In its continued pursuit of better care continuity, the U.S. Centers for Medicare & Medicaid Services has turned its attention to Medicaid and the Children's Health Insurance Program, or CHIP, in two sets of proposed rules that include several large-scale changes aimed at improving the patient experience. The proposals, largely supported by APTA, range from limiting patient waits to increasing provider payment in Medicaid managed care plans. Many of the themes of the proposed changes are echoed in recently finalized U.S. Department of Health and Human Services rules that seek to increase patient access to Affordable Care Act marketplace plans.

The two proposed rules — one focused on Medicaid managed care plans and CHIP and the second on overall access to Medicaid services — could be good news for patients and providers who participate in the nation's largest health programs, with some 83 million enrollees. Those programs saw significant increases in enrollment during the public health emergency, particularly in the managed care arm of the system, which now accounts for more than 70% of the Medicaid and CHIP population, according to CMS.

Based in part on feedback gained from enrollees, provider groups including APTA, and advocacy organizations, the proposed rules are consistent with a larger shift at CMS toward improvements in continuity of care, a focus that also was evident in CMS' recently finalized rules around prior authorization in Medicare Advantage plans that included many changes advocated by APTA.

Medicaid: Reduced Waits, Increased Consumer Focus, Attention to Provider Pay, and More

Here's a look at some of the areas that could change if the Medicaid rules are adopted as proposed.

Patient wait times. The proposed rule for Medicaid and CHIP managed care would establish standards for maximum patient wait times — and require monitoring to ensure compliance. Those oversight efforts would include "secret shopper" reviews and patient surveys and would be accompanied by remedy plans in the event a program isn't meeting standards.

Payment adequacy. If the rule is finalized, both Medicaid managed care and home and community-based services, or HCBS, programs will be required to analyze and report on how payment to primary care, mental and behavioral health, OB/GYN providers, and the direct care workforce compare with Medicare and Medicaid fee-for-service payments. Additionally, in an effort to ensure an adequate direct care workforce, CMS would require Medicaid agencies to spend 80% of all Medicaid payments on compensation for homemaker, home health aide, and personal care services.

State-based changes. CMS proposes further ensuring adequate HCBS care by requiring states to submit an "access analysis" report any time a reduction or restructure of provider rates is being considered.

Problem reporting and resolution. The proposed rules establish a new electronic incident management and grievance system that will identify, report, investigate, and resolve critical incidents and enrollee grievances.

Quality-of-service tracking and consumer awareness. CMS has proposed a range of ways for consumers to report on their experiences and connect with quality metrics. The intended result: a one-stop portal that compares plans for Medicaid managed care enrollees; in HCBS progams, more opportunities for public input by way of two new committees, with requirements that Medicaid agencies share changes and new requirements on their websites.

ACA Insurance Marketplace: Simplified Enrollment, Increased Access, Less Confusion

The final rule adopted by HHS around provisions of the Affordable Care Act shares much of the same APTA-supported focus on consumer access contained in the proposed Medicaid rules. Areas of change include:

Enrollment simplification. In hopes of increasing enrollment in ACA marketplace plans, HHS will allow ACA navigators to go door to door to help consumers get signed up.

Continuity of coverage. Individuals coming off Medicaid and CHIP, and those who can prove that they were influenced by plans with material display errors, will be provided special enrollment periods. Additionally, enrollees with bronze level plans will be permitted to automatically enroll into a silver plan with the same products and network, along with a lower premium.

Access and fees. Enrollees will see a drop in user fees in 2024 and all marketplace plans will now have to comply with network adequacy and essential community provider standards that ensure patients receive care from providers within their plan's network.

Plan proliferation. In light of the growing — and potentially confusing — number of plans available to consumers, HHS introduced requirements for standardized and non-standardized plans that reduce the number of options available. Those restrictions include limiting non-standardized plan options to four per product network type and plan level (gold, silver, bronze) in 2024 and decreasing that number to two for 2025.