CMS releases proposed rules for Medicaid access and payment

The Centers for Medicare & Medicaid Services released two proposed rules focused on ensuring access to services for Medicaid and Children’s Health Insurance Program beneficiaries across fee-for-service and managed care delivery systems. The proposed requirements are intended to increase transparency, improve accountability, and ensure standardized data and monitoring. 

For FFS payments, CMS proposes to require that states publicly publish and update regulatory payment rates for all services and compare Medicaid and Medicare payment rates for primary care, obstetrical and outpatient behavioral health. States also would be required to demonstrate through a specified process that any provider FFS payment rate reduction or restructuring would not put access to care at risk.  

For managed care contracts, CMS proposes to establish maximum appointment wait times for primary care, obstetric and gynecology services, and substance abuse disorder services. It also would require secret shopper surveys and an annual payment analysis for certain services. 

CMS also is proposing several changes to its directed payment policies. It would remove regulatory barriers for states to use directed payments to implement value-based arrangements and eliminate prior approval for state directed payments using minimum fee schedules. The proposal would require that state payment levels for hospital, nursing and professional services at academic medical centers not exceed the average commercial rate. It also would require states to comply with all federal laws concerning funding sources and require providers receiving directed payments to attest that they do not participate in any impermissible provider tax hold-harmless arrangements. In addition, CMS proposes additional Medical Loss Ratio requirements specifically for directed payment programs as well as additional quality reporting requirements. 

Watch for AHA Special Bulletins with more on both rules soon.