Medicaid Program; Medicaid and Children's Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality

<RULE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Centers for Medicare & Medicaid Services</SUBAGY> <CFR>42 CFR Parts 430, 438, and 457</CFR> <DEPDOC>[CMS-2439-F]</DEPDOC> <RIN>RIN 0938-AU99</RIN> <SUBJECT>Medicaid Program; Medicaid and Children's Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality</SUBJECT> <HD SOURCE="HED">AGENCY:</HD> Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS). <HD SOURCE="HED">ACTION:</HD> Final rule. <SUM> <HD SOURCE="HED">SUMMARY:</HD> This final rule will advance CMS's efforts to improve access to care, quality and health outcomes, and better address health equity issues for Medicaid and Children's Health Insurance Program (CHIP) managed care enrollees. The final rule addresses standards for timely access to care and States' monitoring and enforcement efforts, reduces State burdens for implementing some State directed payments (SDPs) and certain quality reporting requirements, adds new standards that will apply when States use in lieu of services and settings (ILOSs) to promote effective utilization and that specify the scope and nature of ILOSs, specifies medical loss ratio (MLR) requirements, and establishes a quality rating system for Medicaid and CHIP managed care plans. </SUM> <EFFDATE> <HD SOURCE="HED">DATES:</HD> <E T="03">Effective Dates:</E> These regulations are effective on July 9, 2024. <E T="03">Applicability Dates:</E> In the <E T="02">Supplemental Information</E> section of this final rule, we provide a table (Table 1), which lists key changes in this final rule that have an applicability date other than the effective date of this final rule. </EFFDATE> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Rebecca Burch Mack, (303) 844-7355, Medicaid Managed Care. Laura Snyder, (410) 786-3198, Medicaid Managed Care State Directed Payments. Alex Loizias, (410) 786-2435, Medicaid Managed Care State Directed Payments and In Lieu of Services and Settings. Elizabeth Jones, (410) 786-7111, Medicaid Medical Loss Ratio. Jamie Rollin, (410) 786-0978, Medicaid Managed Care Program Integrity. Rachel Chappell, (410) 786-3100, and Emily Shockley, (410) 786-3100, Contract Requirements for Overpayments. Carlye Burd, (720) 853-2780, Medicaid Managed Care Quality. Amanda Paige Burns, (410) 786-8030, Medicaid Quality Rating System. Joshua Bougie, (410) 786-8117, and Chanelle Parkar, (667) 290-8798, CHIP. </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">Applicability and Compliance Timeframes</HD> States are required to comply by the effective date of the final rule or as otherwise specified in regulation text. States will not be held out of compliance with the changes adopted in this final rule until the applicability date indicated in regulation text for each provision so long as they comply with the corresponding standard(s) in 42 CFR parts 438 and 457 contained in the 42 CFR, parts 430 to 481, effective as of October 1, 2023. The following is a summary of the applicability dates in this final rule: <GPH SPAN="3" DEEP="625"> <GID>ER10MY24.000</GID> </GPH> <GPH SPAN="3" DEEP="199"> <GID>ER10MY24.001</GID> </GPH> <HD SOURCE="HD1">I. Medicaid and CHIP Managed Care</HD> <HD SOURCE="HD2">A. Background</HD> As of September 2023, the Medicaid program provided essential health care coverage to more than 88 million  <SU>1</SU> <FTREF/> individuals, and, in 2021, had annual outlays of more than $805 billion. In 2021, the Medicaid program accounted for 18 percent of national health expenditures. <SU>2</SU> <FTREF/> The program covers a broad array of health benefits and services critical to underserved populations, including low- income adults, children, parents, pregnant individuals, the elderly, and people with disabilities. For example, Medicaid pays for approximately 42 percent of all births in the U.S. <SU>3</SU> <FTREF/> and is the largest payer of long-term services and supports (LTSS), <SU>4</SU> <FTREF/> services to treat substance use disorder, and services to prevent and treat the Human Immunodeficiency Virus. <SU>5</SU> <FTREF/> Ensuring beneficiaries can access covered services is a crucial element of the Medicaid program. Depending on the State and its Medicaid program structure, beneficiaries access their health care services using a variety of care delivery systems; for example, fee-for-service (FFS) and managed care, including through demonstrations and waiver programs. In 2021, 74.6 percent  <SU>6</SU> <FTREF/> of Medicaid beneficiaries were enrolled in comprehensive managed care plans; the remaining individuals received all or some services through FFS. <FTNT> <SU>1</SU>  September 2023 Medicaid and CHIP Enrollment Snapshot. Accessed at <E T="03">http://www.medicaid.gov/sites/default/files/2023-10/september-2023-medicaid-chip-enrollment-trend-snapshot.pdf.