/ en Fri, 25 Apr 2025 19:44:42 -0500 Mon, 17 Mar 25 15:51:31 -0500 /news/headline/2025-03-17-macpac-recommends-changes-medicaid-managed-care-external-quality-review-home-and-community-based <p>The Medicaid and CHIP Payment and Access Commission released its <a href="https://www.macpac.gov/publication/march-2025-report-to-congress-on-medicaid-and-chip/" target="_blank">March 2025 report</a> to Congress March 13. The first chapter makes three recommendations on improving the external quality review process in Medicaid managed care. Chapter two focuses on enhancing timely access to home- and community-based services. The final chapter analyzes the federal administrative requirements for HCBS programs and makes a recommendation on reducing states’ administrative burden.</p> Mon, 17 Mar 2025 15:51:31 -0500 CHIP /news/headline/2024-10-17-cms-allow-medicaid-chip-coverage-ihs-facilities-tribal-communities <p>The Centers for Medicare & Medicaid Services Oct. 16 <a href="https://www.cms.gov/newsroom/press-releases/biden-harris-administration-takes-groundbreaking-action-expand-health-care-access-covering">approved</a> section 1115 demonstration amendments which will allow Medicaid and Children's Health Insurance Program coverage of traditional health care practices provided by Indian Health Service facilities, Tribal facilities and urban Indian organizations. The amendments will benefit tribal communities in Arizona, California, New Mexico and Oregon. Studies show that traditional health care practices can improve outcomes for patients with various conditions, including mental health and substance use disorders, CMS said.</p> Thu, 17 Oct 2024 16:02:40 -0500 CHIP /news/headline/2024-09-26-cms-releases-guidance-states-meet-screening-diagnostic-and-treatment-requirements-under-medicaid-and <p>The Centers for Medicare & Medicaid Services Sept. 26 released <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf" target="_blank">guidance</a> on state compliance with the Early and Periodic Screening, Diagnostic and Treatment requirements under Medicaid and the Children's Health Insurance Program. The guidance explains statutory and regulatory EPSDT requirements and suggests best practices, such as increasing access through transportation and care coordination services, leveraging incentives, sanctions and contractual requirements in the Medicaid managed care programs, expanding the children-focused workforce, improving care for children with specialized needs (including children in the child welfare system and children with disabilities), and expanding families' awareness of their children’s rights under EPSDT requirements. The guidance also includes information, strategies and best practices to address the needs of children with behavioral health conditions.</p> Thu, 26 Sep 2024 14:03:10 -0500 CHIP /news/headline/2024-07-03-hhs-authorizes-five-states-provide-health-care-coverage-people-transitioning-out-incarceration <p>The Department of Health and Human Services July 2 <a href="https://www.cms.gov/newsroom/press-releases/hhs-authorizes-five-states-provide-historic-health-care-coverage-people-transitioning-out">announced</a> it will provide Medicaid and Children's Health Insurance Program coverage to incarcerated people in Illinois, Kentucky, Oregon, Utah and Vermont prior to release. The coverage, provided under the <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/smd23003.pdf">Medicaid Reentry Section 1115 Demonstration Opportunity</a>, will allow those states to provide coverage up to 90 days before an eligible person's expected release date. Coverage under the measure includes substance-use disorder treatment and treatment for certain behavioral health conditions. Other states participating in the program are California, Massachusetts, Montana and Washington.</p> Wed, 03 Jul 2024 15:03:39 -0500 CHIP /news/headline/2024-05-22-delaware-tennessee-become-first-states-provide-diapers-through-medicaid <p>The Centers for Medicare & Medicaid Services recently announced the approval of <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/de-dshp-dmntn-appvl-05172024.pdf">Delaware</a> and <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/tn-tenncare-iii-demo-aprvl-amndmnt-5.pdf">Tennessee</a> as the first states to provide diapers to children covered by Medicaid. The approvals were granted under section 1115 <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html">demonstrations</a>, which can be used to experiment or test new policies that are likely to assist in promoting Medicaid objectives. Delaware will be allowed to provide up to 80 diapers and one pack of baby wipes per week to mothers in the first twelve weeks postpartum, while Tennessee is authorized to provide 100 diapers per month for all children under age two enrolled in Medicaid or the Children's Health Insurance Program. </p> Wed, 22 May 2024 14:34:43 -0500 CHIP /news/headline/2024-05-10-cms-extends-unwinding-flexibilities-states-through-june-2025 <p>The Centers for Medicare & Medicaid Services May 9 announced <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib050924-e14.pdf">an extension</a> of unwinding flexibilities to support state efforts to protect the continuity of coverage in Medicaid and the Children's Health Insurance Program. States can continue to use certain waiver authorities to streamline eligibility redeterminations until June 30, 2025, adding a year to the