(May 2, 2024) - The Centers for Medicare & Medicaid Services released April 22 a final rule focused on ensuring access to services for Medicaid and Children’s Health Insurance Program beneficiaries in managed care delivery systems. The final rule is intended to increase transparency, improve accountability and ensure standardized data and monitoring, particularly for provider network adequacy requirements and state directed payment programs. CMS also published an Informational Bulletin describing their plan to enforce provider attestation requirements beginning on Jan. 1, 2028.
Key Highlights:
Network Adequacy Metrics and Oversight:
- Establish maximum appointment wait times for primary care, obstetrics and gynecology services and substance use disorder services.
- Require states to use an independent entity to conduct secret shopper surveys to validate managed care plans’ compliance with applicable standards.
- Require states to conduct an annual enrollee experience survey for each managed care plan.
- Mandates states to conduct an annual payment analysis for certain services compared to Medicare payment rates.
State Directed Payments:
- Require SDP levels for hospital, nursing and professional services at academic medical centers do not exceed the average commercial rate.
- Streamline the application and approval process for certain SDP programs. o Prohibit the use of post-payment reconciliation processes for SDPs based on fee schedules.
- Make explicit in regulation the existing requirement SDPs must comply with all federal laws concerning funding sources of the non-federal share.