On May 3, 2023, the Centers for Medicare & Medicaid Services (CMS) published the proposed rule, Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality.
The proposed rule would make transparency-related updates to state directed payments (SDPs). It would also require states to submit an annual payment analysis that compares managed care plans’ payment rates for routine primary care services, obstetrical and gynecological services, and outpatient mental health and substance use disorder services as a proportion of Medicare’s payment rates. The proposal would establish a framework for states to implement a Medicaid or Children’s Health Insurance Program (CHIP) quality rating system to create 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. The rule would also require states to submit an annual payment analysis that compares managed care plans’ payment rates for homemaker services, home health aide services and personal care services as a proportion of the state’s Medicaid state plan payment rate.
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CMS proposes several substantial updates to the Managed Care Rule, including the following:
- Making several process and transparency-related updates to SDPs to ensure integrity of payments and that SDPs meet the goals of the Medicaid program
- Creating new payment transparency for states by conducting a managed care provider payment rate analysis for certain services
- Establishing national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees for four specified service areas
- Requiring states to conduct independent secret shopper surveys of managed care plans to verify compliance with appointment wait time standards and to identify provider directory inaccuracies
- Requiring states to conduct annual enrollee experience surveys for each managed care program
- Requiring states to develop a remedy plan to address identified access issues with specific steps and timelines for implementation and completion, and responsible parties
- Creating new reporting and standard requirements for “in lieu of services”
- Increasing transparency and opportunity for meaningful ongoing public engagement around states’ managed care quality strategies
- Establishing requirements for clinical or quality improvement standards for provider incentive arrangements and for expense allocation reporting and prohibiting the inclusion of administrative costs in reporting quality improvement activities.