Newly proposed standards and requirements would better ensure access to care, accountability, and transparency for Medicaid or CHIP services, including home and community-based services. 

The Centers for Medicare & Medicaid Services (CMS) unveiled two notices of proposed rulemaking (NPRMs), Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM), that together would further strengthen access to and quality of care across Medicaid and the Children’s Health Insurance Program (CHIP), the nation’s largest health coverage programs. These rules build on Medicaid’s already strong foundation as an essential program for millions of families and individuals, especially children, pregnant people, older adults, and people with disabilities.

If adopted as proposed, the rules would establish historic national standards for access to care regardless of whether that care is provided through managed care plans or directly by states through fee-for-service (FFS). Specifically, they would establish access standards through Medicaid or CHIP managed care plans, as well as transparency for Medicaid payment rates to providers, including hourly rates and compensation for certain home care and other direct care workers. The rules would also establish other access standards for transparency and accountability, and empower beneficiary choice.

“The Biden-Harris Administration has made clear where we stand: we believe all Americans deserve the peace of mind that having health care coverage brings,” said HHS Secretary Xavier Becerra. “We are proposing important actions to remove barriers to care, engage consumers, and improve access to services for all children and families enrolled in these critical programs. One in four Americans and over half of all children in the country are enrolled in Medicaid or CHIP – and the Biden-Harris Administration is committed to protecting and strengthening these programs for future generations.”

“Having health care coverage is fundamental to reducing health disparities, but it must go hand-in-hand with timely access to services. Connecting those priorities lies at the heart of these proposed rules,” said CMS Administrator Chiquita Brooks-LaSure. “With the provisions we’ve outlined, we’re poised to bring Medicaid or CHIP coverage and access together in unprecedented ways – a key priority that’s long overdue for eligible program participants who still face barriers connecting to care.”

Covering nearly one in four Americans and over half of all children in the country, Medicaid is the single largest health coverage program in the U.S. Medicaid and CHIP provide robust benefits with little to no out-of-pocket costs for over 92 million people. Many of those enrolled in Medicaid or CHIP come from underserved communities whose populations have disproportionately higher uninsured rates, and who often experience chronic health issues. Over 70 percent of people with Medicaid or CHIP coverage are enrolled in managed care plans. Ensuring families and individuals can find an in-network provider and access health care coverage in a timely way is a foundational principle of health equity, and a critical priority for the Biden-Harris Administration.

Together, the Access NPRM and Managed Care NPRM include new and updated proposed requirements for states and managed care plans that would establish tangible, consistent access standards, and a consistent way to transparently review and assess Medicaid payment rates across states. The rule also proposes standards to allow enrollees to easily compare plans based on quality and access to providers through the state’s website. Other highlights from the proposed rules include:

• Establishing national maximum standards for certain appointment wait times for Medicaid or CHIP managed care enrollees, and stronger state monitoring and reporting requirements related to access and network adequacy for Medicaid or CHIP managed care plans, which now cover the majority of Medicaid or CHIP beneficiaries.
• Requiring states to conduct independent secret shopper surveys of Medicaid or CHIP managed care plans to verify compliance with appointment wait time standards and to identify where provider directories are inaccurate.
• Creating new payment transparency requirements for states by requiring disclosure of provider payment rates in both fee-for-service and managed care, with the goal of greater insight into how Medicaid payment levels affect access to care.
• Establishing additional transparency and interested party engagement requirements for setting Medicaid payment rates for home and community-based services (HCBS), as well as a requirement that at least 80 percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for direct care workers (as opposed to administrative overhead or profit).
• Creating timeliness-of-access measures for HCBS and strengthening necessary safeguards to ensure beneficiary health and welfare as well as promote health equity.
• Strengthening how states use state Medical Care Advisory Committees, through which stakeholders provide guidance to state Medicaid agencies about health and medical care services, to ensure all states are using these committees optimally to realize a more effective and efficient Medicaid program that is informed by the experiences of Medicaid beneficiaries, their caretakers, and other interested parties.
• Requiring states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan to gather input directly from enrollees.
• Establishing a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” for enrollees to compare Medicaid or CHIP managed care plans based on quality of care, access to providers, covered benefits and drugs, cost, and other plan performance indicators.

