The Centers for Medicare & Medicaid Services (CMS) on April 27, 2023, proposed two new rules — Medicaid & CHIP Managed Care Access, Finance, and Quality and Ensuring Access to Medicaid Services — that establish access standards and standardize review and assessment of Medicaid payment rates across states.
Medicaid Managed Care Rule
The Medicaid Managed Care rule aims to improve access to and quality of care for Medicaid and Children’s Health Insurance Program beneficiaries. The proposed rule makes changes in the areas of directed payment policy, medical loss ratio policy and reporting, in lieu of service and setting requirements, access standards and monitoring, and quality reviews.
Of note, CMS proposes to maintain states’ ability to implement directed payments for hospital services that would increase payment levels up to the average commercial rate. The agency frames the commercial rate as an upper limit on directed payments for hospital services, professional services at academic medical centers, and nursing facility services. CMS also proposes to maintain many other flexible implementation policies, although certain proposed changes could affect programs in some states. CMS also proposes more robust evaluation requirements for all directed payment programs.
Medicaid Access Rule
The Medicaid Access rule proposes significant changes to home- and community-based services that increase beneficiary involvement in program design and target payment adequacy and transparency. The rule also focuses on access and rate transparency in fee-for-service Medicaid programs, particularly reviewing the current standard for ensuring payment rates support access. The agency describes the current process as largely procedural in nature and heavily reliant on states to form an analysis and reach conclusions on the sufficiency of their own payment rates.
America’s Essential Hospitals is analyzing the proposed rules and will send members a detailed Action Update in the coming days. Comments on both proposed rules are due July 3.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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