CMS Releases Two Finalized Medicaid Access Rules

CMS to Require States to Publish FFS Medicaid Payment Rates and Assess MCO Network Adequacy

Sarah Hohman, Director of Government Affairs


Continuing the busy regulatory season, CMS released two substantial Medicaid rules, Ensuring Access to Medicaid Services and Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality, intended to advance access to care and quality of care for both Medicaid fee-for-service and Medicaid managed care patients.

While the majority of these provisions impact insurers and patients themselves, NARHC continues to support policies that increase access for rural Medicaid beneficiaries, as well as increase transparency in the Medicaid program.

Ensuring Access to Medicaid Services

This rule requires various things including the establishment of a Medicaid Advisory Committee and Beneficiary Advisory Council (comprised solely of Medicaid beneficiaries) in each state and increases transparency of home- and community-based services (HCBS) and Medicaid fee-for-service (FFS) payments.

Notably, the rule requires that states publish all Medicaid FFS payments rates on a publicly available and accessible website and requires a published state analysis comparing payment rates across primary care/mental health/OBGYN every two years. These requirements begin in 2026.

RHC/FQHC payment rates are not subject to these transparency provisions. CMS states that due to the “unique provider-specific payment floor mandated by Congress for FQHCs and RHCs, we believe access concerns related to payment rates for FQHCs and RHCs are attenuated..." CMS also stated that this would be a great burden for states to publish these rates, explaining “publicizing the FQHC and RHC rates would represent a sharp increase in States’ efforts for rates that are less concerning to CMS due to the statutory payment floor in section 1902(bb) of the Act. We do not believe the increase in burden is justifiable.”

The statutory floor that CMS is referencing is of course the RHC Medicaid payment methodology that has been in effect since the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (also known as BIPA 2000) that established a prospective payment system based on costs as they were in 2000, adjusted by the Medicare Economic Index and changes in scope of services. States are also permitted to pay RHCs under an alternative payment methodology, so long as it is not lower than the PPS methodology rate.

NARHC believes that states being required to publish the RHC rates would be useful in ensuring that every state is following the law as established in BIPA 2000. In the absence of transparency requirements in this rule applying to RHCs, we will continue to compile this data as an organization and act accordingly if the data demonstrates that states are not following the existing policy.

Another important component of the rule is the requirement that if a state is planning to reduce rates to providers in any way, they must perform an analysis of impacts to access. This would apply to any state plan amendments that propose to change rate amount or structuring for RHCs/FQHCs, as well. A component of this provision is also that states must “have ongoing mechanisms for beneficiary and provider input on access to care.” These mechanisms can include hotlines, surveys, etc. 

Finally, the rule will phase in a requirement over the next 6 years that a minimum of 80% of Medicaid payments for home health services must be used for direct compensation of those providing the care, placing a strict 20% limit on overhead/administrative costs.

Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule

This rule, applying to managed care plans in Medicaid and CHIP, establishes maximum appointment wait times for certain care, requires secret shopper surveys of managed care plans’ compliance, and aims to further increase transparency of payments, services, and beneficiary experiences.

Appointment Wait Times

CMS is setting maximum appointment wait time standards for Medicaid MCO patients as follows:

  • 15 business days adult and pediatric primary care and OB/GYN services
  • 10 business days outpatient mental health/SUD services

States must use an independent entity as a “secret shopper” to validate compliance with these wait time standards, and each MCO must conduct a yearly enrollee experience survey. These provisions will go into effect in 3-4 years.

Notably, CMS clarifies how telehealth visits can and cannot be used in meeting network adequacy/appointment wait time standards:

...Appointments offered via telehealth only be counted towards compliance with appointment wait time standards if the provider also offers in-person appointments and that telehealth visits offered during the secret shopper survey be separately identified in the survey results. We believe it is appropriate to prohibit managed care plans from meeting appointment wait time standards with telehealth appointments alone and by separately identifying telehealth visits in the results because this will help States determine if the type of appointments being offered by providers is consistent with expectations and enrollees’ needs.

Medicaid Managed Care Rate Analysis
States must submit a yearly payment analysis comparing MCOs’ payment rates to Medicare payment rates. Note: RHC payments are intentionally exempt from this requirement as CMS states, “bundled payments are challenging to disaggregate, and we believe it best to not include them in the payment analysis at this time.”
As mentioned, these rules will have significant impacts to Medicaid FFS and Managed Care plans, as well as patients as they are phased in over the next several years. Please contact with any questions.