Medicaid Program; Ensuring Access to Medicaid Services

<RULE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Centers for Medicare & Medicaid Services</SUBAGY> <CFR>42 CFR Parts 431, 438, 441, and 447</CFR> <DEPDOC>[CMS-2442-F]</DEPDOC> <RIN>RIN 0938-AU68</RIN> <SUBJECT>Medicaid Program; Ensuring Access to Medicaid Services</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 takes a comprehensive approach to improving access to care, quality and health outcomes, and better addressing health equity issues in the Medicaid program across fee-for-service (FFS), managed care delivery systems, and in home and community-based services (HCBS) programs. These improvements increase transparency and accountability, standardize data and monitoring, and create opportunities for States to promote active beneficiary engagement in their Medicaid programs, with the goal of improving access to care. </SUM> <EFFDATE> <HD SOURCE="HED">DATES:</HD> These regulations are effective on July 9, 2024. </EFFDATE> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Karen LLanos, (410) 786-9071, for Medicaid Advisory Committee. Jennifer Bowdoin, (410) 786-8551, for Home and Community-Based Services. Jeremy Silanskis, (410) 786-1592, for Fee-for-Service Payment. </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">I. Background</HD> <HD SOURCE="HD2">A. Overview</HD> Title XIX of the Social Security Act (the Act) established the Medicaid program as a joint Federal and State program to provide medical assistance to eligible individuals, including many with low incomes. Under the Medicaid program, each State that chooses to participate in the program and receive Federal financial participation (FFP) for program expenditures must establish eligibility standards, benefits packages, and payment rates, and undertake program administration in accordance with Federal statutory and regulatory requirements. The provisions of each State's Medicaid program are described in the Medicaid “State plan” and, as applicable, related authorities, such as demonstration projects and waivers of State plan requirements. Among other responsibilities, CMS approves State plans, State plan amendments (SPAs), demonstration projects authorized under section 1115 of the Act, and waivers authorized under section 1915 of the Act; and reviews expenditures for compliance with Federal Medicaid law, including the requirements of section 1902(a)(30)(A) of the Act relating to efficiency, economy, quality of care, and access to ensure that all applicable Federal requirements are met. The Medicaid program provides essential health coverage to tens of millions of people, covering a broad array of health benefits and services critical to underserved populations, <SU>1</SU> <FTREF/> including low-income adults, children, parents, pregnant individuals, older adults, and people with disabilities. For example, Medicaid pays for approximately 41 percent of all births in the U.S. <SU>2</SU> <FTREF/> and is the largest payer of long-term services and supports (LTSS), <SU>3</SU> <FTREF/> the largest, single payer of services to treat substance use disorders, <SU>4</SU> <FTREF/> and services to prevent and treat the Human Immunodeficiency Virus. <SU>5</SU> <FTREF/> <FTNT> <SU>1</SU>  Executive Order 13985: <E T="03">https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government/</E> . </FTNT> <FTNT> <SU>2</SU>  National Center for Health Statistics. Key Birth Statistics. Accessed at <E T="03">https://www.cdc.gov/nchs/nvss/births.htm</E> . </FTNT> <FTNT> <SU>3</SU>  Colello, Kirsten J. <E T="03">Who Pays for Long-Term Services and Supports?</E> Congressional Research Service. Updated September 2023. Accessed at <E T="03">https://crsreports.congress.gov/product/pdf/IF/IF10343</E> . </FTNT> <FTNT> <SU>4</SU>  Soni, Anita. Health Care Expenditures for Treatment of Mental Disorders: Estimates for Adults Ages 18 and Older, U.S. Civilian Noninstitutionalized Population, 2019. Statistical Brief #539, pg 12. February 2022. Agency for Healthcare Research and Quality, Rockville, MD. Accessed at <E T="03">https://meps.ahrq.gov/data_files/publications/st539/stat539.pdf</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> On January 28, 2021, the President signed Executive Order (E.O.) 14009, <SU>6</SU> <FTREF/> “Strengthening Medicaid and the Affordable Care Act,” which established the policy objective to protect and strengthen Medicaid and the Affordable Care Act and to make high-quality health care accessible and affordable for every American. The E.O. also directed executive departments and agencies to review existing regulations, orders, guidance documents, and policies to determine whether such agency actions are inconsistent with this policy. On April 5, 2022, E.O. 14070, <SU>7</SU> <FTREF/> “Continuing To Strengthen Americans' Access to Affordable, Quality Health Coverage,” directed Federal agencies with responsibilities related to Americans' access to health coverage to review agency actions to identify ways to continue to expand the availability of affordable health coverage, to improve the quality of coverage, to strengthen benefits, and to help more Americans enroll in quality health coverage. Consistent with CMS' authorities under the Act, this final rule implements E.O.s 14009 and 14070 by helping States to strengthen Medicaid and improve access to and quality of care provided. <FTNT> <SU>6</SU>  Executive Order 14009: <E T="03">https://www.federalregister.gov/documents/2021/02/02/2021-02252/strengthening-medicaid-and-the-affordable-care-act</E> . </FTNT> <FTNT> <SU>7</SU>  Executive Order 14070: <E T="03">https://www.federalregister.gov/documents/2022/04/08/2022-07716/continuing-to-strengthen-americans-access-to-affordable-quality-health-coverage</E> . </FTNT> Ensuring that beneficiaries can access covered services is necessary to the basic operation 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, FFS, fully-capitated managed care, partially capitated managed care, etc.), including through demonstrations and waiver programs. The volume of Medicaid beneficiaries enrolled in a managed care program in Medicaid has grown from 81 percent in 2016 to 85 percent in 2021, with 74.6 percent of Medicaid beneficiaries enrolled in comprehensive managed care organizations. <E T="51">8 9</E> <FTREF/> The remaining individuals received all of their care or some services that have been carved out of managed care through FFS. <FTNT> <SU>8</SU>  Medicaid Managed Care Enrollment Report. <E T="03">https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html</E> . <SU>9</SU>  Throughout this document, the use of the term “managed care plan” includes managed care organizations (MCOs), prepaid inpatient health plans (PIHPs), and prepaid ambulatory health plans (PAHPs) [as defined in 42 CFR 438.2] and is used only when the provision under discussion applies to all three arrangements. An explicit reference is used in the preamble if the provision applies to primary care case managers (PCCMs) or primary care case management entities (PCCM entities). </FTNT> Current access regulations are neither comprehensive nor consistent across delivery systems or coverage authority (for example, State plan and demonstration authority). For example, regulations at 42 CFR 447.203 and 447.204 relating to access to care, service payment rates, and Medicaid provider participation in rate setting apply only to Medicaid FFS delivery systems and focus on ensuring that payment rates are consistent with the statutory requirements in section 1902(a)(30)(A) of the Act. The regulations do not apply to services delivered under managed care. These regulations are also largely procedural in nature and rely heavily on States to form an analysis and reach conclusions on the sufficiency of their own payment rates. With a program as large and complex as Medicaid, access regulations need to be multi-factorial to promote consistent access to health care for all beneficiaries across all types of care delivery systems in accordance with statutory requirements. 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 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 the spring of 2022, we released a request for information (RFI)  <SU>10</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 Chi ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 2260k characters. Full document text is stored and available for version comparison. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━