previous deadline of June 2024. CMS said the extension for coverage renewals allows states to shift resources to help reduce processing times for applications. </p> Fri, 10 May 2024 14:17:47 -0500 CHIP <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) released April 22 a <a href="https://public-inspection.federalregister.gov/2024-08085.pdf">final rule</a> focused on ensuring access to services for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries in managed care delivery systems. The final rule is intended to increase transparency, improve accountability and ensure standardized data and monitoring, particularly for provider network adequacy requirements and state directed payment (SDP) programs. CMS also published an <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib042224.pdf">Informational Bulletin</a> describing their plan to enforce provider attestation requirements beginning on Jan. 1, 2028. </p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><ul><li>Network Adequacy Metrics and Oversight:<ul><li>Establish maximum appointment wait times for primary care, obstetrics and gynecology services, and substance use disorder services.</li><li>Require states to use an independent entity to conduct secret shopper surveys to validate managed care plans’ compliance with applicable standards.</li><li>Require states to conduct an annual enrollee experience survey for each managed care plan.</li><li>Mandates states to conduct an annual payment analysis for certain services compared to Medicare payment rates.</li></ul></li><li>State Directed Payments:<ul><li>Require that SDP levels for hospital, nursing and professional services at academic medical centers not exceed the average commercial rate (ACR).</li><li>Streamline the application and approval process for certain SDP programs.</li><li>Prohibit the use of post-payment reconciliation processes for SDPs that are based on fee schedules.</li><li>Make explicit in regulation the existing requirement that SDPs must comply with all federal laws concerning funding sources of the non-federal share. </li></ul></li></ul></div></div><h2>AHA TAKE</h2><p>The AHA appreciates that CMS acknowledges the critical role hospitals play in state Medicaid financing and the importance of supplemental payments to sustain beneficiary access to care. In response to growing pressure and scrutiny of SDPs among federal oversight agencies, CMS contemplated a range of policy options in proposed rulemaking last year, some of which could have been devastating for the ongoing viability of certain hospital supplemental payment programs that support patient access to care, such as capping payments at Medicare rates or at an aggregate percentage of overall managed care spending. In response to feedback from AHA and the hospital field, we are pleased that CMS did not advance problematic proposals that could have significantly curbed SDP funding and reduced state flexibility to align payments with state quality and access goals. Instead, CMS finalized provisions that preserve existing SDP programs for the near future and permit ongoing state flexibility to make certain supplemental payments consistent with commercial rates where appropriate.</p><p>Specifically, AHA appreciates that CMS codified provisions that establish the<strong> </strong>ACR as the upper payment limit for SDP programs and the provisions that offer states additional flexibility on the methodology for calculating the ACR. In codifying these provisions, CMS recognizes that hospitals treat all patients the same — regardless of coverage — and ensures that hospitals have appropriate resources to serve Medicaid patients. The AHA provided support for these provisions in comments on the proposed rule. The final rule also streamlines application and approval of certain existing arrangements, which reduces burden for state Medicaid agencies that continue with the critical mission of eligibility redetermination and ensures needed payments to safety net providers are not delayed or withheld due to administrative hurdles.</p><p>However, the AHA remains concerned about provisions that could restrict permissible financing approaches for Medicaid payments. Specifically, the finalized regulatory language regarding attestations could cause a chilling effect on financing mechanisms that states rely on to provide coverage to our most vulnerable communities. Implementing this entirely unnecessary policy will only create undue burden on both providers and states. As such, the AHA appreciates the delay in enforcement until 2028, but remains concerned that this policy could result in financing restrictions that have long-term consequences for coverage and access.</p><p>Finally, the AHA also applauds CMS’ efforts to strengthen network adequacy requirements and oversight of managed care programs. The finalized provisions will ensure that Medicaid managed care beneficiaries can access the services they need.