CMS’s proposed rule to streamline eligibility processes in Medicaid and the Children’s Health Insurance Program (“CHIP”) and the solicitation of public comments on the creation of a national provider database impacts states, payers and providers. To inform the development of public comment, this article summarizes the main elements of these recent agency publications.
Medicaid Eligibility Notice on Proposed Rulemaking
On September 7, 2022, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule titled “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes” in the Federal Register.1 This proposed rule is CMS’s response to the Biden administration’s April 2022 request.2 and January 20213 Executive decrees to improve access to health coverage. As the title of the proposed rule suggests, CMS aims to reduce the burdens on individuals applying for Medicaid, CHIP, or Basic Health Program (“BHP”) coverage and to make it easier to maintain coverage by reducing procedural hurdles. .
The proposed changes would reduce Medicaid coverage turnover, increase the predictability and stability of health plan enrollment, and promote continuity of treatment. Although the proposed rule affects all Medicaid, CHIP and BHP enrollees, there are special provisions for elderly, blind and disabled populations and eligible beneficiaries of Medicare savings programs. If finalized, the regulatory changes would likely require changes to the eligibility system, policies, and potential state regulations during the unfolding period of the public health emergency (“PHE”). PHE is currently authorized until January 11, 2023,4 and if the PHE is not extended, notice must be issued by Health and Human Services Secretary Xavier Becerra around November 12, 2022.5
Parity in eligibility renewal standards for MAGI and non-MAGI populations. CMS is proposing to extend Medicaid eligibility renewal standards for Modified Adjusted Gross Income (“MAGI”)-based eligibility groups to non-MAGI-based eligibility groups. This means that those eligible for Medicaid due to age, blindness, or disability would be subject to renewal determinations once every 12 months; have at least 30 days to return the pre-populated state form and any requested information; and not be required to attend an in-person eligibility interview. Additionally, states would be required to reconsider the eligibility of an individual returning the pre-populated form within ninety days of termination.
Standardize people’s response times to requests for additional information. Current regulations specify timelines for state Medicaid agencies to make eligibility decisions and renewals, but do not establish a standard time frame for individuals to provide the additional information requested. The proposed rule would establish these timelines, based on the date the application is stamped or the electronic application is sent, as follows: 15 calendar days for new applicants applying on a basis other than disability status; 30 calendar days for new applicants applying on the basis of a disability; and 30 days for current beneficiaries in the renewal process.seven
Use of Returned Mail for Loss of Eligibility. CMS is proposing that states can no longer use returned mail or notification of an in-state or out-of-state forwarding address as proof of Medicaid ineligibility without performing data checks (e.g., health plan enrollee information) to validate eligibility status. States would be required to contact individuals by methods other than mail and take additional prescribed steps before termination.8
Streamlined enrollment in Medicare savings programs. The proposed rule supports streamlined and increased enrollment of low-income Medicare beneficiaries in Medicare Savings Programs (“MSPs”) which, depending on the eligibility pathway, provide Medicaid coverage for the payment of Medicare Parts A premiums and B and cost sharing. To do so, states would be required to initiate the MSP determination process based on the Social Security Administration’s Medicare Part D Low-Income Subsidy (“LIS”) data and limit requests for information from individuals to complete the determination process. CMS also proposes regulations to align MSP revenue and resource methodologies with those of the LIS program.9
CHIP proposals. In addition to several proposals to streamline CHIP eligibility and renewals, CMS is proposing to eliminate the state’s option to impose a coverage lock-in period for non-payment of premiums.ten
Public comment period. Public comments were due November 7, 2022, and CMS is particularly interested in comments on reasonable compliance deadlines for States to implement the proposed changes. For example, CMS invites comments on the feasibility of state compliance with the provisions of the final rule within 90 days, 6 months, or 12 months from the effective date.11 While the Office of Information and Regulatory Affairs has yet to release the Fall 2022 Unified Regulatory and Deregulatory Action Plan, the author expects the final rule to be released by the spring. 2023.12
Request for information on the creation of a national supplier directory
On October 7, 2022, CMS issued a Request for Information (“RFI”)13 seeking public input on the creation of a standardized and interoperable National Directory of Health Providers and Services (“NDH”) to be developed and maintained by CMS.
