Managed Care and Chips: CMS Issues Proposed Rule CMS-2439-P

The Centers for Medicare & Medicaid Services (CMS) just issued the above proposed rule—Managed Care Access, Finance and Quality.  Before digging into the rule,  I am going to provide some basic definitions.

Medicaid is a federal and state program that provides health coverage to low-income individuals and families. It is jointly funded by the federal government and the state government, and the eligibility requirements and benefits can vary by state.

Medicaid covers a wide range of medical services, including doctor visits, hospital care, prescription drugs, and long-term care. It is the largest source of health coverage for low-income Americans, including children, pregnant women, adults with disabilities, and elderly individuals.

The Children’s Health Insurance Program (CHIP) is a federal program that provides low-cost health coverage to children and families who do not qualify for Medicaid but cannot afford private health insurance. Like Medicaid, CHIP is jointly funded by the federal government and the state government, and the eligibility requirements and benefits can vary by state.

The proposed rule major requirements include the following:

• Every other year, states will be required to publish an analysis that compares Medicaid and Medicare payment rates for critical services, including primary care, obstetrical and gynecological services, and outpatient behavioral health. This analysis must be granular, meaning that if a state varies its payment rates, the analysis must separately compare rates paid to providers based on population (children and adults), different provider types, and different geographic locations in the state. This level of detail will enable stakeholders to better understand how Medicaid payment rates compare to Medicare and whether there are discrepancies in payment rates across different groups and regions.

• Every other year, states will be required to publish a disclosure of the average hourly rate paid to direct care workers providing certain Home and Community-Based Services (HCBS), specifically personal care, home health care, and homemaker services. This information would separately disclose rates for individual direct care providers and direct care providers employed by an agency.

• 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.
• 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.

There will be a 60-day comment period for the notices of proposed rulemaking (NPRM), and comments must be submitted to the Federal Register no later than 60 days after date of NPRM publication in the Federal Register.

This is just a proposed rule, and I will be breaking down the details and potential impacts over the next several weeks – stay tuned.