CMS proposes rate transparency rules for Medicaid

CMS proposed two new rules April 27 that would establish national standards of care provided through fee-for-service Medicaid/CHIP and managed care plans, along with a requirement to publicly disclose provider payment rates online. 

"These rules are focused on increasing transparency and accountability by those that are managing the Medicaid program," HHS Secretary Xavier Becerra told reporters during a briefing on the proposals. "We're going to standardize data and monitor it more so we can keep tabs on how companies are implementing the Medicaid program in various states."

"In order to ensure access, we need to know how much Medicaid providers are getting paid in comparison to other forms of health insurance," CMS Administrator Chiquita Brooks-LaSure said. "These two new rules will also raise the bar on how state Medicaid programs engage with enrollees and consider their lived experience and feedback."

Seven key proposals:

  • States would be required to publicly disclose Medicaid provider payment rates for FFS and managed care in relation to Medicare FFS rates.

  • States would be required to maintain a single public web page where enrollees can review Medicaid FFS and managed care payment rates across states and allow them to compare plans based on quality and access standards. CMS would establish the framework for states to implement a quality rating system enrollees could use to compare plans.

  • CMS would enforce maximum appointment wait times for certain services under managed care plans and implement stronger state monitoring and reporting requirements related to access and network adequacy. Those services include routine primary care for adults and children, obstetric/gynecological services, outpatient mental health and substance use disorders, and a state-selected service.

  • States would be required to conduct independent "secret shopper surveys'' of managed care plans to verify compliance with appointment wait times and ensure that provider directories are accurate. States would also have to conduct enrollee experience surveys every year for those enrolled in managed care plans.

  • For home and community based services, at least 80 percent of FFS and managed care Medicaid payments for personal care, homemaker and home health aide services would be required to be spent on direct care worker salaries. 

  • States would be required to publish the FFS and managed care average hourly rate paid to direct care workers and establish an advisory group regarding provider rates to direct care workers.

  • Medical Care Advisory Committee structures within state Medicaid agencies would be modified to support more accessible engagement by all committee members. A new State Beneficiary Advisory Group with crossover to the restructured MCAC would include perspectives from Medicaid beneficiaries.

The full proposal for managed care plans is available here. For FFS, the proposed rule is available here.

Comments on the proposed rules will be accepted through July 3.


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