New Rule Targets Improved Access and Experience for Enrollees
On May 3, 2023, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule aimed at reforming regulations for Medicaid managed care and the Children’s Health Insurance Program (CHIP). This sweeping proposal is designed to enhance care delivery, improve transparency, and elevate the quality of services for the tens of millions of Americans enrolled in these programs.
Building on earlier reform efforts, this proposed rule marks a significant step in modernizing Medicaid managed care oversight. It addresses long-standing concerns about network adequacy, beneficiary access, rate-setting transparency, and the need for stronger program integrity measures.
CMS Administrator Chiquita Brooks-LaSure emphasized that these changes aim to “deliver better value and outcomes to Medicaid and CHIP enrollees, especially those in vulnerable communities who rely on these programs for essential healthcare.”
Key Proposed Reforms
The proposed rule introduces several core changes, targeting both the structural and operational aspects of managed care programs. Notable proposals include:
1. Stricter Network Adequacy Standards
- States would be required to set and enforce time and distance standards for primary care and behavioral health providers.
- CMS would introduce appointment wait time standards, ensuring that enrollees do not face long delays for routine or urgent care.
- Managed care organizations (MCOs) must maintain real-time provider directories and regularly report on network availability.
2. Increased Rate-Setting Transparency
- The rule proposes greater standardization of rate development, requiring states to publicly disclose how managed care rates are calculated and justified.
- CMS would require states to align rates with performance outcomes and access goals, linking payment more directly to quality of care delivered.
3. Improved Beneficiary Experience and Oversight
- CMS calls for expanded beneficiary input into managed care program design, including the establishment of enrollee advisory boards.
- The rule would mandate clearer grievance and appeals processes, ensuring that patients understand how to challenge denied services or coverage changes.
- Additional protections for language access and disability accommodations are proposed to ensure services are inclusive and accessible to all enrollees.
4. Enhanced Program Integrity and Fiscal Responsibility
- CMS plans to tighten oversight of contractual obligations and payment arrangements between states and managed care entities.
- The rule includes measures to detect and prevent fraud, waste, and abuse, reinforcing accountability in the use of public funds.
Context: A Vital System in Need of Reform
Over 70% of Medicaid enrollees now receive care through managed care arrangements. These organizations are contracted by states to coordinate care, manage costs, and improve health outcomes. While managed care has enabled states to control Medicaid spending and expand benefits, concerns have grown over uneven access to care, opaque financial practices, and inconsistent quality monitoring across states.
The proposed reforms are part of a broader CMS agenda to modernize Medicaid and CHIP, with special attention to health equity, transparency, and person-centered care. The timing is especially significant, as states across the U.S. are currently undergoing the “unwinding” process—redetermining eligibility for millions of enrollees following the end of the COVID-19 public health emergency.
Reactions from Stakeholders
Initial reactions from healthcare advocates and industry stakeholders have been largely positive, with many praising the focus on accountability and equity. Organizations such as the National Association of Medicaid Directors (NAMD) and Medicaid Health Plans of America (MHPA) acknowledged the proposals as a step toward standardizing oversight and ensuring better service delivery.
However, some state agencies and managed care entities have expressed concern about implementation timelines, data reporting burdens, and the financial implications of compliance. CMS has indicated that it will work closely with states to ensure a phased, collaborative rollout of any finalized rules.
Public Comment Period and Next Steps
The proposed rule is open for public comment through the Federal Register, allowing stakeholders—including states, health plans, providers, and beneficiaries—to submit feedback. CMS will review these comments before issuing a final rule, expected later in 2023 or early 2024.
If adopted, these regulations could reshape the landscape of Medicaid managed care, laying the groundwork for a more transparent, equitable, and effective system that better serves the health needs of low-income and vulnerable Americans.
Source:
Burr & Forman LLP – Hot Topics in Health Care: May 2023
