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CMS Releases Medicaid Access and Managed Care Rules

CMS Releases Medicaid Access and Managed Care Rules


Courtesy of the National Association for Home Care & Hospice

On April 27, 2023, the Centers for Medicare & Medicaid Services (CMS) released a pair of proposed regulations that will significantly impact the Medicaid program if finalized. The two rules jointly address a wide range of issues regarding access to and payment for Medicaid services.

Access to Medicaid Services

Home and Community-Based Services (HCBS) Payment Adequacy

CMS proposes to require that at least 80% of all Medicaid payments, including but not limited to base payments and supplemental payments, with respect to the following services be spent on compensation to direct care workers who provide homemaker services, home health aide services, and personal care services. Compensation would include salary, wages, and other remuneration as defined by the Fair Labor Standards Act (FLSA) and implementing regulations, and benefits (such as health and dental benefits, sick leave, and tuition reimbursement). In addition, CMS proposes to define compensation to include the employer's share of payroll taxes for direct care workers delivering services under section 1915(c) waivers.

CMS would require that these requirements apply to services delivered under both fee-for-service and managed care delivery systems. Further, CMS requests comment on whether these requirements should apply to section 1905(a) state plan for personal care and home health services.

The proposed rule includes reporting requirements for states around payment adequacy for home- and community-based services (HCBS) and revisions to the HCBS quality measure set.

Additionally, CMS proposes to add a new section to promote public transparency related to the administration of Medicaid-covered HCBS.

Click here to access the proposed rule.

Medicaid Managed Care

In the proposed rule, CMS intends to advance 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 the burden for some state-directed payments and certain quality reporting requirements, and add new standards that would apply when states use in lieu of services and settings (ILOSs).

This is an initial summary of some of the prominent provisions. A more detailed analysis will be forthcoming shortly. While these rules are substantial and could be significantly impactful, it is important to remember that both releases are proposed rules, and changes are likely to be made before they are finalized.

Click here to access the proposed rule.

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