For fact sheets about the Ensuring Access to Medicaid Services NPRM, please see:

Summary of CMS’s Access-Related Notices of Proposed  Rulemaking: https://www.cms.gov/newsroom/fact-sheets/summary-cmss-access-related-notices-proposed-rulemaking-ensuring-access-medicaid-services-cms-2442-p

Summary of Medicaid and CHIP Payment-Related Provisions: https://www.cms.gov/newsroom/fact-sheets/summary-medicaid-and-chip-payment-related-provisions-ensuring-access-medicaid-services-cms-2442-p

Summary of Key Home and Community-Based Services (HCBS) Provisions: https://www.cms.gov/newsroom/fact-sheets/ensuring-access-medicaid-services-cms-2442-p-notice-proposed-rulemaking

Summary of the Medical Care Advisory Committee and Beneficiary Advisory Group Provisions: https://www.cms.gov/newsroom/fact-sheets/ensuring-access-medicaid-services-cms-2442-p-notice-proposed-rulemaking

For a fact sheet about the Medicaid or Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality NPRM, please see:

https://www.cms.gov/newsroom/fact-sheets/notice-proposed-rulemaking-medicaid-and-childrens-health-insurance-program-chip-managed-care-access

Both NPRMs can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection.

CMS looks forward to receiving feedback on both during the public comment period, which ends July 3, 2023.

U.S. Department of Agriculture (USDA) Rural Development Under Secretary Xochitl Torres Small announced that USDA is inviting applications for grants to strengthen rural cooperatives and expand access to new and better markets for people in rural America.

USDA is making the $5.8 million in grants available under the Rural Cooperative Development Grant (RCDG) program to start, improve or expand rural cooperatives and other mutually owned businesses that will help
improve economic conditions in rural areas.

Nonprofit organizations and institutions of higher education are eligible to apply for grants to provide technical and cooperative development assistance to individuals and rural businesses.

The maximum award is $200,000. Grants are awarded on a competitive basis through a national competition.

To learn more, read full Stakeholder Announcement.

By Eric Scicchitano erics@cnhinews.com, The Daily Item, April 22, 2023

Changes to Medicaid coinciding with the end of the pandemic health emergency could exacerbate financial and operational stressors already burdening hospitals across Pennsylvania.

Medicaid enrollment grew by 30% in Pennsylvania during the pandemic, climbing to about 3.6 million members. Continuous enrollment stalled the Department of Human Services from performing its eligibility determination work during the pandemic and members benefited from temporary automatic enrollment.

Both policies ended April 1 and the redetermination process is now underway.

An estimated 617,000 members are at risk of losing health care coverage once eligibility is reassessed while another 598,000 hadn’t completed membership renewal as of January, Human Services officials told WESA 90.5.

The U.S. Department of Health and Human Services estimates that nationally, as many as 15 million Medicaid recipients and Children’s Health Insurance Program enrollees could lose coverage.

“Hospitals are facing this perfect storm. They’re in a precarious financial situation for a number of reasons. One of the most important is the workforce shortage and the impact on the financial viability of hospitals,” said Jeffrey Bechtel, senior vice president of health economics and policy, The Hospital and Healthsystem Association of Pennsylvania (HAP).

“The unwinding of Medicaid,” Bechtel said, “that’s just going to be another challenge hospitals will have to face during these difficult times.”

The Shapiro Administration has worked to contact enrollees about their potential risks and to ensure that they reapply to maintain benefits. Visit www.dhs.pa.gov/COMPASS, download the myCOMPASS PA mobile app, call 1-877-395-8930 or for CHIP, 1-800-986-KIDS (5437).