</p><h2>SUMMARY OF KEY PROVISIONS</h2><p>The rule finalizes numerous changes to federal requirements for the Medicaid managed care program. The stated objective is to improve oversight of the program and ensure adherence to program integrity requirements. These regulatory changes span access improvements, network adequacy, provider payment, home and community-based services, quality reporting, <em>In Lieu of Service and Setting</em> (ILOS) requirements and SDP programs. The following summary focuses on those finalized provisions of particular interest to hospitals and health systems including implementation timeframes. </p><h3>Access and Network Adequacy</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>Maximum Appointment Wait Time Standard:</u> Establish appointment wait time standards for routine primary care,* obstetric/gynecological, and substance use disorder services* and a state selected service* (*adult and pediatric). Wait times would be comparable to ACA Marketplace standards.</td><td width="180">The first rating period on or after July 9, 2027.</td></tr><tr><td width="444"><u>Secret Shopper and Enrollee Experience Survey:</u> Require states to use an independent entity to validate managed care plan compliance with wait time standards and accuracy of provider directories. Also require states to conduct enrollee experience survey.</td><td width="180">The first rating period on or after July 9, 2027.</td></tr><tr><td width="444"><u>Annual Payment Analysis:</u> Require states to conduct and submit annual payment analysis that compares managed care plans’ payments for certain services as a proportion of Medicare’s payment rate, and for certain home and community-based services, the state’s Medicaid state plan rate.</td><td width="180">The first rating period on or after July 9, 2026.</td></tr><tr><td width="444"><u>State Remedy Plan and Public Website:</u> Require states implement a remedy plan for any managed care plan that needs improvement in meeting required access standards. Require states to maintain a single website that is readily identifiable to the public, easy to use and contains required information for public transparency.</td><td width="180"><p>Remedy plan: The first rating period on or after July 9, 2024.</p><p>Website: No later than July 9, 2025.</p></td></tr></tbody></table><h3>State Directed Payment Programs</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>Streamline Approval for Certain SDPs:</u> Removes regulatory barriers to help states use SDPs to implement value-based purchasing payment arrangements and include non-network providers in SDPs. Establishes submission timeframes for SDP preprints. Also eliminates written prior approval for SDPs that are minimum fee schedules set at the Medicare payment rate.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><u>Average Commercial Rate Limitations:</u> Requires that provider payment levels for SDPs for inpatient and outpatient hospital services, nursing facility services and the professional services at an academic medical center not exceed the average commercial rate.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><u>Prohibit Post Payment Reconciliation:</u> Prohibits the use of post-payment reconciliation processes for SDPs that are based on fee schedules.</td><td width="180">The first rating period on or after July 9, 2024.</td></tr><tr><td width="444">Prohibits the use of separate payment terms and requires that all SDPs be included in actuarially sound capitation rates.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><p><u>Financing Restrictions:</u> Requires that states ensure each provider receiving an SDP attest that it does not participate in any arrangement that holds taxpayers harmless for the cost of a tax. CMS concurrently released an informational bulletin regarding CMS’ exercise of enforcement discretion until calendar year 2028 for existing health care-related tax programs with certain hold-harmless arrangements involving the redistribution of Medicaid payments.</p><p>Makes explicit in regulation the existing requirement that SDPs must comply with all federal laws concerning funding sources of the non-federal share.</p></td><td width="180"><p>Jan. 1, 2028</p><p>Additional CMS guidance on the exercise of enforcement discretion until CY 2028 can be found in the concurrently issued <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib042224.pdf">Informational Bulletin</a>.</p></td></tr><tr><td width="444"><u>State Appeals Process:</u> Establish, through the U.S. Department of Health and Human Services Departmental Appeals Board, a process for states to appeal SDP disapprovals.</td><td width="180">The first rating period on or after July 9, 2024.</td></tr><tr><td width="444"><p><u>State Reports and Evaluations:</u> Requires provider-level reporting on actual SDP expenditures in the Transformed Medicaid Statistical Information System.</p><p><u></u></p><p>Require that states submit to CMS SDP evaluations every three years if the SDP costs exceed 1.5% as a percentage of total capitation payments.</p></td><td width="180">The first rating period on or after July 9, 2027.</td></tr></tbody></table><h3>Medical Loss Ratio</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>MLR and Quality Expenditures:</u> Revises how quality expenditures are allocated for purposes of the medical loss ratio (MLR) calculation. These revisions to provider incentive payments and expense allocation reporting are intended to align with recent regulatory changes for Marketplace plans.</td><td width="180">Effective date of final rule.</td></tr><tr><td width="444"><p><u>MLR Specifications:</u> Requires managed care plans to provide medical loss ratios for each managed care plan.</p><p>Requires managed care plans to report identified or recovered overpayments to the state within 30 calendar days.</p></td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2025.