CMS Solicits Input on Medicaid and CHIP Reforms Regarding Eligibility, Enrollment, and Access to Care
Allison Orris and Julian Polaris, Manatt Health
Overview of the Request for Information (RFI)
On February 17, the Centers for Medicare & Medicaid Services (CMS) released an 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–as well as the standards for defining and monitoring enrollee 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 enrollees 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 requests input on specific 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.
Objective 2. Minimize coverage losses when eligibility is redetermined, and when enrollees transition to other coverage programs.
Access to Services
Objective 3. Establish minimum federal standards that guarantee enrollee access to timely, high-quality care under both 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 enrollee experiences.
Objective 5. Ensure that provider reimbursement rates in Medicaid and CHIP are sufficient to enlist and retain enough providers that services are readily accessible.
The RFI’s questions, or prompts for commenters, echo the core priorities laid out in CMS’ November 20 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. Below we provide additional discussion of the RFI’s prompts regarding enrollment, redeterminations, and access to care.
Enrollment in Coverage (RFI Objective 1)
The RFI illustrates CMS’ concern about ensuring that low- and middle-income people are aware of Medicaid and CHIP as potential coverage options and CMS’ desire for states to establish streamlined, accessible processes for eligible individuals to enroll and begin receiving services in a timely manner. To that end, CMS has asked for feedback on issues such as the following:
- How can CMS support states in achieving timely eligibility determinations and timely enrollments, including (as applicable) enrollment in managed care plans?
- How can CMS and states address enrollment barriers for populations such as:
- People living in rural or urban centers, or people who lack stable housing?
- People with limited English proficiency?
- People who have disabilities and/or behavioral health needs?
- What additional capabilities would allow states to improve timeliness, such as enhanced system capabilities (including improved data-sharing across systems), modified staffing arrangements, or tools for monitoring waiting lists?
- What key indicators should CMS consider monitoring (e.g., denial rates)?
CMS substantially revised the rules on eligibility and enrollment almost a decade ago, following passage of the Affordable Care Act (ACA), most recently making changes regarding notices, verification practices, and appeals at the end of the Obama administration. Both the Trump and Biden administrations have included additional eligibility and enrollment rulemaking in the Department of Health & Human Services’ (HHS) regulatory agenda; the RFI will likely inform such rulemaking.
Maintaining Coverage (RFI Objective 2)
CMS seeks input on strategies regarding redeterminations to ensure that Medicaid and CHIP enrollees are not disenrolled despite remaining eligible, and to minimize gaps in enrollment for individuals who transition to other coverage programs. These issues are particularly urgent, CMS notes, due to the eventual expiration of the “continuous coverage” requirement, which has prevented states from disenrolling any Medicaid enrollees during the COVID-19 PHE as a condition of the enhanced federal funding available to states under the Families First Coronavirus Response Act. CMS has already released several guidance documents advising states on strategies to minimize coverage losses following the PHE, and now seeks input on the following.
- Strategies to support state enhancements to their redetermination processes, such as:
- Verifying enrollee information with managed care organizations and other partners.
- Adopting optional policies like express lane eligibility and 12-month continuous coverage for children.
- Strengthening data-sharing systems to enhance ex-parte redeterminations.
- Potential standards for state communication with enrollees at risk of disenrollment.
- Potential CMS actions to promote continuity of coverage for enrollees who transition from one Medicaid/CHIP eligibility group to another, or who are able to transition out of Medicaid/CHIP and into another health coverage program.
Access to Care (RFI Objectives 3 to 5)
The bulk of the RFI is dedicated to access to care, including sections on federal access standards, access monitoring, and provider payment rates. Federal law currently establishes two separate access regimes for FFS and managed care delivery systems, both of which devolve substantial authority to the states to define standards for minimally acceptable access to services. With this RFI, CMS seeks suggestions for a new, more robust federal access framework that operates more consistently across programs and delivery systems, while accounting for the meaningful variability in what adequate access looks like across states, enrollee groups, and types of covered services.
Notably, CMS has solicited input on the possibility of establishing minimum federal standards, for both FFS and managed care, that define equitable and timely access to providers and services. RFI prompts include:
- How should federal access standards account for potential differences regarding delivery systems, provider type, geography, and enrollee language needs/cultural practices?
- How could CMS use federal access standards to advance the concepts of “whole person” care and care coordination across physical health, behavioral health, long-term services and supports (LTSS), and health-related social needs?
- How should CMS use these federal standards with respect to enforcement actions against non-compliant states, establishing benchmarks for quality-improvement activities, or incorporating these standards into the procedures for grievances and appeals filed by enrollees who have difficulty accessing services?
In addition to defining a federal “floor” for access standards, CMS has posed questions about potential approaches for monitoring and enforcing these standards, including:
- What new or existing data sources, reports, and metrics should CMS use to monitor performance against the federal access standards?
- What special considerations should CMS keep in mind with respect to monitoring access to HCBS and other LTSS?
- What are the most significant gaps where CMS should provide states with technical assistance or other support?
One key factor that affects enrollee access is provider payment rates, which are often lower in the Medicaid program than under Medicare or commercial insurance. CMS seeks public comments on how to ensure that Medicaid and CHIP reimbursement rates are adequate to attract and retain a sufficient number of providers, including providers with historically low participation rates (e.g., dental and behavioral health providers).
- How can CMS assess the impact of state payment policies and contracting arrangements on access in order to identify and promote the most favorable arrangements?
- For some services, such as inpatient hospital services, it is possible to compare Medicaid FFS rates against Medicare rates. How should CMS assess payment sufficiency for services that are not covered under Medicare, such as most HCBS and dental services?
- How can CMS align payment standards across Medicaid and CHIP, across FFS and managed care delivery systems, and across service types to ensure access to services is as consistent as possible for all enrollees?
- In addition to payment considerations, CMS is interested in policies that could help reduce the administrative costs associated with provider participation in Medicaid and CHIP (e.g., relating to claims denials or provider enrollment and credentialing).
Comments on the RFI are due April 18. The responses will inform CMS’ future guidance and rulemaking on issues related to enrollment, redeterminations, and access to care, as will CMS’ ongoing internal efforts to engage with subject matter experts, convene stakeholder roundtables, and perform regulatory gap analyses. Eligibility, enrollment, and access are important and complex topics, as evidenced by the consistent interest across administrations and the uneven history of proposed and final rulemaking. With this RFI, the Biden administration has publicly launched the most robust reassessment of these issues in more than half a decade. Achieving substantial reforms in these areas 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 enrollees’ ability to enroll in coverage and access covered services.
 See, for example, CMS’ recent toolkits regarding general state processes and managed care programs.
 Ex-parte renewals meaning renewals based on information available to the state, without any need for the enrollee to fill out a form.