CMS released a proposed rule related to Medicare hospital outpatient and ambulatory surgical center payments that also includes provisions codifying the Consolidated Appropriations Act of 2023 (CAA) requirement that states provide 12-months of continuous eligibility to all children in Medicaid and CHIP under age 19 as of January 1, 2024. While most of the rule is dedicated to Medicare payment policy, it also includes important provisions to strengthen access to and quality of maternal health care.
12-Month Continuous Eligibility for Children
The pandemic era Medicaid continuous coverage protection clearly demonstrated how continuous enrollment promotes continuity of coverage and access to care. As part of codifying the statutory requirement that all states provide 12-month continuous eligibility for children in Medicaid and CHIP, the proposed rule reiterates that the statutory requirement does not permit states to terminate CHIP coverage for non-payment of premiums until the end of the 12-month renewal period, as CMS already made clear in guidance issued in October 2023. The only exceptions to the 12-month continuous eligibility are if 1) the child moves out of the state; 2) the family requests voluntary disenrollment; 3) the child dies; 4) or the agency determines that eligibility was erroneously granted at the most recent determination, redetermination, or renewal of eligibility because of agency error or fraud.
Minimum Standards for Hospital Obstetrical Services
It’s no secret that the United States has the worst maternal health outcomes than any other industrialized nation. Deficiencies in coverage and the delivery of care have a disproportionate impact on Black and Indigenous women, who are two to three times more likely to suffer a pregnancy-related death than non-Hispanic White women. The proposed rule would establish baseline standards regarding organization, staffing, training, quality assessment and performance improvement, and delivery of obstetrical services in hospitals and Critical Access Hospitals (CAHs) by revising Conditions of Participation (CoPs) requirements. CoPs, which may be a new term for some Medicaid stakeholders, are designed to protect patient health and safety by ensuring that enrollees in any federally funded healthcare program, including Medicare, Medicaid, and CHIP, receive quality care from all participating organizations. The proposed rule expressly indicates that both physical and behavioral health services are subject to the proposed CoPs.
Emergency Services Readiness
CMS is also revising its Emergency Services Conditions of Participation to CMS to improve facility readiness in caring for emergency services patients, including pregnant, birthing, and postpartum women. It is important to note that these proposed emergency services requirements would apply to all hospitals and CAHs offering emergency services, regardless of whether they provide specialty care, such as obstetric services.
Medicaid Reimbursement for Certain Services Outside a Clinic
The proposed rule would require states to reimburse for services furnished outside the “four walls” of a freestanding clinic operated by Indian Health Services (IHS) and tribes, which are typically paid for via a facility-based payment rate that generally accounts for more overhead costs. Under current law, states receive a 100% federal matching rate for Medicaid-covered services provided to AI/AN individuals through an IHS or tribal facility such as a clinic.
At state option, federal reimbursement would also be available for services provided outside the “four walls” of non-FQHC or non-Rural Health Clinic behavioral health clinics and clinics in rural areas. The rule seeks public comment on different definitions of “rural” for adoption in the final rule.
CCF staff will be working to further analyze the proposed rule as we work on comments to support these changes. A summary of the provisions can be found here. Public comments are due on September 9, 2024.
