The Centers for Medicare & Medicaid Services (CMS) released a Request For Information (RFI) seeking public input on accessing healthcare and related challenges, understanding provider experiences, advancing health equity, and assessing the impact of waivers and flexibilities provided in response to the COVID-19 Public Health Emergency.

The Make Your Voice Heard: Promoting Efficiency and Equity Within CMS Programs RFI furthers CMS’ commitment to engaging and learning from partners, communities, and individuals across the health system to inform how we can better support the populations we serve. In alignment with Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, the CMS Strategic Plan Pillar: Health Equity and the CMS Framework for Health Equity (2022-2032), this RFI aims to gather feedback and perspectives related to challenges and opportunities for the Agency to embed health equity into our efforts encouraging innovation, reducing burden, and creating efficiencies across the healthcare system.

“Advancing health equity is core work of the Centers for Medicare & Medicaid Services. That’s why I am inviting stakeholders to help achieve our goal of an equitable and efficient health system, by working with us as we transform the healthcare experience for the individuals we serve,” said CMS Administrator Chiquita Brooks-LaSure. “Health equity is embedded within the DNA of CMS and serves as the lens through which we view all of our work.”

Disparities in health and healthcare continue despite decades of research and widespread efforts to improve health outcomes in the United States. Many populations, including racial and ethnic minorities, members of federally-recognized Indian Tribes, people with disabilities, patients seeking substance use and mental health services, individuals dually eligible for Medicare and Medicaid, and those living in rural and underserved areas are more likely to experience challenges accessing healthcare services, lower quality of care, and below average health outcomes when compared to the general population.

CMS is seeking to better understand individual and community-level burdens, health-related social needs, and opportunities for improvement that can reduce disparities and promote efficiency and innovation across our programs. CMS is requesting information related to strategies that successfully address drivers of health inequities, including opportunities to address social determinants of health and challenges underserved communities face in accessing comprehensive, quality care. For example, challenges accessing care may include understanding coverage options, receiving culturally and linguistically appropriate care, accessing oral health services, and accessing comprehensive and timely healthcare services and medication.

Through this RFI, CMS also seeks to better understand the factors impacting provider wellness and learn more about the distribution of the healthcare workforce. We are particularly interested in understanding the greatest challenges for healthcare workers in meeting the needs of individuals, and the impact of CMS policies, documentation and reporting requirements, operations, and communications on provider experiences.

Comments received in response to the Make Your Voice Heard RFI will be used to identify opportunities for improvement and to increase efficiencies across CMS programs. In addition, CMS hopes to learn how specific programs have benefited providers, practices, and the people we serve. We work to continually improve our programs and build solutions that will help close gaps in healthcare quality, access, and outcomes to ensure that all those served by CMS programs have a fair and just opportunity to attain their optimal level of health.

CMS encourages comments from all interested stakeholders, in particular, patients and their families, providers, clinicians, consumer advocates, and healthcare professional associations. We also encourage comments from individuals serving and located in underserved communities, and from all CMS stakeholders serving populations facing disparities in health and healthcare. The RFI is open for a 60-day public comment period beginning September 6, 2022. Comments must be received by November 4, 2022 to be considered.

The web-based public comment form was specifically designed to provide easy access and an improved user experience for submitting information. For more information on the Make Your Voice Heard: Promoting Efficiency and Equity Within CMS Programs RFI and to access the web-based public comment form, please visit: https://www.cms.gov/request-information-make-your-voice-heard

The U.S. Department of Homeland Security (DHS) issued a final rule applicable to noncitizens who receive or wish to apply for benefits provided by the U.S. Department of Health and Human Services (HHS) and States that support low-income families and adults. The rule, which details how DHS will interpret the “public charge” ground of inadmissibility, will help ensure that noncitizens can access health-related benefits and other supplemental government services to which they are entitled by law, without triggering harmful immigration consequences. By codifying in regulation the “totality of the circumstances” approach that is authorized by statute and which has long been utilized by DHS, the rule makes it clear that individual factors, such as a person’s disability or use of benefits alone will not lead to a public charge determination.

The final rule applies to noncitizens requesting admission to the U.S. or applying for lawful permanent residence (a “green card”) from within the U.S. When assessing whether a noncitizen is “likely to become primarily dependent on the government for subsistence,” DHS will not penalize individuals who choose to access the vast majority of health-related benefits and other supplemental government services available to them, including most Medicaid benefits (except for long-term institutionalization – such as residing in nursing home – at government expense) and the Children’s Health Insurance Program (CHIP). DHS will also not consider non-cash benefits provided by other government agencies including food and nutrition assistance such as the Supplemental Nutrition Assistance Program (SNAP); disaster assistance received under the Stafford Act; pandemic assistance; benefits received via a tax credit or deduction; and government pensions or other earned benefits. Receipt of cash-based benefits, such as Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), and other similar programs, will not automatically exclude an individual from admission or green card eligibility, and will instead be considered in a “totality of the circumstances” analysis.

