ADVI Instant: CMS Issues Two Medicaid-Related Proposed Rules

These rules cover a broad range of proposed policies intended to improve transparency and access to care. Below, ADVI provides highlights from the proposed rules. If you have any questions or would like further information, please do not hesitate to get in touch.

Ensuring Access to Medicaid Services Proposed Rule
States are required to periodically assess whether beneficiaries have sufficient access to care using metrics such as enrolled providers in a geographic area, changes in utilization of covered services, beneficiary population characteristics, and provider payment rates. However, the evaluation process is not standardized and limits comparisons between the States.

  • CMS proposes to rescind the current requirements entirely and replace it with new requirements. Specifically, these new requirements would:
    • Require States publish approved FFS Medicaid payment rates in a clearly accessible, public location on their website no later than January 1, 2026 or approximately 2 years after the effective date of the final rule.
    • For certain services such as primary care, OB/GYN and outpatient behavioral health, conduct a comparative payment rate analysis between Medicaid and Medicare and make this analysis publicly available. This comparative analysis would be updated no less than every 2 years starting January 1, 2026.
    • Establish standard information that States must submit as part of a State Plan Amendment (SPA) that includes provider payment rate reductions or restructuring that could diminish patient access. States would be required to submit additional analyses if any of the following apply:
      • Aggregate Medicaid payment rates are below 80% of Medicare payment ratesChanges to Medicaid payment rates would result in a >4% reduction in FFS Medicaid expenditure during the fiscal year.
      • Public comment processes raise access to care concerns from patients, providers or other interested parties.
  • CMS considered, but did not propose, including covered outpatient drugs (including professional dispensing fees) as an additional category of service in the comparative payment rate analysis due to the complexity of drug pricing policies and use of rebate programs that does not fit into their proposed comparative payment rate analysis methodology.
    • CMS is still seeking public comment regarding the decision not to include inpatient behavioral health services and covered outpatient drugs including professional dispensing fees as additional proposed categories of services subject to the comparative payment rate analysis requirements in proposed § 447.203(b)(2).

Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Proposed Rule

  • Establishes maximum appointment wait time standard for certain services and requires states to conduct enrollee experience surveys for each managed care plan starting 3 years after the effective date of the final rule.
  • Requires managed care plans to submit to States a payment analysis comparing managed care payment rates to Medicare payment rates for primary care, OB/GYN, mental health and substance use disorder services. States would then be required to submit this information to CMS starting 2 years after the effective date of the final rule
  • Allow states to use state directed payments to implement value based payment arrangements and include non-network providers.
  • These policies would establish the MAC QRS as a one-stop-shop where beneficiaries could access information about Medicaid and CHIP eligibility and managed care; including comparing plans based on quality and other factors key to beneficiary decision making, such as the plan’s drug formulary and provider network.

ADVI will continue monitoring developments and next steps. This is a delayed release. ADVI Instant content is distributed in real time for retainer clients. Get in touch to learn more about how we can support your commercialization, market access, and policy needs.

Interested in getting in touch with Lindsay?

Lindsay Bealor Greenleaf, JD, MBA

Solution Leader, Federal and State Policy