</p></td></tr></tbody></table><h3>Other Provisions</h3><p>The rule finalizes several provisions regarding use of ILOS<em> </em>in managed care settings. ILOS allows for managed care plans to offer ILOS as a substitute for a service or setting that is covered in the state plan; for example, some home- and community-based services or a medically-tailored meal. In general, the final rule provides greater specificity around what services qualify for ILOS and increased documentation. CMS also finalizes quality provisions that are designed to encourage greater public engagement and more transparency around state External Quality Review programs. </p><p>Lastly, the rule provides further direction and encouragement for states to establish a rating system for beneficiaries to compare managed care plans on quality and other factors.</p><h2>FURTHER INFORMATION</h2><p>For additional detail, the <a href="https://www.cms.gov/newsroom/fact-sheets/medicaid-and-childrens-health-insurance-program-managed-care-access-finance-and-quality-final-rule">CMS Fact Sheet</a> on the final rule summarizes key provisions and the <a href="https://www.medicaid.gov/medicaid/managed-care/downloads/applicability-date-chart-mc.pdf">implementation chart</a> includes effective dates for applicable regulatory changes.</p><p>If you have further questions, please contact AHA at 800-424-4301. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/cms-finalizes-medicaid-access-and-payment-managed-care-rule-bulletin-4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-cms-finalizes-medicaid-access-and-payment-managed-care-rule-bulletin-4-24-24-2.jpg" data-entity-uuid data-entity-type="file" alt=" Cover Special Bulletin: CMS Finalizes Medicaid Access and Payment Managed Care Rule" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 13:55:29 -0500 CHIP <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) released April 22 a <a href="https://public-inspection.federalregister.gov/2024-08363.pdf">final rule</a> focused on ensuring access to services for Medicaid beneficiaries in fee-for-service delivery systems in keeping with the Administration’s objectives to improve access for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. The finalized provisions are intended to increase transparency, improve accountability and ensure standardized data and monitoring. </p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><ul><li>Medical Advisory Committee and Beneficiary Advisory Group: Renames and expands the scope of states’ Medical Care Advisory Committees (MAC) and requires that states establish a Beneficiary Advisory Group (BAG). The MACs and the BAGs are intended to promote transparency and accountability amongst the state, stakeholders and Medicaid beneficiaries related to the effective administration of the Medicaid program.</li><li>Fee-for-service Provider Payment Rate Transparency: Removes state access monitoring review plan requirements and replaces them with new payment rate transparency standards and documentation requirements. It also requires states to conduct a payment rate analysis for certain services every two years.</li><li>Home- and Community-Based Services: Strengthens safeguards and provides for a more coordinated administration of policies and procedures for individuals receiving Medicaid-covered home and community-based services. </li></ul></div></div><h2>AHA TAKE</h2><p>Ensuring access and coverage for Medicaid and CHIP populations is a key priority for the AHA and adequate provider payment is a critical component. We applaud CMS’ efforts to improve patient access to high-quality care in the Medicaid program and promote greater transparency and accountability, especially with respect to mitigating payment-related barriers to provider participation in the program. We also support CMS’ efforts to improve stakeholder and beneficiary engagement and improve access to home- and community-based services. </p><h2>SUMMARY OF KEY PROVISIONS</h2><p>The rule finalizes many of the proposed changes to ensure access to services for beneficiaries by promoting greater transparency and accountability in Medicaid fee-for-service (FFS). Central to these provisions is the statutory requirement that states must make FFS provider payments sufficient to enlist enough providers to ensure Medicaid beneficiaries have sufficient access to covered services. The following summary will focus on changes of particular interest to hospitals and health systems.</p><h3>Medical Advisory Committee and Beneficiary Advisory Group</h3><p>The final rule renames and expands the scope of state Medical Care Advisory Committees. The rule requires that states establish a MAC and a BAG, the core purpose of which is to provide advice and feedback on a state’s Medicaid program. The rule requires that Medicaid stakeholders comprise MAC membership, including consumer advocacy groups, beneficiaries, clinicians, health care administrators and other state agencies serving Medicaid populations. At least two MAC meetings per year are required to be open to the public and must include a public comment period. BAGs will be a stand-alone group of Medicaid beneficiaries, families and caregivers. States will be required to ensure transparency by posting MAC and BAG membership lists, meeting schedules, minutes, by-laws, recruitment processes and an annual report on MAC activities on its website.