CMS' latest batch of Medicaid, CHIP proposals include maximum appointment wait times, greater pay transparency

The Centers for Medicare & Medicaid Services (CMS) proposed two new rules today broadly focused on increasing access to care, quality of care and opportunities to provide feedback for people enrolled in Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service and managed care plans.

The rulemaking, unveiled Thursday afternoon, is a push from the administration to better serve the 92 million Americans enrolled in the low-income coverage programs, CMS officials said during a call with reporters.

“For too many people, the break comes from not having real access: being able to reach that doctor [or] knowing how to access that hospital when you need it most,” Department of Health and Human Services Secretary Xavier Becerra said on the call. “You may have insurance on paper, but if you can’t in practice get them to care, then it really doesn’t make a difference. Today’s rules are game changers when it comes to making sure people not only have healthcare, but they have access to the healthcare they need.”

If finalized, they would place new performance and reporting responsibilities on states as well as managed care plans, under which more than 70% of Medicaid and CHIP enrollees are covered.

Some of the changes, such as the establishment of a “national maximum appointment wait time standard” of about two weeks for routine primary care, are designed to bring the delivery of services covered under the programs in line with their commercial counterparts, officials said.

That effort comes with stronger state monitoring and reporting requirements including “independent secret shopper surveys” to verify compliance and, if found to be falling short, the submission of a “remedy plan” to CMS that details how a managed care plan will work to remove the barriers to access, officials said.  

“Everyone, including those with Medicaid and CHIP coverage, deserves access to quality, affordable healthcare services—that has always been true, but the last couple of years have made it crystal clear how important it is for people to have coverage,” CMS Administrator Chiquita Brooks-LaSure said during the press call. “With the access and managed care proposed rules announced today, CMS continues our work to strengthen the Medicaid and CHIP programs.”

Other proposed changes highlighted by the agency include a requirement that states disclose provider payment rates for fee-for-service and managed care, which officials said will be benchmarked against Medicare fee-for-service rates for outcome insights.

Another transparency requirement for home and community-based service payment rates is paired with a new requirement that at least 80% of Medicaid payments for personal care and various home health services go directly toward compensating “traditionally undervalued” healthcare workers “as opposed to administrative overhead or profit,” Brooks-LaSure said.

“Strengthening this workforce will result in higher quality care for home and community-based service recipients,” she said.

Similar to the routine care access push, fee-for-service home and community-based services would also see “timeliness-of-access measures” and a state-established grievance system per the proposed rules.

CMS paired these and the other proposed quality and access changes with a slew of new requirements for states to solicit feedback from and engage program enrollees.

Here, the agency is proposing that states’ Medical Care Advisory Committees (which would be renamed as Medicaid Advisory Committees) be expanded and implemented uniformly across states, while also incorporating a mandatory “beneficiary advisory group” representing enrolled beneficiaries.

States would also be required to conduct annual enrollee experience surveys for direct feedback on each managed care plan, implement a quality rating system and eventually establish a “one-stop-shop” website for beneficiaries to find and compare different fee-for-service and managed care plans, according to the proposed rules.

“All of these provisions are going to be a game changer,” Becerra told reporters, while acknowledging that many of the proposals may not receive initial recognition from the public. “The end result will be better service, better care and higher quality for those Americans who really depend on Medicaid.”

The two notices of proposed rulemaking, "Ensuring Access to Medicaid Services" and "Managed Care Access, Finance, and Quality," are published on the Federal Register with a public comment period slated to run through July 3.