Biden Administration Proposes Two New Rules to Significantly Improve Access to Care for Consumers Enrolled in Medicaid and CHIP

Editor’s Note: Since this post was published, CCF submitted formal comments on both the Medicaid Access and Managed Care proposed rules. 

If you thought you saw fireworks last night, it could be in celebration of the Biden Administration posting two(!) proposed rules yesterday tackling access to care in Medicaid and CHIP. It will take some time to unpack all of the provisions, but it’s clear that the Administration is committed to making meaningful and parallel access improvements in both fee-for-service (FFS) and managed care and across Medicaid authorities (whether the state is operating under state plan or waiver authority). The first access rule, with regulatory provisions directed mostly at FFS and home and community-based services (HCBS) is available here and the managed care-specific rule here. They laid the groundwork for these rules last year, with a formal request for information on Medicaid/CHIP access.

This is no small feat. The Medicaid statute sets out a broad access standard at §1902(a)(30)(A), calling on states to ensure that, “care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” But this requirement is implemented under different regulatory regimes, and historically, updates to FFS and managed care access regulations come at different times, often under different administrations, leading to a confusing matrix of standards that don’t always work well together. The Administration should be applauded for trying to set standards that are more comprehensive and consistent across delivery systems.

Most Medicaid/CHIP enrollees get their care through comprehensive, risk-based managed care arrangements. In 2020, MACPAC reported that 70% of Medicaid beneficiaries were enrolled in managed care, but managed care penetration has grown since then. Still, the 2020 data are useful because they show that there are meaningful differences by eligibility group and by state. Nationally, children and Medicaid expansion enrollees are the most likely to be in managed care (about 82% for both groups) compared to people with disabilities (about 52%) and people over 65 years old (about 37%). In 9 states, over 90% of all Medicaid beneficiaries are enrolled in managed care (Arizona, Hawaii, Iowa, Kansas, Louisiana, Nebraska, New Jersey, Pennsylvania and Tennessee). (See MACStats Exhibit 30.)

Having strong access rules in Medicaid managed care – and making sure they are implemented and enforced – is key to making sure that Medicaid enrollees actually receive necessary services. The managed care proposed rule would establish appointment wait time standards and require testing network adequacy through secret shopper surveys, helping to make sure that the standards laid out on paper are working in practice. It would also require states to survey enrollees annually; submit annual payment analyses; and post required information on a single, easy to use webpage, including plan-specific quality data to help beneficiaries select a plan. This is a big step forward – data transparency has been sorely lacking.

Finalizing one rule, just on managed care, would be a big deal. But as noted above, stopping here would neglect particular groups (people with disabilities, people dually enrolled in Medicare and Medicaid) and people of all ages and health status in particular states (Alabama, Arkansas, Alaska, Connecticut, Idaho, Maine, Montana, Oklahoma, South Dakota, Vermont, and Wyoming) where comprehensive, risk-based managed care serves less than 1% of total Medicaid enrollees. Moreover, it would mean missing a critical opportunity to set more consistent rules across all delivery systems.

Like the managed care proposed rule, the FFS/HCBS access rule would increase transparency, particularly around provider payment rates. It would also set new access standards for home and community-based services, require states to engage beneficiaries through standing advisory groups, and simplify data submission requirements.

With more than 90 million people, including more than half of U.S. children, receiving their health care through Medicaid, ensuring that families can receive the services they need in a timely way is essential. Greater transparency and accountability and more meaningful ways for families and other stakeholders to provide feedback are all important principles to ensure that Medicaid is the very best that it can be.

It’s time to get comfy in your favorite reading chair – there’s a lot to digest. We’ll continue to write about the rules over the next couple of weeks. Comments are due 60 days after formal publication, probably around July 2nd. Just in time for the real fireworks.

Kelly Whitener is an Associate Professor of the Practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.