CMS Proposes New Rules to Strengthen Transparency and Access to Quality Care in Medicaid and CHIP Programs

Published in Government Relations on May 01, 2023

CMS has released two new proposed rules that look to strengthen transparency as well as access to quality care within the Medicaid and CHIP programs. One of the proposed rules is titled Ensuring Access to Medicaid Services, and the other is Managed Care Access, Finance, and Quality. The proposed rules aim to create uniform access standards for Medicaid and CHIP-managed care plans, transparency in payments to providers, and other access standards for transparency and accountability, with an emphasis on beneficiary choice. 

A summary of the key components of the proposed rules would 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.
  • States must conduct independent secret shopper surveys of Medicaid or CHIP-managed care plans to verify compliance with appointment wait time standards and 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 to 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 the quality of care, access to providers, covered benefits and drugs, cost, and other plan performance indicators.

A couple of links with additional information about both proposed rules are included here: 

Most DME providers would agree that there is much room for improvement when it comes to Medicaid programs, especially managed Medicaid MCOs, ensuring network adequacy, beneficiary choice, and access to proper care when and where it is needed. While there is no specific mention of DME specifically in these proposed rules, the good news is that these are simply proposed rules and there is a comment period that is open until July 3, 2023. If you would like to promote positive change to rules that govern these Medicaid plans, please join us in submitting comments to these proposed rules before the comment submission deadline.


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