2 CMS proposals aim to set Medicaid base payment standards


The Centers for Medicare and Medicaid Services plans to issue rules to bring reimbursements from Medicaid managed care plans in line with the rates set under fee-for-service systems, the agency announced Thursday.

CMS issued two notices of proposed rulemaking that it says would boost access to care and promote price transparency. States would provide CMS with provider payment rate analyzes every year that compare Medicaid fee-for-service and managed care payments to Medicare rates. State Medicaid agencies also would have to publish the rates on their websites.

“[The rules are] focused on increasing transparency and accountability by those who are managing the Medicaid program,” Health and Human Services Secretary Xavier Becerra said during a call with reporters. “We are going to standardize data and monitor more so we can keep tabs,” he said.

The upcoming draft regulations would require states to set standards for Medicaid payments that are proportionate to Medicare reimbursements, which typically are higher. This would allow CMS to accurately evaluate and compare Medicaid rates in every state, which it currently cannot do, Center for Medicaid Director Dan Tsai said during the call.

In addition to reporting on payments for primary care, OB-GYN, and outpatient mental health and substance abuse services, states would have to report total spending on provider reimbursements under state-directed payment arrangements. CMS would also require payments to be made within the contracted timeframe rather than reconciling them later.

Insurers would be required to report the total expenses and revenues from these payments to states, which would then appear as line items in the states’ annual medical loss ratio report to CMS. States would also have to create consumer-friendly “one-stop-shop” websites to enable beneficiaries to compare Medicaid plans.

The pending rules also would direct states to pass along 80% of reimbursements for home- and community-based services to direct care workers and to standardize public quality, compliance and performance reporting.

CMS also seeks to expand the adoption of “in lieu of services and settings” benefits that use Medicaid funding to pay for non-medical assistance as tools to address social determinants of health.


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