Washington, DC – The Centers for Medicare & Medicaid Services (CMS) has announced the publication of three final rules aimed at enhancing the quality, transparency, and oversight of Medicaid managed care and fee-for-service (FFS) programs. These rules underscore a commitment to improving the Medicaid program’s effectiveness, transparency, and quality of care, create new mechanisms for Medicaid enrollees to provide direct feedback on Medicaid policy, and take steps to increase provider availability, especially for home and community-based services (HCBS) for people with disabilities. CMS also finalized a rule that, for the first time, establishes federal minimum staffing requirements for nursing facilities. Together, these rules promise to make Medicaid programs nationwide more accountable and responsive for millions of Medicaid enrollees while reducing common barriers to needed care.
Ultimately, we hope this will increase access to critical HCBS services that let people with disabilities live in their own communities while also improving historical inequities in how this workforce is paid.
“Nationally, there is a critical direct care workforce shortage. All too often, people eligible for HCBS, which allow people with disabilities and complex medical needs to live in their homes and communities, cannot actually find anyone to provide these essential supports,” said Jennifer Lav, Senior Attorney at the National Health Law Program (NHeLP). “The HCBS access rule creates a mechanism to address historically insufficient rates and establishes that a fair share of state and federal Medicaid dollars go directly to wages for direct care workers, a workforce that is largely composed of immigrants and people of color. Ultimately, we hope this will increase access to critical HCBS services that let people with disabilities live in their own communities while also improving historical inequities in how this workforce is paid.“
The Medicaid managed care final rule creates new standards for plans on appointment wait times and availability. Among these new requirements, states will have to conduct annual independent secret shopper surveys to directly evaluate the accuracy of managed care plan provider directories and the actual availability of network providers. These approaches can help states reduce so-called ghost networks in managed care.
“Nearly three in four people on Medicaid are enrolled in managed care plans,” said Dave Machledt, Senior Policy Analyst with NHeLP. “The final rule strengthens accountability measures to address some of the most common barriers people face when trying to access services. If implemented faithfully, it will make it easier to get timely, high-quality care, and harder for managed care plans to create unfair barriers for the sake of profits.”
Key highlights of the final rules include:
Direct Care Workforce Support: CMS proposes that states and individual providers spend at least 80% of Medicaid payments for personal care, homemaker, and home health aide services directly toward compensating the direct care workforce. States must publish the average hourly rate paid to direct care workers delivering these services. CMS allows states to adopt a separate standard for small providers and/or exempt certain small providers based on reasonable criteria, and provides six years to fully implement this change.
Payment Analysis Requirement and Increased Transparency: States will need to submit an annual payment analysis comparing managed care plan payment rates for certain services to Medicare’s payment rate. Furthermore, states must disclose all FFS Medicaid payment rates on state websites and report on their Medicaid rates relative to comparable Medicare FFS rates every two years. CMS also proposes that states make all FFS Medicaid payment rates public and easily accessible online and creates a process for states to receive input on and regularly review the adequacy of HCBS rates. These measures aim to provide stakeholders with greater insight into Medicaid reimbursement structures.
Centering Feedback from Medicaid Enrollees: The final access rule strengthens channels for Medicaid enrollees to engage directly with state policy through stakeholder advisory groups, including the new Beneficiary Advisory Council and a restructuring of the state’s Medicaid Advisory Committee (MAC). States must also create Interested Party Advisory Groups, including enrollees, their representatives, and direct care workers to provide input on HCBS payment rates and payment adequacy.
Strengthened Oversight and Quality Assurance: A new strategy for oversight, monitoring, and quality assurance is set to be established for Home and Community-Based Services (HCBS) programs. Additionally, states will be required to develop grievance systems in FFS HCBS programs within two years and an incident management system to protect individuals receiving HCBS from abuse and neglect within three years.
Better Tracking of Care Quality: States will have to create and maintain a webpage with annual quality metrics and benchmarks for each plan. To better track health disparities, CMS will now require some metrics to show outcomes by race/ethnicity, and states will also publicly report on a core set of HCBS quality measures. In keeping with the larger push to center enrollee feedback, the HCBS core set requires experience of care surveys that focus on community integration, care coordination and service planning, and other key components of health and welfare for these individuals receiving HCBS. Managed care plans will also have to conduct annual experience of care surveys for all enrollees.
Improving Care in Nursing Facilities: CMS established federal minimum staffing requirements for nursing facilities based on research showing how vital adequate staffing is to delivering timely, high-quality long-term care.
Making it easier to get needed care: The Medicaid managed care access rule sets standards for average wait times for appointments for primary care providers, mental and behavioral health providers, and obstetrics/gynecology. To enforce these standards states must arrange for annual independent secret shopper surveys to measure how well plans meet these standards and to provide data on the accuracy of provider directories. This data will provide a basis to identify gaps and track improvements in access to Medicaid services.
