May 16, 2023 – The Centers for Medicare and Medicaid Services (CMS) recently proposed new standards that are designed to improve access to quality health care in Medicaid and the Children’s Health Insurance Program (CHIP). CMS unveiled two notices of proposed rulemaking (NPRMs), Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM), which build on Medicaid’s foundation. 

If these proposed regulations come into effect as they currently stand, they would set unprecedented nationwide criteria for access to care, irrespective of whether that care is delivered through managed care plans or directly by states via fee-for-service (FFS) models. In particular, the regulations would set up benchmarks for access through Medicaid or CHIP managed care plans while also ensuring transparency for Medicaid payment rates to healthcare providers. This includes clarity on hourly rates and compensation for certain direct care workers. In addition to these, the regulations would put into place other standards aimed at enhancing transparency and accountability, while also promoting the power of choice for beneficiaries.

The proposed rules are part of a broader strategy to ensure that Medicaid and CHIP programs serve beneficiaries effectively. The move has been welcomed by health advocates and professionals who see it as a critical step in reducing health disparities and improving health outcomes for some of the nation’s most vulnerable citizens. The proposal also has strong support from those within the Biden-Harris Administration. 

“The Biden-Harris Administration has made clear where we stand: we believe all Americans deserve the peace of mind that having health care coverage brings,” said HHS Secretary Xavier Becerra. “We are proposing important actions to remove barriers to care, engage consumers, and improve access to services for all children and families enrolled in these critical programs. One in four Americans and over half of all children in the country are enrolled in Medicaid or CHIP – and the Biden-Harris Administration is committed to protecting and strengthening these programs for future generations.”

CMS Administrator Chiquita Brooks-LaSure added, “Having health care coverage is fundamental to reducing health disparities, but it must go hand-in-hand with timely access to services. Connecting those priorities lies at the heart of these proposed rules. With the provisions we’ve outlined, we’re poised to bring Medicaid or CHIP coverage and access together in unprecedented ways—a key priority that’s long overdue for eligible program participants who still face barriers connecting to care.”

Other highlights from the proposed rules include:

• Establishing national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees 
• Requiring states to conduct independent secret shopper surveys of Medicaid or CHIP managed care plans 
• Creating new payment transparency requirements for states 
• Establishing additional transparency and interested party engagement requirements for setting Medicaid payment rates for home and community-based services (HCBS
• Creating timeliness-of-access measures for HCBS 
• Strengthening how states use state Medical Care Advisory Committees
• Requiring states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan 
• Establishing a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” for enrollees to compare Medicaid or CHIP managed care plans 

In the coming months, the CMS will be collecting public comments on these proposed rules. The goal is to ensure that the changes made will genuinely benefit the beneficiaries of Medicaid and CHIP. This inclusive approach underscores the administration’s commitment to creating a healthcare system that works for all Americans.