Steered to Pennie

Those losing coverage will be steered to the state’s health care marketplace, Pennie, or other programs. The administration pledges that no one will lose coverage without the opportunity to renew coverage.

Private health plans like Geisinger and Highmark are efforting such contacts among their own members in jeopardy.

The anticipated surge in uninsured Pennsylvanians is expected to tax hospital resources and safety net providers like free clinics and federally qualified health centers.

Hospitals and health care providers have already been beset by staffing shortages causing labor costs to swiftly balloon. And, they’re hardly immune to supply chain disruptions, high-interest rates and inflated costs.

Vacancy rates in Pennsylvania hospitals for registered nurses, nursing support staff, respiratory therapists, nurse practitioners and medical assistants hovered above 30% as recently as November, according to the latest data available from HAP.

“What we fear is that people will not know what they have to do, and that a significant number of people are going to lose their coverage as a result,” said Robert Dewar, chief revenue officer at Geisinger.

Dewar supports Medicaid expansion, not contraction.

“I feel like everybody loses in this. Patients lose; a significant number of patients. Hospitals lose. I don’t think it’s gong to help our taxes. It’s not going to lead to less cost for individual taxpayers. It’s just not good policy. I just don’t see any winners in this,” Dewar said.

A report by the Pennsylvania Health Care Cost Containment Council released last year found that in Pennsylvania, rising expenses and lost revenue due to the pandemic totaled $678.3 million through the first half of 2022 and nearly $7.9 billion to that point since the pandemic’s start.

The healthcare management consulting firm Kaufman Hall found that more than half of all U.S. hospitals ended 2022 at a fiscal loss, marking it as the worst financial year since the pandemic’s start.

Hospital losses

UPMC reported a net loss of $916 million last year. Geisinger’s reported loss totaled $842 million.

That year’s first half proved especially bad though steady improvement into the late winter months signaled a potential turnaround in 2023. While operating margins were up 16% in February year over year, profits fell 6% month over month compared to January, Kaufman Hall stated in a report released last month.

All told, hospital profits were down 32% nationally year-to-date in February compared to February 2020, the March report states.

Bechtel estimates Medicaid enrollees account for about 15% of hospital revenues. Combined with Medicare, the share leaps to 50%. Reimbursement falls below cost, he said.

Those revenues, even below cost, disappear for those members who become uninsured. The anticipation is that some will trend toward seeking costlier care at emergency departments for ailments best treated by primary care physicians or avoided altogether through preventative care afforded by health insurance.

“Having health insurance does not automatically equal access to care but it sure helps,” said Lisa Davis, director of the Pennsylvania Office of Rural Health and outreach associate professor with Penn State, a reference to rural health care deserts across the commonwealth.

According to Davis, rural hospitals are especially at risk of accumulating bad debt through uncompensated care. Comparatively, she said urban hospitals tend to have higher rates of commercially insured patients.

Patients losing health insurance risk putting off preventative care and may end up more sickly, Davis said. She said it likely will result in the safety net system taking on more clients.

“I think that’s probably the biggest impact, the increase of uncompensated care,” Davis said. “It really does put the hospital at financial risk.”

Expected surge

Staff at Community Health Centers including Federally Qualified Health Centers anticipate a surge of people seeking medical care once their insurance is lost as well as assistance in finding Medicaid alternatives, according to Tia N. Whitaker, statewide director of outreach and enrollment, Pennsylvania Association of Community Health Centers.

The network of health centers treats one million patients across three million visits annually, Whitaker said. It has 132 employees tasked with helping find insurance through Pennie.

“We fully anticipate in the next few months that requests for assistance will be flowing in because folks will be terminated,” Whitaker said.

Whitaker expressed concern that the Pennsylvania Department of Human Services staffing complement may not be enough to meet the demand to process applications and determine eligibility for Medicaid.

To seek help through the Pennsylvania Association of Community Health Centers, contact 717-761-6443, 1-866-944-2273 or pachc@pachc.org.

