3 Policies and Regulations Look to Change the Future of Medicare and Medicaid

How CMS is Proposing Changes to Medicare and Medicaid, and Medicaid Managed Care 1. CMS Establishes a Managed Care Group The Centers for Medicare & Medicaid Services has established a new entity, the Managed Care Group, in a notice published in the Federal Registry on June 5, 2023. The entity provides national leadership in the development and management of Medicaid program policy and operations regarding managed care programs and provides technical assistance to States and other stakeholders. The entity establishes Medicaid program policy around access, and accountability for all managed care programs regardless of authority used and including all populations (e.g., Temporary Assistance for Needy Families, dually eligible, foster care children, individuals who need long-term services and supports) and the following: Provides Medicaid managed care policy and operational guidance to States and internal and external stakeholders to ensure appropriate application of the policy. Provides subject matter expertise and technical support/assistance in the review, approval, and oversight of managed care in Section 1115 demonstrations. Supports delivery systems reform through the development and implementation of policy around state-directed payments, including technical assistance to states, review and approval of 438.6(c) preprints, and responding to external inquires related to the 438.6(c) approval process. Establishes and reviews policy and performs operations related to 1915(b) waivers and 1932(a) SPAs, including the review and approval of new managed care programs, renewals and amendments to ensure appropriate application of Medicaid managed care policy in state Medicaid programs. Leads reviews of state contracts and amendments with managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, primary care case management entities, enrollment brokers and external quality review organizations to confirm that contracts and capitation rates, when applicable, satisfy federal laws and regulations and are consistent with the Federal managed care authority(ies) approved by CMS. Reviews at-risk capitation rates for consistency between the rate certification, the contract provisions, and the Federal managed care authority (ies) approved by CMS. Reviews and approves state plan amendments and capitation rates for Programs of All-Inclusive Care of the Elderly. Reviews States' risk mitigation strategies for consistency between the contract and the rate certification and tracks the status of risk mitigation reconciliation activities. Conducts readiness assessment reviews and ongoing monitoring and oversight of Medicaid managed care programs. Collaborates with States in their implementation of approved managed care programs. Serve as the policy lead and liaison with the Office of the Actuary in the review and approval of effective and efficient rate methodologies. The primary point of contact for policy questions on Mental Health Parity and the application of that policy in the review of documents provided by States. 2. CMS Exploring Who Gets Paid For Coordinating Social Determinants CMS exploring models centered on social health factors According to agency officials, CMS is exploring programs that would pay social or community health workers to address patients’ social needs for greater investments in food, housing, transportation ,and other social determinants of health. At a CMS health equity conference, CMS CMO Lee Fleisher, CMMI head Liz Fowler and Medicare Director Meena Seshamani talked on a panel during about trying to work around restrictions regarding what groups Medicare is allowed to pay as they look to address social determinants of health. “We are looking at that. For example, in maternal health, thinking about the role of doula and community health workers,” Liz Fowler said. Advocates have been calling for greater investment in the nation’s underfunded social care programs, to address downstream factors that result in poor health outcomes. Though it might seem backward for healthcare programs to address things like food or housing insecurity, the reality is that they have more money to spend, Fowler said. However, legal requirements stipulating who Medicare is allowed to pay — essentially, traditional healthcare providers — can hamstring the creation of more social-focused programs, said Meena Seshamani, CMS Medicare director. 3. Ensuring Access to Medicaid Services (Access NPRM); and Managed Care Access, Finance, and Quality (Managed Care NPRM) The Centers for Medicare & Medicaid Services (CMS) unveiled two notices of proposed rulemaking (NPRMs), Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM), that together would further strengthen access to and quality of care across Medicaid and the Children’s Health Insurance Program (CHIP), the nation’s largest health coverage programs. If adopted as proposed, the rules would establish historic national standards for access to care regardless of whether that care is provided through managed care plans or directly by states through fee-for-service (FFS). Specifically, they would establish access standards through Medicaid or CHIP managed care plans as well as transparency for Medicaid payment rates to providers, including hourly rates and compensation for certain direct care workers. The rules would also establish other access standards for transparency and accountability, and empower beneficiary choice. Together, the Access NPRM and Managed Care NPRM include new and updated proposed requirements for states and managed care plans that would establish tangible, consistent access standards, and a consistent way to transparently review and assess Medicaid payment rates across states. The rule also proposes standards to allow enrollees to easily compare plans based on quality and access to providers through the state’s website. Other highlights from the proposed rules include: Establishing national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees, and stronger state monitoring and reporting requirements related to access and network adequacy for Medicaid or CHIP managed care plans, which now cover the majority of Medicaid or CHIP beneficiaries. Requiring states to conduct independent secret shopper surveys of Medicaid or CHIP managed care plans to verify compliance with appointment wait time standards and to identify where provider directories are inaccurate. Creating new payment transparency requirements for states by requiring disclosure of provider payment rates in both fee-for-service and managed care, with the goal of greater insight into how Medicaid payment levels affect access to care. Establishing additional transparency and interested party engagement requirements for setting Medicaid payment rates for home and community-based services (HCBS), as well as a requirement that at least 80 percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for direct care workers (as opposed to administrative overhead or profit). Creating timeliness-of-access measures for HCBS and strengthening necessary safeguards to ensure beneficiary health and welfare as well as promote health equity. Strengthening how states use state Medical Care Advisory Committees, through which stakeholders provide guidance to state Medicaid agencies about health and medical care services, to ensure all states are using these committees optimally to realize a more effective and efficient Medicaid program that is informed by the experiences of Medicaid beneficiaries, their caretakers, and other interested parties. Requiring states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan to gather input directly from enrollees. Establishing a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” for enrollees to compare Medicaid or CHIP managed care plans based on quality of care, access to providers, covered benefits and drugs, cost, and other plan performance indicators. Download ArticleDownload the Entire Issue

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3 Policies and Regulations Look to Change the Future of Medicare and Medicaid

How CMS is Proposing Changes to Medicare and Medicaid, and Medicaid Managed Care

1. CMS Establishes a Managed Care Group

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