April 23, 2024

Press Release from CMS, 4/22/24

Biden-Harris Administration Takes Historic Action to Increase Access to Quality Care, and Support to Families and Care Workers

Nursing home minimum staffing standards promote resident care and safety
Medicaid and CHIP to have historic access standards, advance fair compensation for direct care workers

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today issued three final rules to fulfill President Biden’s commitment to support family caregivers, boost compensation and job quality for care workers, expand and improve care options, and improve the safety and quality of care in federally-funded nursing homes. The actions, announced during Care Workers Recognition Month and the Month of Action on Care, represent a transformational investment to support America’s families and workers.

The three rules announced today build on the President’s historic Action Plan for Nursing Home Reform and support of President Biden’s April 2023 Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers (Care EO). They also follow through on President Biden’s State of the Union commitments to improve the quality of nursing home care; support older adults, people with disabilities, and care workers; and strengthen the economy.

• “Minimum Staffing Standards for Nursing Homes” establishes, for the first time, national minimum staffing requirements for nursing homes to improve the care that residents receive and support workers by ensuring that they have sufficient staff.
• “Ensuring Access to Medicaid Services” (“Access Rule”) creates historic national standards that will allow people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) to better access care when they need it and also strengthens home and community-based services (HCBS), which millions of older adults and people with disabilities rely upon to live in the community. This landmark final rule will set minimum threshold standards for payments to the direct care workforce, create meaningful engagement with Medicaid consumers, and advance provider rate transparency.
• “Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” (“Managed Care Rule”) will improve access to care, accountability and transparency for the more than 70 percent of Medicaid and CHIP beneficiaries who are enrolled in a managed care plan. It will require a limit on how long enrollees have to wait for an appointment and allow people to compare plan performance based on quality and access to providers.

“Everyone should have equal access to the critical care they need. Our caregivers – those who are taking care of the ones we love – deserve our respect and full support. That’s why HHS has been at the center of the Biden-Harris Administration’s efforts to improve care and caregiving for Americans at all stages of their lives,” said HHS Secretary Xavier Becerra. “We are taking important steps to strengthen care provided through Medicaid and CHIP, and establishing national staffing standards for nursing homes to enhance care for residents while improving conditions for workers. This will help ensure that millions of people have access to high-quality health care and that the dedicated workers who provide care to our loved ones are fully valued for their work.”

“We’ve implemented significant changes across CMS programs to ensure eligible people can benefit from the critical lifeline afforded by health care coverage. Now, CMS has set its sights on an equally ambitious goal: making sure that coverage connects people to consistently high-quality care, regardless of where they live or receive care,” said CMS Administrator Chiquita Brooks-LaSure. “That goal is ambitious, attainable, and rooted in the Biden-Harris Administration’s priority to ensure millions of people have access to affordable, quality health coverage and can stay healthy and thrive.”

Medicaid Access and Managed Care

The Access and Managed Care rules create the strongest requirements yet for improving accountability, transparency, and access to health coverage in the nation’s largest health care program. Building on Medicaid and CHIP’s already strong foundation, these two rules together create historic national standards that will allow people with Medicaid and CHIP to better access care when they need it, finalize payment standards for direct care workers providing HCBS, and will make provider rates more transparent. Adding to recent progress to streamline and strengthen Medicaid and CHIP enrollment and eligibility, today’s rules establish tangible, consistent standards for millions of children, families, adults, and people with disabilities regardless of the state in which they live.

For example, for the first time ever, states will be required to have national appointment wait time standards. States will enforce these wait time standards by conducting “secret shopper” surveys, which can help verify compliance with appointment wait time rules and correct provider directory inaccuracies. States will also now be required for the first time to disclose provider payment rates publicly. Additionally, the rules will create a new beneficiary advisory committee in every state, which will allow for direct feedback to state Medicaid and CHIP programs on benefits and service delivery from the people who access it daily.

The Access Rule strengthens HCBS by requiring that at least 80 percent of Medicaid HCBS payments directly compensate direct care workers rather than cover “administrative overhead.” The rule also requires states to report how they establish and maintain HCBS wait lists, assess wait times, and report on quality measures. This policy would allow states to take into account small providers and providers in rural areas, promote training and quality, and ensure smooth implementation with additional data collection prior to full phase-in.

It protects the health and safety of people who receive HCBS by improving states’ incident management systems and requires states to have a grievance process for all HCBS participants. 

The Managed Care rule defines the scope of “in lieu of services and settings” (ILOS) services in managed care to better address enrollees’ health-related social needs (e.g., support for housing- and nutrition-related services). Additionally, it establishes a quality rating system for Medicaid and CHIP managed care plans – a “one-stop-shop” where beneficiaries can learn about eligibility for plans and compare them based on quality and other factors.

For additional information on the rules issued today, please consult the CMS fact sheets on nursing home staffing standards, Access, and Managed Care.
April 22, 2024 04:12 PM 52 MINUTES AGO

CMS finalizes sweeping Medicaid managed care rules

NONA TEPPER, MODERN HEALTHCARE, 4/22//24

Regulators enacted a pair of wide-reaching rules on Monday intended to increase transparency and improve the patient experience for the more than 80 million enrollees in Medicaid managed care plans. 

The Centers for Medicare and Medicaid Services will require states and Medicaid insurers to annually report how carriers spend state-directed payments to providers, how their rates compare to Medicare, and survey managed care enrollees about their experience with insurance companies. CMS also mandated states create “one-stop-shop” websites that allow enrollees to compare the quality ratings of Medicaid managed care plans. 
The new rules come as states continue to adjust their Medicaid rolls after Congress lifted the continuous coverage provision that was part of the COVID-19 public health emergency

Regulators also finalized proposals capping how much home care agencies can profit from state Medicaid payments. CMS will require at least 80% of state Medicaid payments to personal care, home health aide and other home- and community-based service organizations be spent on direct payments to workers, rather than kept by agencies as administrative overhead or profits. States must also publish the average hourly rate paid to those workers. 

The agency also completed rules establishing national wait time standards for routine primary care appointments, such as obstetric services or outpatient mental health treatment, and will require states to conduct “secret shopper” surveys of insurers’ provider networks. State Medicaid directors in comments to regulators wrote that establishing national wait times failed to account for local provider shortages in certain areas. 

In addition, CMS capped insurers’ state-directed payments for inpatient and outpatient hospital, nursing facility and professional services at academic medical centers to the average commercial rate. Previously, there was no maximum for state-directed payments. The agency will require states to disclose how much Medicaid insurers spend on patients’ medical costs, quality and administrative expenses and how much is kept as profit. This metric is known as the medical loss ratio. President Joe Biden’s draft budget for fiscal 2025 likewise called on states to set Medicaid MLRs. 

Regulators also codified guidance on how Medicaid agencies can pay for nonclinical care.

The Biden administration has pledged to increase oversight of Medicaid insurers as more states have privatized coverage. Forty-one states contract with insurance companies to manage care for their Medicaid enrollees. The CMS fact sheet for the final rule noted that oversight of carriers “has been limited by outdated regulations that need to be more comprehensive and consistent across delivery systems and coverage authorities.” 

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