DACA recipients would have access to health care through Affordable Care Act Marketplaces, Medicaid, and the Children’s Health Insurance Program

The Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), released a notice of proposed rulemaking (NPRM) that, if finalized, would expand access to health care by reducing barriers for Deferred Action for Childhood Arrivals (DACA) recipients. Earlier this month, HHS announced its intention to release this rule by the end of April, and today’s announcement marks the fulfillment of that promise. The proposed change applies to the Health Insurance Marketplaces, the Basic Health Program, and some Medicaid and Children’s Health Insurance Programs (CHIP).

“DACA recipients, like all Dreamers, are Americans, plain and simple. The United States is their home, and they should enjoy the same access to health care as their fellow Americans,” said HHS Secretary Xavier Becerra. “Every day, nearly 580,000 DACA recipients wake up and serve their communities, often working in essential roles and making tremendous contributions to our country. They deserve access to health care, which will provide them with peace of mind and security.”

“Young people who come to this country—in many cases, the only country they have ever known as home—work hard to build their lives here, and they should be able to keep themselves healthy,” said CMS Administrator Chiquita Brooks-LaSure. “The Biden-Harris Administration is committed to ensuring affordable, quality health care for all, and to providing DACA recipients the opportunities and support they need to succeed.”

The proposed rule, if finalized, would remove the current exclusion that treats DACA recipients differently from other individuals with deferred action who would otherwise be eligible for coverage under select CMS programs. If the rule is finalized as proposed, it could lead to 129,000 previously uninsured DACA recipients receiving health care coverage. Over the last decade, DACA has provided peace of mind and work authorization to more than 800,000 Dreamers.

The proposed rule would amend the definition of “lawfully present” to include DACA recipients for the purposes of Medicaid and CHIP. In effect, this would extend Medicaid and CHIP coverage to children and pregnant women in states that have elected the “CHIPRA 214” option for children and/or pregnant individuals, the Basic Health Program, and Affordable Care Act Marketplace coverage. DACA recipients would need to meet all other eligibility requirements to qualify for coverage. Additionally, DACA recipients would be eligible for financial assistance through the Marketplace, such as advance payments of the premium tax credit and cost-sharing reductions if they meet all other eligibility requirements.

If the rule is finalized as proposed, DACA recipients would qualify for a special enrollment period to select a qualified health plan through a Marketplace during the 60 days following the effective date of the final rule.

This NPRM has a proposed effective date for all provisions of November 1, 2023. CMS is requesting comment from the public on proposed regulations, and specifically on the feasibility of this date and whether to consider a different effective date.

Children in every community in Pennsylvania rely on Medicaid and the Children’s Health Insurance Program for their comprehensive health insurance, including more than 1.3 million children enrolled in Medicaid and more than 130,000 children enrolled in CHIP.

Medicaid and CHIP helped improve the state’s child uninsured rate during the COVID-19 pandemic. The three fact sheets in this series show enrollment by Congressional, state House, and state Senate districts:

• Enrollment by Congressional District
• Enrollment by State House District
• Enrollment by State Senate District

Our last two newsletters covered the Medicaid unwinding and significant operational changes to CHIP. We encourage you to share Katie Meyer’s in-depth coverage about reenrolling in Medicaid and ensuring that CHIP or other health care options cover kids.

The USDA Rural Development program provides funding to agricultural producers and rural small businesses for renewable energy systems or to make energy efficiency improvements. More flexible Inflation Reduction Act Changes. Contact your State Energy Coordinator.

Application Deadline: 6 quarterly Cycles

By: January Contreras, Assistant Secretary, Administration for Children and Families and CMS Administrator Chiquita Brooks-LaSure

The Medicaid “continuous enrollment” period is ending.  As trusted community voices, you can help millions of children and families stay connected to affordable, comprehensive care through Medicaid and the Children’s Health Insurance Program (CHIP), Medicare, the Health Insurance Marketplaces, or employer-sponsored coverage.

