CMS Proposes New Access, Network Adequacy Rules for Medicaid and CHIP

The Centers for Medicare and Medicaid Services (CMS) issued two proposed rules on April 27, 2023 to strengthen beneficiary access and quality of care in Medicaid and the Children's Health Insurance Program (CHIP), the largest health coverage programs. The Ensuring Access to Medicaid Services Notice of Proposed Rulemaking (NPRM) and the Managed Care Access, Finance, and Quality NPRM propose several updates to the Medicaid and CHIP regulations, including a proposal to establish national maximum standards for certain appointment wait times and strengthen state monitoring requirements related to network adequacy.

Under the managed care NPRM, Medicaid managed care plans would be bound by certain appointment wait time standards for specific services, including services to treat outpatient mental health and substance use disorder (adult and pediatric). The managed care regulations if finalized would also require states to use an independent entity to conduct secret shopper surveys to validate states’ compliance with appointment wait time standards and to ensure that provider directories are accurate. The managed care NPRM would also require states to (1) conduct and publicly report the results of an annual enrollee experience survey for each Medicaid managed care plan, (2) submit an annual analysis of payment rates for certain services as a portion of Medicare’s payment rate, and (3) maintain a single webpage for hosting the publicly reportable items identified in the NPRM.

Separately, the Medicaid fee for service (FFS) NPRM would require states to make all FFS payment rates publicly available, and include a requirement for states to report their state Medicaid rates for certain services as a proportion of Medicare FFS rates every two years. The Medicaid FFS NPRM would also require that states setup an interested parties advisory group comprised of Medicaid beneficiaries, providers, and other interested parties to advise on current or proposed payment rates. The proposed regulations would require some overlap between the advisory group and the states’ Medical Care Advisory Committees, which the NPRM proposes to rename to Medicaid Advisory Commission. CMS has also proposed in this NPRM to change the way the Access Monitoring Review Plans (AMRP) process is conducted with a tiered approach to determine whether changes in state Medicaid payment rates are sufficient.

As part of CMS’ effort to improve transparency and beneficiary engagement, states would also need to establish a dedicated hub for beneficiaries to compare plans, determine eligibility, review plans’ drug formularies, and determine provider network participation.

More information about these proposals can be found here and here. Comments on both NPRMs are due July 3, 2023.