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CMS Issues Two Proposed Rules for States Regarding Quality and Access to Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) recently announced two proposed rules: Ensuring Access to Medicaid Services (the “Access Rule”) and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (the “Managed Care Rule”). The deadline for public comment is July 3rd.

The “Access Rule” requires states to provide certain access requirements for fee-for-service (FFS) beneficiaries, while the "Managed Care Rule” increases access to services in managed care programs. A LeadingAge National article on the two rules can be found here.

The “Access Rule” makes the following proposals regarding states’ administration of home and community-based services (HCBS) delivered through 1915(c), (i), (j), and (k) programs:

  • Person-Centered Planning (PCP): establishes reassessment and PCP review timelines annually for 90 percent of enrollees receiving HCBS in 1915(c), (i), (j), and (k) programs.
  • Grievance Systems: requires states to establish a beneficiary grievance system for FFS HCBS.
  • Incident Management System: requires states to amend critical incident definitions to include minimum requirements and adopt electronic incident management systems that collect, track, and trend data on critical incidents.
  • HCBS Payment Adequacy: requires 80 percent of Medicaid reimbursements, including supplemental payments, to support compensation to direct care workers in three service categories: homemaker, home health aide, and personal care.

The aim of the “Managed Care Rule” is aligned with that of the “Access Rule”: increase access to services in managed care programs. Some highlighted provisions include the following:

  • CMS proposes to use the Average Commercial Rate (ACR) as an upper limit for inpatient services like nursing facility services. ACR review would include any related state directed payments.
  • CMS proposes changes to documentation and transparency for state directed payments to better compel value-based payments and quality improvement initiatives.
  • CMS clarifies that In Lieu of Services (ILOS) can be used as preventive measures. Preventive ILOS can be approved for either short- or longer-term substitution of a covered state plan service.

These rules impose significant requirements and infrastructure development on states. Implementation timelines for various provisions range from 60 days following publication as final to three years post-publication.

LeadingAge NY encourages members to provide feedback to us and to LeadingAge National. The deadline for public comment on both proposed rules is July 3rd.

Contact: Meg Everett, meverett@leadingageny.org, 518-867-8871