With your partnership, we can maximize our outreach and ensure people experience smooth coverage transitions.  This blog explains where we are now and what you can do to help.

Where We Are Now

During the COVID-19 pandemic, Medicaid served its core purpose of providing reliable health coverage to millions of individuals and families during unprecedented circumstances. Individuals could count on having stable health coverage during the pandemic, regardless of changes in income or other circumstances, because of a “continuous enrollment” provision. This continuous enrollment provision is now coming to an end, and states must return to normal eligibility and enrollment operations.

This means that states will redetermine eligibility for each person currently covered by Medicaid or CHIP – a total of 91 million people – between April 1, 2023 and July 31, 2024. You can find the anticipated timeline for each state at Medicaid.gov/unwinding.

The Biden-Harris Administration is committed to engaging with states and community partners throughout this process to support individuals’ and families’ access to coverage and care. States are working to simplify and streamline processes, connect people to the Health Insurance Marketplaces, and adopt other innovative approaches. But we need your help to reach every person who may be affected by this process and help them maintain their health coverage or enroll in a new plan.

What You Can Do

The Administration for Children and Families (ACF), the Centers for Medicare & Medicaid Services (CMS), and other federal agencies are working together to recruit partners like you to help people stay connected to health care coverage.  There are several ways to help.

First, it’s critical that state Medicaid programs have accurate contact information for the children, individuals, and families enrolled in Medicaid and CHIP.  We need your assistance to share key messages to help people stay covered. Families and individuals should:

• Update their contact information with their state Medicaid or CHIP office. You can find state-specific contact information at Medicaid.gov/renewals.
• Check their mail.  The state will mail a letter about coverage, which will let them know if they need to complete a renewal form to see if they still qualify for Medicaid or CHIP.
• Complete their renewal form (if they get one). Fill out the form and return it to their state right away to help avoid a gap in coverage.

You can find these messages available in English, Spanish, Chinese, Hindi, Korean, Tagalog, and  Vietnamese, at Medicaid.gov/unwinding.

Second, you can amplify our message and help people learn the actions they need to take to keep health care coverage.  Below are several strategies to consider:

• Ensure front-line staff are knowledgeable on steps families can take to renew their health care coverage.  For example, they can help patients understand the 90-day reconsideration period.
• Promote Medicaid and CHIP renewal awareness on your websites, social media channels, and in your physical offices.  You can use our Medicaid Unwinding Toolkit graphics (English and Spanish).
• Share key information on Medicaid and CHIP renewal as part of your application intake or renewal process for other programs.  You can also tell people about their other health care coverage options, like HealthCare.gov and Medicare.gov.

Your work will help people enrolled in Medicaid and CHIP take the necessary actions to stay connected to health care coverage.  We are counting on ACF and CMS partners to be a part of our nationwide effort to ensure no one is left behind when it comes to health care.

Thank you for your continued collaboration to promote the well-being of children, youth, families, and communities.

Other helpful resources:

• Unwinding Homepage: Where states and stakeholders can learn more about Unwinding and access resources to help plan and prepare.
• Unwinding Communications Toolkit: Provides key messages and materials for states and stakeholders to help families get ready to renew, including flyers, postcards, tear pads, conference cards, and rack cards.
• Renew Your Medicaid or CHIP Coverage: Includes contact information for each state and territory’s Medicaid enrollment office.
• 50-State Unwinding Tracker.
• Child Uninsured Rate Could Rise Sharply if States Don’t Proceed with Caution – Center For Children and Families (georgetown.edu).

Beyond the Basics released two sets of frequently asked questions (FAQ) on unwinding Medicaid continuous coverage. The first set explains how unwinding the Medicaid continuous coverage requirement will work, the challenges Medicaid beneficiaries may face during the process, and what enrollment assisters such as health centers can do to help. The second set offers outreach and enrollment tips to assist people to retain coverage.