The Final Medicaid Access and Managed Care Rules Expected Soon from CMS: Are You Ready?

The Medicaid policy community is anticipating the release of two final rules that could create many new requirements for states, with the goal of improving access to Medicaid services.  Last April, the Centers for Medicare & Medicaid Services (CMS) released two notices of proposed rulemaking (NPRMs) intended to improve access to care for Medicaid beneficiaries: Ensuring Access to Medicaid Services (CMS-2442-P), referred to as the Access NPRM, and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-P), also known as the Managed Care NPRM. We recapped provisions of these NPRMs focusing on home and community-based services (HCBS) in a prior blog post. 

CMS is expected to finalize these regulations in the coming weeks, as part of an active regulatory season that has included rulemaking across Medicaid, Medicare, and the Marketplaces. As publication of the final rules draws closer, we are focused on the following questions. 

How Will CMS Respond to Stakeholder Comments? 

CMS received approximately 2,200 comment letters on the Access NPRM and about 400 comment letters on the Managed Care NPRM. In particular, the HCBS payment adequacy provision in the Access NPRM garnered a great deal of feedback. The proposal would require that within the next four years, states ensure that at least 80% of state Medicaid payments for certain services goes directly to HCBS direct care worker compensation, including wages and benefits. In recent decades, states have expanded their HCBS programs, which allow individuals who need long-term care and support to receive services in their homes rather than an institutional setting. However, this progress is threatened by a persistent and growing HCBS workforce shortage, and this proposal aims to ensure competitive wages and benefits, one of the many necessary factors to address the workforce shortage. Joint comments submitted by the National Association of Medicaid Directors, ADvancing States, and the National Association of State Directors of Developmental Disability Services illustrate concerns about the HCBS payment adequacy proposal. Rather than establishing a universal threshold, these groups requested that CMS pursue a state-tailored approach by, for example, allowing states to propose their own rate-setting strategy or electing their own minimum percentage pass-through amount. They also suggested changing the services that are stipulated by the requirement, proposed that the implementation timeline be extended from four years to at least six years, and requested that, if CMS is to use a universal threshold, it be lowered to 70 percent. 

Given the high volume of comments and concerns raised, CMS may use stakeholder data and alternative proposals to refine its policies. Might the final rules reflect significant shifts from the NPRMs?  

What Lessons Can be Learned from Other States for Implementation? 

As states and other stakeholders digest the Access and Managed Care final rules, the implementation work ahead will be significant. However, prior innovations can inform state approaches to this work. For example, if CMS finalizes the HCBS payment adequacy provision, states that have already implemented enforcement provisions associated with wage pass-through policies for direct care workers can serve as case studies (as documented in a report authored by Aurrera Health for the National Governors Association Center for Best Practices). One such case study is Colorado, which requires that providers use rate increases towards achieving a minimum wage for direct care workers, currently $15.75 an hour, and those who do not comply must return funds to the state. States may need to look beyond the rules’ provisions and consider similar upstream policy changes to ensure compliance with an HCBS payment adequacy threshold. How can states look to each other as resources and facilitate sharing innovations and best practices? 

Will the Rules Produce the Intended Result? 

CMS’ stated intent for these rules is advancing its health equity goals and improving beneficiary access to care, improving quality of care, and improving health outcomes in both fee-for-service (FFS) and managed care delivery systems. Many of the provisions support building an infrastructure for both CMS and states to better understand where access currently stands and track improvements across time, but their ultimate effects on access may take time to realize. What benchmarks will help monitor and ensure progress? 

Introducing Aurrera Health Blog Series on Access and Managed Care Final Rules 

Aurrera Health Group was pleased to support CMS in its development of the Access NPRM through a partnership with the MITRE Corporation. Our staff provided technical assistance to inform the development of the rule by providing policy analysis and advice, conducting environmental scans, and gathering stakeholder insights. This work leveraged our deep expertise on HCBS, community and stakeholder engagement, and quality and performance measurement. Given the wide scope of the initial proposals, implementing the final rules will be a major effort for states. Aurrera Health will continue this blog series to digest the Access and Managed Care final rules, look at state experiences to identify lessons, and provide insights that can inform implementation plans. We look forward to helping states and other stakeholders understand and implement requirements to support Medicaid beneficiary access. If you would like to discuss how we can help your state, please reach out to Aurrera Health Managing Principals Megan Thomas or Kristal Vardaman. 

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Authors

Kristal Vardaman [Managing Principal]