The Biden administration has proposed new rules aiming to standardize reimbursement for Medicaid care, whether it’s provided through managed care plans or directly by states in fee-for-service arrangements, and inject more transparency into Medicaid payment rates to providers.
The two rules proposed Thursday would require states to publicly disclose provider payment rates for managed care plans versus in fee-for-service every year.
In addition to disclosing and updating fee-for-service rates, states would have to compare their Medicaid and Medicare payment for certain services.
The goal is to create a way for regulators to transparently review Medicaid payment rates across states, and determine how Medicaid payment levels affect care access, the CMS said in a fact sheet on the rules. Medicaid typically pays providers less than in other government programs like Medicare, but has lower reporting requirements.
The rules would also create maximum waiting times for certain appointments, in addition to requiring stronger quality monitoring and reporting standards for Medicaid and Children’s Health Insurance Program managed care plans.
To assist with enforcement, the CMS would require states to implant secret shoppers to verify wait time standards. The new standards include a two-week maximum wait for routine primary care, mental and behavioral health treatment and OB/GYN services.
Also, in a bid for price transparency in home and community-based services, the agency would require that 80% of Medicaid payments for personal care and home health aid services be spent on direct compensation for healthcare workers, instead of contributing to profit or administrative overhead.
The proposed rules would improve Medicaid and CHIP coverage and access, “a key priority that’s long overdue,” CMS Administrator Chiquita Brooks-LaSure said in a statement.
If finalized, the rules would also establish a framework for states to create a “one-stop-shop” quality rating system for Medicaid and CHIP enrollees, who would be able to compare plans based on physician access, covered benefits and other features, according to the CMS.
The Association for Community Affiliated Plans, which represents safety-net payers, said it looked forward to a “careful review” of both regulations, though it’s supportive of the CMS’ steps toward developing a quality rating system for Medicaid managed care plans.
“We’re also supportive of the concept of aligning quality measurement systems across different lines of business, which will provide health plans, health providers and other entities that report on quality measures a common track to run on and facilitate apples-to-apples comparisons,” Margaret Murray, ACAP CEO, said in a statement. “At the same time, these measures should reflect differences in populations served by different plans.”
The rulemaking comes as states resume eligibility checks for coverage that are expected to result in millions of Americans being booted off Medicaid. In addition, Republican leadership in Congress have proposed adding work requirements in Medicaid as part of their package to increase the debt ceiling, a controversial policy requiring enrollees to work, volunteer or receive training to receive government benefits.