“People who qualify for Medicaid, CHIP, and other health programs should receive the care they need without fear of jeopardizing their immigration status,” said HHS Secretary Xavier Becerra. “As we have experienced with COVID, it’s in the interest of all Americans when we utilize the health care and other services at our disposal to improve public health for everyone.”

“This final rule reinforces a core principle of the Biden-Harris Administration: that healthcare is a right, not a privilege, and no one should be deterred from accessing the care they need out of fear,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s final rule is an important step toward achieving this goal for many Medicaid and CHIP enrollees and their families, and CMS will continue to do everything in our authority to make sure people have access to programs that keep them safe and healthy.”

“Federal civil rights laws require that all people be afforded fair and just decisions when applying for health benefits and other supplemental government services, free of bias, stigma, and discrimination,” said Office for Civil Rights Acting Director Melanie Fontes Rainer. “Today’s rule sets up safeguards to help ensure that people with disabilities and older adults who are not U.S. citizens can access health care without fear.  OCR will continue our robust enforcement of civil rights laws to ensure the rights of historically marginalized groups are upheld and defended.”

“People with disabilities and older adults who are not U.S. citizens no longer have to fear that using services that can help them maintain their health, live independently and contribute to their communities will cost them legal residency in our country,” said Alison Barkoff, Acting Administrator of the Administration for Community Living. “The rule explicitly rejects stereotypes that people with disabilities are more likely to become a public charge and is in keeping with the civil rights protections that are the bedrock of American values.”

This final rule is the product of action first taken by the Biden-Harris Administration in 2021 to reverse the previous administration’s 2019 public charge rule, which had the harmful effect of discouraging many immigrants from seeking benefits, such as CHIP and other government services for which they, their children, or their families were eligible, out of fear of jeopardizing their immigration status. This chilling effect extended even to those categories of noncitizens who, by law, are exempt from the public charge ground of inadmissibility, including refugees, asylees, noncitizens applying for or re-registering for temporary protected status (TPS), special immigrant juveniles, T (trafficking victims) and U (crime victims) nonimmigrants, and self-petitioners under the Violence Against Women Act (VAWA). With the publication of today’s final rule, the Biden-Harris Administration is continuing its efforts to reverse these harmful effects and ensure that these programs remain accessible for eligible individuals and families in need.

The final rule does not expand eligibility for Medicaid, CHIP, or other benefits to more people but clarifies DHS policy regarding recipients.

The final rule will be effective on December 23, 2022.

It’s been a rough couple of years for the Centers for Disease Control and Prevention. Facing a barrage of criticism for repeatedly mishandling its response to the covid-19 pandemic and more recently monkeypox, the agency has acknowledged it failed and needs to change.

CDC Director Dr. Rochelle Walensky has tapped Mary Wakefield — an Obama administration veteran and nurse — to helm a major revamp of the sprawling agency and its multibillion-dollar budget. Making the changes will require winning over wary career CDC scientists, combative members of Congress, and a general public that in many cases has stopped looking to the agency for guidance.

“If she can’t fix it, she’ll say, ‘It’s not fixable, here’s why, and here’s what needs to be done next,’” said Eileen Sullivan-Marx, dean of the New York University Rory Meyers College of Nursing, who has known Wakefield professionally for decades.

Other former colleagues said Wakefield’s experience as a nurse, congressional staffer, policy wonk, and administrator give her the perspective and leadership tools to rise to the occasion, even as they acknowledged the magnitude of the job ahead.

“She has high standards, and she’ll expect people to perform,” said Brad Gibbens, a former employee and the acting director of the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences. “She’s very fair, but you need to know what you’re doing.”

Wakefield will have to navigate rough waters in the wake of a series of missteps by the agency. The CDC botched the covid testing rollout early in the pandemic, issued confusing guidance on prevention measures such as masking and quarantining, and has been slow to release scientific findings on the fast-moving coronavirus.

Walensky has stressed that, as part of the reset, she wants the CDC to give Americans clear, accurate, and timely guidance on community health threats.

“I am confident that the appointment of Mary Wakefield will be instrumental in accomplishing our goals to modernize and optimize CDC,” Walensky said in a written statement. “It is clear that Mary is an action-oriented leader who can lead effective change.”

