CMS Solicits Input on Potential Medicaid and CHIP Reforms Around Eligibility, Enrollment and Access – Manatt, Phelps & Phillips, LLP

On February 17, the Centers for Medicare & Medicaid Services (CMS) released a Request for Information (RFI) regarding the federal standards that govern access to care in Medicaid and the Children’s Health Insurance Program (CHIP). The RFI casts a wide net, soliciting suggestions for reform regarding access to coverage—namely, the processes for enrollment and eligibility redeterminations—and the standards for defining and monitoring beneficiary access to care under both fee-for-service (FFS) and managed care delivery systems. Comments on the RFI are due by April 18.

The RFI outlines CMS’ goal of developing a “comprehensive access strategy … to improve health outcomes, advance health equity, and address disparities in access to health coverage and care,” with due consideration for the needs of beneficiaries and providers as well as “states’ capacity and resources.” CMS intends to pursue these goals through a mix of guidance and rulemaking, likely including short-term measures aimed at minimizing coverage disruptions following the end of the COVID-19 Public Health Emergency (PHE) as well as longer-term reforms, such as the long-expected rulemaking on “Streamlining the Medicaid and Chip Application, Eligibility Determination, Enrollment, and Renewal Processes” and “Assuring Access to Medicaid Services.”

To inform those next steps, the RFI seeks input on several questions regarding five objectives, which are organized under three overarching themes:

Enrollment in Coverage

Objective 1: Ensure that individuals eligible for Medicaid/CHIP are aware of their coverage options and are able to enroll in and receive benefits.

Maintaining Coverage

Objective 2: Minimize coverage losses when beneficiary eligibility is redetermined and when beneficiaries transition to other coverage programs. CMS flags these strategies as “particularly important” as states recommence Medicaid redeterminations following the end of the COVID‑19 PHE.1

Access to Services

Objective 3: Establish minimum federal standards that guarantee beneficiary access to timely, high-quality care under both FFS and managed care. Until now, CMS has generally allowed states to define their own minimum standards for access. Moreover, the federal requirements and monitoring processes differ substantially between FFS and managed care.

Objective 4: Establish an oversight system that includes monitoring of, and supports improvements in, measures related to potential access (i.e., provider capacity), realized access (i.e., utilization), and subjective beneficiary experiences.

Objective 5: Ensure that provider reimbursement rates in Medicaid and CHIP are sufficient to enlist and retain enough providers so that services are readily accessible.

The RFI’s questions, or prompts for commenters, echo the core priorities laid out in CMS’ November 2021 vision statement for Medicaid and CHIP: coverage and access, health equity, and integrated whole-person care, including special attention to unique challenges regarding behavioral health services and home and community-based services (HCBS), as well as health-related social needs.

With this RFI, the Biden administration has publicly launched a robust reassessment of these issues to help advance its vision. Achieving substantial reforms in the areas of eligibility, enrollment, and access to coverage and care will require a concerted effort to clarify policy objectives and advance rulemaking. The outcome may be revised federal standards that significantly affect Medicaid operations for states and managed care plans, payment rates for participating providers, and beneficiaries’ ability to enroll in coverage and access-covered services.

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1 Since March 2020, states have been prohibited from disenrolling any Medicaid beneficiaries as a condition of receiving enhanced federal funding under the Families First Coronavirus Response Act (FFCRA). This temporary requirement lasts only as long as the federal COVID-19 PHE, which will expire on April 15 unless further renewed by the Department of Health & Human Services (HHS).