CMS Proposed Rules Aim to Increase Medicaid and CHIP Access, Transparency

— “Secret shoppers” and maximum wait times to see a doctor are among the provisions

by
Joyce Frieden, Washington Editor, MedPage Today
April 27, 2023

WASHINGTON — The Centers for Medicare & Medicaid Services (CMS) on Thursday proposed two new rules aimed at improving access to Medicaid and the Children’s Health Insurance Program (CHIP), as well as making the programs more transparent.

“For those who really believe that the real cornerstone to healthcare for all in America is the Medicaid program, those folks will understand just how important today’s announcement of these two rules will be,” said HHS Secretary Xavier Becerra on a phone call with reporters. “When you consider that Medicaid is the route through which 92 million Americans today can access good quality healthcare, you begin to realize how important Medicaid is …. For too many people, the [problem] comes from not having real access and not being able to reach that doctor. You may have insurance on paper, but if you can’t in practice get to that chair [in the doctor’s office], it really does make a difference.”

The two rules — the Ensuring Access to Medicaid Services proposed rule and Managed Care Access, Finance, and Quality proposed rule — would:

• Establish national maximum standards for some appointment wait times for Medicaid or CHIP managed care enrollees, and strengthen reporting requirements related to 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 times meet the standards and that provider directories are accurate
• Require disclosure of provider payment rates in Medicaid fee-for-service and managed care plans
• Increase transparency rules for setting Medicaid payment rates for home and community-based services, and institute a requirement 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 administrative costs or profits
• 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 make sure all states are using these committees optimally
• Require states to conduct enrollee experience surveys in Medicaid managed care annually for each plan, to gather input directly from enrollees
• Establish a framework for states to implement a Medicaid or CHIP quality rating system, which enrollees could use to compare Medicaid or CHIP managed care plans based on quality of care, cost, access to providers, and other factors

“These two new rules will also raise the bar on how state Medicaid programs engage with Medicaid enrollees and consider their lived experience and feedback,” said CMS Administrator Chiquita Brooks-LaSure on the call. “We propose strengthening how states use their Medical Care Advisory Committees through which the public provides guidance to state Medicaid agencies about health and medical care services. CMS aims to ensure Medicaid programs are informed by the experiences of Medicaid enrollees, their caretakers, and others.”

As for finding out more about how states set their Medicaid payment rates for providers, Daniel Tsai, director of the Center for Medicaid and CHIP Services at CMS, told MedPage Today on the call that “historically, CMS does not have a good way — and advocates and providers do not have a good way — of understanding and benchmarking where Medicaid payment rates are across the country and across the different state programs. So we propose that every state has to make their base rates of payment transparently available and easily accessible, and that every state has to benchmark their base rates for Medicaid relative to Medicare payment rates, which is a national standard that allows for comparison and easy benchmarking across states.”

What happens if a state or its Medicaid managed care plan fails to meet the appointment wait time standards? “To the extent that states or managed care plans are finding that someone is not able to access primary care efficiently and in a timely way, they are accountable for submitting to CMS what we call a ‘remedy plan’ that must outline what the problem is” and propose solutions, which could range from increasing provider payment rates, to leveraging telehealth and expanding workforce capacity, Tsai said. Such solutions “will actually help target what people care about: ‘Can I see my doctor in a reasonable amount of time?'”

Joan Alker, MPhil, executive director of the Center for Children and Families at Georgetown University here, said in an email that she was pleased about the proposed rules. “We will of course await the fine print, but overall I am very pleased to see CMS digging into critical questions of access to care for children, families, and people with disabilities who rely on Medicaid for their healthcare,” she said. “Establishing maximum wait times and secret shopper surveys to check on which providers are taking patients are both exciting steps … Overall, more accountability and transparency is needed for Medicaid managed care companies who serve the vast majority of families in Medicaid, so this is a vitally important subject.”

Both rules are available for viewing in the Federal Register. CMS is accepting comments on both rules through July 3.