Apr 27 -- The Centers for Medicare & Medicaid Services (CMS) today unveiled a notice of proposed rulemaking (NPRM), Managed Care Access, Finance, and Quality (Managed Care NPRM). This proposed rule aims to help states build stronger programs to better meet the needs of the Medicaid and CHIP populations by improving access to and quality of care provided to Medicaid and CHIP managed care enrollees. Medicaid and CHIP are the nation’s largest health coverage programs. If adopted as proposed, this rule would build on Medicaid’s already strong foundation as an essential program for millions of families and individuals, especially children, pregnant people, older adults, and people with disabilities.
Over 70 percent of the Medicaid and CHIP population are enrolled in managed care plans. In recent years, States have struggled to ensure beneficiaries’ access to high-quality care, ensure adequate provider payment during extreme workforce shortages, and provide adequate program monitoring and oversight. Executive Order 14009 in 2021 established the policy objective to protect and strengthen Medicaid and the Affordable Care Act (ACA), and to make high-quality health care accessible and affordable for every American. In 2022, Executive Order 14070 directed agencies to identify ways to continue to expand the availability of affordable health coverage, to improve the quality of coverage, strengthen benefits, and to help more Americans enroll in quality health coverage.
This proposed rule would advance CMS’s efforts to improve access to care, quality and health outcomes, and better address health equity issues for Medicaid and CHIP managed care enrollees. The proposed rule would specifically strengthen standards for timely access to care and states’ monitoring and enforcement efforts; enhance quality as well as fiscal and program integrity standards for Medicaid state-directed payments (SDPs); specify the scope of in lieu of services and settings to better address health-related social needs (HRSNs); further specify medical loss ratio (MLR) requirements; and establish a framework and other requirements for states to implement a quality rating system (QRS) to compare Medicaid and CHIP managed care plans.
The proposed rule includes significant regulatory revisions in the following areas: . . .
The proposed rule is available at https://www.federalregister.gov/d/2023-08961
. Summary: This proposed rule would advance CMS' efforts to improve access to care, quality and health outcomes, and better address health equity issues for Medicaid and Children's Health Insurance Program (CHIP) managed care enrollees. The proposed rule would specifically address standards for timely access to care and States' monitoring and enforcement efforts, reduce burden for some State directed payments and certain quality reporting requirements, add new standards that would apply when States use in lieu of services and settings (ILOSs) to promote effective utilization and specify the scope and nature of ILOS, specify medical loss ratio (MLR) requirements, and establish a quality rating system for Medicaid and CHIP managed care plans. Public comments are due by July 3, 2023.
Fact sheet: https://www.cms.gov/newsroom/fact-sheets/notice-proposed-rulemaking-medicaid-and-childrens-health-insurance-program-chip-managed-care-access
Summary of CMS’s Access-Related Notices of Proposed Rulemaking: Ensuring Access to Medicaid Services (CMS 2442-P) and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-P): https://www.cms.gov/newsroom/fact-sheets/summary-cmss-access-related-notices-proposed-rulemaking-ensuring-access-medicaid-services-cms-2442-p
Summary of Medicaid and CHIP Payment-Related Provisions: Ensuring Access to Medicaid Services (CMS 2442-P) and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-P): https://www.cms.gov/newsroom/fact-sheets/summary-medicaid-and-chip-payment-related-provisions-ensuring-access-medicaid-services-cms-2442-p