</p><h3>Fee-for-service Provider Payment Rate Transparency</h3><p>CMS finalizes its proposal to remove state access monitoring review plan requirements and replaces them with new payment rate transparency standards and documentation requirements. The final rule requires that states publicly disclose and regularly update Medicaid FFS payment rates for all services on a state’s website. The final rule also requires states to publish an analysis that compares Medicaid and Medicare payment rates for critical services every two years, including primary care, obstetrical and gynecological care, and outpatient behavioral health services.</p><p>States are required to demonstrate that any state plan amendment that proposes to reduce provider rates or restructure provider payments would not put access at risk. An access analysis is required if any of the following conditions are not met.</p><ul><li>Aggregate Medicaid payments are at or above 80% of the most recently published Medicare payment rates.</li><li>Payment rate reductions result in no more than a 4% reduction in FFS expenditure for each benefit category.</li><li>Public process has not identified access concerns.</li></ul><p>If these conditions are not met when a state proposes a rate reduction or restructuring, states must provide detailed information to CMS for the agency to evaluate the proposed payment changes. Such information would include a comparison of relevant Medicaid and Medicare payment rates. Also, states would need to provide data on participating providers, beneficiaries receiving services and analysis related to services affected by rate reduction or restructuring, as well as estimates on how change would affect access.</p><h3>Home- and Community-Based Services</h3><p>The rule finalizes provisions intended to strengthen safeguards and better coordinate policies and procedures for individuals receiving Medicaid-covered home and community-based services (HCBS). Under the rule, states are required to:</p><ul><li>Establish a grievance system for FFS HCBS programs. Ensure that at least 80% of Medicaid payments for personal care, homemaker and home aide services be spent on compensation for the direct care workforce.</li><li>Publish average hourly rates for personal care, home health care, homemaker and habilitation services every two years.</li><li>Create an advisory group to advise on direct care worker provider rates. </li><li>Report publicly on waiting lists for HCBS waiver programs and standardized sets of quality and compliance measures.</li></ul><p>CMS will align the new requirements across the various HCBS Medicaid authorities found in 1915 (c),(i),(j), and (k) as well as 1115 demonstration authority.</p><h2>Further Information</h2><p>For additional detail, the <a href="https://www.cms.gov/newsroom/fact-sheets/ensuring-access-medicaid-services-final-rule-cms-2442-f#:~:text=The%20Ensuring%20Access%20to%20Medicaid,HCBS)%20provided%20through%20those%20delivery">CMS Fact Sheet</a> on the final rule summarizes key provisions and the <a href="https://www.medicaid.gov/medicaid/access-care/downloads/applicability-date-chart-ac.pdf">implementation chart</a> includes effective dates for applicable regulatory changes.</p><p>If you have further questions, please contact AHA at 800-424-4301. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/cms-finalizes-medicaid-access-and-payment-fee-for-service-rule-bulletin4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-cms-finalizes-medicaid-access-and-payment-fee-for-service-rule-bulletin-4-24-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Special Bulletin: CMS Finalizes Medicaid Access and Payment Fee-for-service Rule" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 13:24:25 -0500 CHIP /news/headline/2024-04-19-massachusetts-medicaid-demonstration-expands-services-continuous-eligibility <p>The Centers for Medicare & Medicaid Services April 19 approved an <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ma-masshealth-ca-04192024.pdf" target="_blank">amendment</a> to a Massachusetts Medicaid and Children’s Health Insurance Program demonstration to add health-related social needs services; expand Marketplace subsidies and cost-sharing assistance; provide pre-release services to eligible incarcerated beneficiaries; and expand continuous eligibility to 24 months for older adults experiencing homelessness and 12 months for other adults. According to the <a href="https://www.mass.gov/news/masshealth-receives-federal-authority-to-expand-eligibility-for-individuals-and-lower-insurance-costs-for-massachusetts-families" target="_blank">state</a>, the amendment covers up to six months of post-hospitalization/pre-procedure housing as a health-related social needs service.</p> Fri, 19 Apr 2024 13:53:53 -0500 CHIP <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) March 27 issued a <a href="https://public-inspection.federalregister.gov/2024-06566.pdf">final rule</a> designed to streamline the eligibility and enrollment process for Medicaid and the Children’s Health Insurance Program (CHIP). This proposed rule is the continuation of efforts by CMS to improve access and coverage for the Medicaid and CHIP populations by removing enrollment barriers and reducing coverage disruptions for eligible individuals as state Medicaid programs conduct eligibility redetermination following the conclusion of the COVID-19-related continuous coverage period.