Following an internal audit, Walensky announced plans to restructure how the agency communicates with the public, to eliminate bureaucratic redundancies, and to help the CDC better interact with other parts of the federal government.

Wakefield’s first day on the job was in mid-August. She declined to speak to KHN for this article, but those who know her painted a rich picture of her management philosophy and style.

NYU’s Sullivan-Marx said Wakefield’s experience as a nurse makes her well suited to solve the complex set of problems facing the CDC, which she compared to a patient in need of stabilization.

“When you look at someone in a bed in intensive care, all you see are beeps and lines and monitors going off — people moving in and out like a train station,” said Sullivan-Marx. “The nurse is central to that for the patient, pulling all of that together.”

Sullivan-Marx also said Wakefield’s perspective as a front-line health care worker could help the CDC better understand how clinicians will receive and interpret its guidelines and recommendations.

For most of the Obama administration, Wakefield led the Health Resources and Services Administration. HRSA, a division of the Department of Health and Human Services, is responsible for a wide portfolio of programs — those that serve people living with HIV, provide compensation for people injured by vaccination, and document disciplinary action against health care providers.

Former HHS Secretary Kathleen Sebelius called Wakefield a “change agent” who was able to win the trust of HRSA staff members, many of whom are full-time employees, not political appointees.

“Folks understood that they were there before she came in and they’d be there after she left,” Sebelius said. “They had to be convinced that she was a good leader and they were going to follow her. That’s pretty significant, that she did so well in that agency.”

(Sebelius is a member of KFF’s Board of Trustees. KHN is KFF’s editorially independent newsroom.)

Sebelius said such experience could be helpful to Wakefield at the CDC, which employs just over 12,000 people, some of whom could be skeptical of changes. Covid was a serious stress test for the CDC, leaving some staffers wondering if it had lost its way.

Sebelius also noted as a plus Wakefield’s experience working with the CDC as acting deputy secretary of HHS. She was nominated to be deputy secretary but never confirmed because of political squabbles over abortion.

Details about changes coming at the CDC are still trickling out, though top brass have said they’ll need the support of Congress to implement them.

Sheila Burke, head of public policy at the law firm Baker Donelson, got to know Wakefield while working in Congress. She said Wakefield’s experience on Capitol Hill will come in handy when dealing with lawmakers who sit on committees that oversee the CDC.

“She’ll be keenly aware of the role of the members who care deeply about these issues,” Burke said.

Top health officials have had a hard time justifying the federal government’s pandemic response to certain members of Congress. Walensky and Dr. Anthony Fauci, the Biden administration’s lead medical adviser, who will soon step down, faced intense questioning from legislators on several occasions.

“I think she’s uniquely positioned to understand how you navigate that relationship,” Burke said of Wakefield.

Multiple former employees pointed to what Gibbens, from the University of North Dakota, characterized as Wakefield’s “infatigable amount of energy.” He said it wasn’t uncommon for him to arrive at work to phone messages she’d left him at 4:30 in the morning.

He described Wakefield as someone who knows “when somebody is trying to play her.” But he also said she doesn’t take herself too seriously. He recalled a kitschy animatronic singing fish on her office wall, a nod to her love of fishing. And the time she declined to fly on Air Force Two from Washington, D.C., to North Dakota, choosing to take a commercial flight “like a regular person.”

“She said, ‘You gotta be really careful with that stuff. You don’t want to get used to that,’” Gibbens recalled.

The work ahead for Wakefield could be a stress test of her belief in the human value of public policy. Walensky has said the changes she hopes to implement at the CDC won’t happen overnight, and it’s likely they won’t be easy.

Much like the CDC in the current moment, in 2005 Wakefield found herself at a possible turning point. That year, Wakefield’s brother and two of his children were killed in a car accident that seriously injured her sister-in-law and young nephew.

“Health policy as a focal area of my work before, now felt of very little consequence,” Wakefield wrote at the time in the Journal of Forensic Nursing.

Then she received word that her former boss, Sen. Kent Conrad (D-N.D.), had joined with others to introduce the Wakefield Act, a bill aimed at improving emergency medical care for kids. Even though it didn’t pass, it reminded Wakefield that pulling the levers of government can have real-life consequences.

“They acknowledged my family’s loss and put their support behind legislation that can affect the lives of children of other families who may have a chance at survival,” Wakefield wrote. “Public policy is important — isn’t it?”