CMS recognizes the costs to providers, payers, and patients and the burdens resulting from different provider directory requirements in terms of the type of information collected, frequency of updates, and available formats. Provider directories are a primary source for measuring and monitoring the adequacy of provider networks in health insurance programs, and inaccuracies have been well documented.14 CMS requests comments on the following points:
- NDH’s platform and technical standards to streamline validation, verification, and interoperability of provider directory information, such as HL7® Fast Healthcare (“FHIR”) interoperability resources, application programming interface (“API”) and supplier data integration from other CMS systems.
- Incentives and policies to support accurate and timely data reporting and use of NDH.16
- Standardized provider directory data elements, including information related to social determinants of health.17
- Considerations for implementation, including stakeholder engagement, technical and political prerequisites, and potential risks or challenges.18
Public comment period. Public comments are expected by December 6, 2022, and commenters can selectively comment on questions posed by CMS in the RFI.19
These two opportunities for public comment should be of interest to the entire healthcare community. The Medicaid Eligibility Rule, as Proposed, Removes Procedural Barriers That Can Lead to Coverage Interruptions or Delays Impacting Continuity of Health Services and Health Plan Enrollment in Managed Care States by Medicaid. The inaccuracy of provider directory information in coverage programs has been the subject of several studies and is a long-standing administrative challenge for payers and providers. The public comments received on the many key areas defined by CMS will inform the agency’s actions regarding the future development of rules to establish a national supplier directory.
1: Department of Health and Social Services; Centers for Medicare & Medicaid Services, “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes,” Federal Register Vol. 87, no. 172 (7 September 2022): 54760, https://www.govinfo.gov/content/pkg/FR-2022-09-07/pdf/2022-18875.pdf.
2: “Executive Order 14070 of April 5, 2022, Continuing to Strengthen Americans’ Access to Affordable, Quality Health Care Coverage,” Federal Register Vol. 87, no. 68 (8 April 2022): 20689, https://www.govinfo.gov/content/pkg/FR-2022-04-08/pdf/2022-07716.pdf.
3: “Executive Order 14009 of January 28, 2021, Strengthening Medicaid and the Affordable Care Act,” Federal Register Vol. 86, no. 20 (2 Feb 2021): 7793, https://www.govinfo.gov/content/pkg/FR-2021-02-02/pdf/2021-02252.pdf.
4: Administration for Strategic Preparedness & Response, Secretary Xavier Becerra, “Renewal of Determination that a Public Health Emergency Exists,” (October 13, 2022), https://aspr.hhs.gov/legal/PHE/Pages/covid19-13oct2022 .aspx.
5: Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, “Letter to Governors on COVID-19 Response.” (January 21, 2022), https://aspr.hhs.gov/legal/PHE/Pages/Letter-to-Governors-on-the-COVID-19-Response.aspx.
6: See note 1 on pages 54780-54786.
7: See note 1 on pages 54786-54791.
8: See note 1 on pages 54791-54794.
9: See note 1 on pages 54763-54776.
10: See note 1 on pages 54813-54814.
11: See note 1 on pages 54760 and 54763.
12: The current Unified Agenda for Regulatory and Deregulatory Actions is available at https://www.reginfo.gov/public/do/eAgendaMain.
13: Centers for Medicare and Medicaid Services, “Request for Information; National Directory of Health Care Providers and Services,” (October 7, 2022), https://www.federalregister.gov/public-inspection/2022-21904/request-for-information-national-directory-of-healthcare- providers- And services.
14: See, for example, Centers for Medicare and Medicaid Services, “Online Provider Directory Review Report,” (last accessed October 31, 2022), https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads /Provider_Directory_Review_Industry_Report_Round_2_Updated_1-31-18.pdf.
15: See note 13 on pages 61023-61025.
16: See note 13 on page 61024.
17: See note 13 on pages 61025-61026.
18: See note 13 on page 61028.
19: See note 13 on page 61018.
© Copyright 2022. The views expressed herein are those of the authors and not necessarily those of FTI Consulting, Inc., its management, subsidiaries, affiliates, or other professionals.
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