</p><p>The Department of Health and Human Services also concurrently released March 27  a <a href="https://aspe.hhs.gov/reports/increased-childrens-coverage-continuous-eligibility-expansion">new report</a> highlighting that the continuous eligibility requirements that Congress passed in December 2022, which took effect Jan. 1, could protect as many as 17 million children from coverage disruptions.</p><p>AHA TAKE</p><p>The final rule aims to simplify the Medicaid and CHIP enrollment processes, minimize disruption of coverage for eligible individuals, reduce temporary loss of coverage due to changed circumstances (churn), and ease administrative burden for state Medicaid and CHIP programs. The AHA strongly supports these objectives, which are particularly critical as Medicaid agencies nationwide conduct eligibility redeterminations following the conclusion of the COVID-19 public health emergency.</p><p><strong>HIGHLIGHTS OF THE PROPOSED RULE</strong></p><p>The rule contains a number of proposals intended to facilitate enrollment into coverage, as well as to help protect against loss of coverage. These include:</p><p>Prohibiting annual and/or lifetime limits on CHIP benefits. Currently CHIP regulations do not prohibit such limits, and several states have implemented them on CHIP benefits. The proposed rule would prohibit such limits consistent with existing prohibitions in the Medicaid program. The final rule also removes the state option to require a waiting period prior to CHIP enrollment.</p><ul><li>Allowing children covered by CHIP to remain enrolled or reenroll without a lockout period for failure to pay premiums. States currently have the regulatory option to impose a premium lockout period, which is a specified period that a child or a pregnant individual must wait until being allowed to reenroll in the CHIP program after a certain period of non-payment of premiums. This policy change would align CHIP rules with those for the Medicaid program, which does not permit premium lockout periods.</li><li>Establishing a clear process to prevent termination of eligible beneficiaries who should be transitioned between Medicaid and CHIP when their income changes or when the beneficiary appears to be eligible for the other program, even if the beneficiary fails to respond to a request for information.</li><li>Clarifying that states are permitted to establish an optional eligibility group for children with disabilities under age 21 whose eligibility is excepted from use of the Modified Adjusted Gross Income counting rules (e.g., for those living with a disability) or for other circumstances where such coverage is not already permitted in regulation.</li><li>Requiring that states apply the same timeliness standard for renewal of enrollment as they do to initial applications. In addition, the rule would require that states allow sufficient time for beneficiaries to provide the documentation needed to retain enrollment (at least 15 days to return information related to an initial application and at least 30 days for information needed to retain enrollment). Finally, the rule provides states with options to use available information to update addresses when beneficiaries move within the state.</li><li>Removing certain potential barriers to enrollment, such as requiring a person to apply for other benefits as a condition of Medicaid eligibility.</li><li>Requiring that states conduct renewals no more than once every 12 months for those whose eligibility is based on being 65 or older, blind or disabled and prohibit requirements for in-person interviews for these populations. For these eligibility groups, states will also be required to use prepopulated renewal forms, provide a minimum 90-day reconsideration period after procedural termination, limit requests for information about a change in circumstances, and accept renewals through multiple modalities.</li><li>Includes a variety of program integrity provisions such as updating outdated recordkeeping regulations, removing regulatory references to outdated technology, and establishing standards for retention of state records and case documentation.</li></ul><p>The rule takes effect 60 days after publication in the April 2 Federal Register.</p><p><strong>FURTHER INFORMATION</strong></p><p>For additional detail, the <a href="https://www.cms.gov/newsroom/fact-sheets/streamlining-medicaid-childrens-health-insurance-program-and-basic-health-program-application">CMS Fact Sheet</a> on the proposed rule summarizes key provisions. If you have further questions, please contact Michelle Millerick, AHA’s senior associate director of health insurance and coverage policy, at <a href="mailto:mmillerick@aha.org">mmillerick@aha.org</a>. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/03/cms-issues-final-eligibility-and-enrollment-rule-for-medicaid-childrens-health-insurance-program-and-basic-health-program-bulletin-3-29-2024.pdf" target="_blank"><img src="/sites/default/files/2024-03/cover-cms-issues-final-eligibility-and-enrollment-rule-for-medicaid-childrens-health-insurance-program-and-basic-health-program-bulletin-3-29-2024.png" data-entity-uuid data-entity-type="file" alt="Cover Special Bulletin: CMS Issues Final Eligibility and Enrollment Rule for Medicaid, Children’s Health Insurance Program and Basic Health Program" width="510" height="653"></a></div></div></div> Fri, 29 Mar 2024 10:34:25 -0500 CHIP