Proposed rule would reduce red tape and streamline administrative processes to help children, older adults, people with disabilities, and others from underserved communities connect to health care coverage through Medicaid and CHIP 

The Biden-Harris Administration proposed a new rule to overhaul the enrollment processes for Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Programs (BHPs), and eliminate arbitrary coverage caps for children in CHIP. In a Notice of Proposed Rule Making (NPRM), the Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is working to reduce red tape and simplify application and verification processes to make it easier for children, older adults, and people with lower incomes with Medicaid and CHIP coverage to enroll in and retain vital health insurance. This proposed rule follows President Biden’s executive orders in April 2022 and January 2021 directing federal agencies to take action to expand affordable, quality health coverage, including by strengthening Medicaid and the Affordable Care Act.

Under the Biden-Harris Administration, thanks to the American Rescue Plan and other Administration efforts, more Americans than ever before have health insurance coverage. Today’s proposed rule will build on these efforts and support President Biden’s calls to strengthen Medicaid and access to affordable, high-quality health coverage.

“Medicaid and CHIP provide essential health care to millions of families across the country, and we are making it easier to enroll children and others in health insurance and to maintain coverage,” said HHS Secretary Xavier Becerra. “With these steps, we’re delivering on our promise to make high-quality health care more accessible and affordable for all Americans.”

“CMS is acting today to protect and strengthen health care coverage for the more than 88 million people enrolled in Medicaid, CHIP, and the Basic Health Program,” CMS Administrator Chiquita Brooks-LaSure said. “This proposed rule will ensure that these individuals and families, often from underserved communities, can access the health care and coverage to which they are entitled – a foundational principle of health equity. In addition, this proposed rule will help more people pay their Medicare premiums by making it easier for them to enroll in the Medicare Savings Programs.”

This rule, if finalized, would standardize commonsense eligibility and enrollment policies, such as limiting renewals to once every 12 months, allowing applicants 30 days to respond to information requests, requiring prepopulated renewal forms, and establishing clear, consistent renewal processes across states.

Medicaid and CHIP are critical sources of health care insurance for families across the country. Medicaid is the single largest health coverage program in the U.S., covering nearly one in four Americans and providing robust benefits with little to no out of pocket costs. Together, Medicaid and CHIP provide 51% of our nation’s children and youth – more than 40 million children – access to quality, affordable health care. However, enrollment in these programs can be jeopardized because of cumbersome application or renewal processes and lack of uniformity in states across the country. This NPRM takes aim at those concerns, and includes a suite of proposed options to provide easier access to and retention in health care coverage.

In a major transformation to the programs and a historic win for American families, the Biden-Harris Administration is proposing to end lifetime benefit limits in CHIP and allow children to enroll in coverage right away by eliminating pre-enrollment waiting periods, consistent with nearly all other health coverage. The proposed rule would also permit states to transfer children’s eligibility directly from Medicaid to CHIP when a family’s income rises, preventing unnecessary redetermination processes from causing lapses in coverage.

The NPRM proposes simplifications that would increase enrollment and retention for people age 65 and older, as well as those who have blindness or a disability. The proposed rule, if finalized, would streamline the application process for these programs by removing unnecessary administrative hurdles for people who do not have – but are eligible for – Medicaid, CHIP, or BHP coverage. These individuals are often eligible for Medicaid, but are not yet enrolled or have trouble staying enrolled because of systemic barriers, potentially missing life-saving coverage and care because of burdensome processes.

The proposed rule also includes policies that would improve access to programs that help make health coverage more affordable for older adults and individuals with disabilities. It offers ways to simplify enrollment for Medicare Savings Programs, which permit Medicaid to pay Medicare premiums or cost sharing for Medicare beneficiaries with lower incomes. The proposed rule would also allow for automatic enrollment in Medicare Savings Programs for certain individuals receiving the Social Security Administration’s Supplemental Security Income – a key goal for streamlining connections to care for those who need them most.

A recent study estimated that only about half of eligible low-income individuals enrolled in Medicare were also enrolled in Medicare Savings Programs. This proposed rule would automatically consider older adults for Medicare Savings Programs enrollment when they apply for low-income subsidies to help pay for Part D Medicare coverage, reducing the burdens of both time and expense by eliminating the need to complete multiple applications.

Lastly, proper documentation is critical to enabling appropriate oversight, identifying errors in state policies and operations, and reducing inconsistent and outdated practices across states, which contribute to improper payments. This proposed rule would update and standardize recordkeeping requirements for states, which would help to address deficiencies in outdated state recordkeeping systems and improve program integrity.

For more information on the NPRM, consult the fact sheet available at https://www.cms.gov/newsroom/fact-sheets/streamlining-eligibility-enrollment-notice-propose-rulemaking-nprm.

To review or comment on the NPRM during its 60-day public comment period, visit the Federal Register.