</E> </FTNT> <FTNT> <SU>2</SU>  CMS National Health Expenditure Fact Sheet. Accessed at <E T="03">https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet.</E> </FTNT> <FTNT> <SU>3</SU>  National Center for Health Statistics. Key Birth Statistics (2020 Data. Final 2022 Data forthcoming). Accessed at <E T="03">https://www.cdc.gov/nchs/nvss/births.htm.</E> </FTNT> <FTNT> <SU>4</SU>  Colello, Kirsten J. <E T="03">Who Pays for Long-Term Services and Supports?</E> Congressional Research Service. Updated June 15, 2022. Accessed at <E T="03">https://crsreports.congress.gov/product/pdf/IF/IF10343.</E> </FTNT> <FTNT> <SU>5</SU>  Dawson, L. and Kates, J. Insurance Coverage and Viral Suppression Among People with HIV, 2018. September 2020. Kaiser Family Foundation. Accessed at <E T="03">https://www.kff.org/hivaids/issue-brief/insurance-coverage-and-viral-suppression-among-people-with-hiv-2018/.</E> </FTNT> <FTNT> <SU>6</SU>   <E T="03">https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html.</E> </FTNT> With a program as large and complex as Medicaid, to promote consistent access to health care for all beneficiaries across all types of care delivery systems in accordance with statutory requirements, access regulations need to be multi-factorial. Strategies to enhance access to health care services should reflect how people move through and interact with the health care system. We view the continuum of health care access across three dimensions of a person-centered framework: (1) enrollment in coverage; (2) maintenance of coverage; and (3) access to high-quality services and supports. Within each of these dimensions, accompanying regulatory, monitoring, and/or compliance actions may be needed to ensure access to health care is achieved and maintained. In early 2022, we released a request for information (RFI)  <SU>7</SU> <FTREF/> to collect feedback on a broad range of questions that examined topics such as: challenges with eligibility and enrollment; ways we can use data available to measure, monitor, and support improvement efforts related to access to services; strategies we can implement to support equitable and timely access to providers and services; and opportunities to use existing and new access standards to help ensure that Medicaid and CHIP payments are sufficient to enlist enough providers. Some of the most common feedback we received through the RFI related to promoting cultural competency in access to and the quality of services for beneficiaries across all dimensions of health care and using payment rates as a driver to increase provider participation in Medicaid and CHIP programs. Commenters were also interested in opportunities to align approaches for payment regulation and compliance across Medicaid and CHIP delivery systems and services. <FTNT> <SU>7</SU>  CMS Request for Information: Access to Coverage and Care in Medicaid & CHIP. February 2022. For a full list of question from the RFI, see <E T="03">https://www.medicaid.gov/medicaid/access-care/downloads/access-rfi-2022-questions.pdf.</E> </FTNT> As noted above, the first dimension of access focuses on ensuring that eligible people are able to enroll in the Medicaid program. Access to Medicaid enrollment requires that a potential beneficiary knows if they are or may be eligible for Medicaid, is aware of Medicaid coverage options, and is able to easily apply for and enroll in coverage. The second dimension of access in this continuum relates to maintaining coverage once the beneficiary is enrolled in the Medicaid program. Maintaining coverage requires that eligible beneficiaries are able to stay enrolled in the program without interruption, or that they know how to and can smoothly transition to other health coverage, such as CHIP, Marketplace coverage, or Medicare, when they are no longer eligible for Medicaid coverage. In September 2022, we published a proposed rule, <E T="03"> Streamlining the Medicaid, Children's Health Insurance Program, and Basic Health Program Application, Eligibility, Determination, Enrollment, and Renewal Processes </E> (87 FR 54760; hereinafter the “Streamlining Eligibility & Enrollment proposed rule”) to simplify the processes for eligible individuals to enroll and retain eligibility in Medicaid, CHIP, or the Basic Health Program (BHP). <SU>8</SU> <FTREF/> This rule was finalized on March 27, 2024. <SU>9</SU> <FTREF/> <FTNT> <SU>8</SU>  We finalized several provisions from the proposed rule in a September 2023 <E T="04">Federal Register</E> publication entitled <E T="03">Streamlining Medicaid; Medicare Savings Program Eligibility Determination and Enrollment.</E> See 88 FR 65230. </FTNT> <FTNT> <SU>9</SU>   <E T="03">https://www.federalregister.gov/public-inspection/2024-06566/medicaid-program-streamlining-the-m ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 2027k characters. 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