programs – are adequate to ensure both quality and access. Key measures to ensure adequate access include new minimum wait time standards, increased transparency of payment rates, and increased access monitoring requirements.
Among other things, the proposed “Access Rule” would:
- Require states to publish all Medicaid fee-for-service payment rates on a website accessible to the public;
- Publish an analysis comparing the FFS rates to the corresponding Medicare rate for certain services;
- Impose new requirements regarding Medicaid advisory committees and subcommittees comprised of current and former beneficiaries and their family members;
- Create new requirements regarding HCBS rate transparency and payment adequacy with respect to ensuring a sufficient direct care workforce;
- Require use of a new HCBS Quality Measure Set;
Highlights of the proposed “Managed Care Rule” include:
- A broad range of provisions regarding the monitoring and enforcement of network adequacy;
- Codifying recent changes and parameters for “In Lieu of Services”;
- New requirements regarding state directed payments passed through managed care plans;
- New rules regarding quality rating systems and changes to the existing requirements regarding external quality review.
Comments for both rules are due by July 3rd.
For more information, see this CMS factsheet summarizing the provisions of the proposed rules and listing their effective dates.