/ en Thu, 07 Aug 2025 04:07:51 -0500 Mon, 16 Jun 25 23:00:00 -0500 /advisory/2025-06-16-senate-finance-committee-releases-legislative-text-reconciliation-bill <div class="container"><div class="row"><div class="col-md-8"><p>The Senate Committee on Finance has released <a href="https://www.finance.senate.gov/chairmans-news/chairman-crapo-releases-finance-committee-reconciliation-text" target="_blank" title="United States Senate Committee on Finance: Chairman Crapo Releases Finance Committee Reconciliation Text">bill text</a> for its portion of the budget reconciliation bill. The committee has jurisdiction over taxes and significant portions of the health care system, including the Medicare and Medicaid programs.</p><p>While the AHA continues to review the bill's text, below are some key provisions of importance to hospitals and health systems, as well as a statement AHA shared with the media. While many of the provisions are the same or similar to <a href="/advisory/2025-05-22-aha-summary-one-big-beautiful-bill-acts-provisions-impacting-hospitals-and-health-systems">The One Big Beautiful Bill Act (H.R. 1)</a>, there are several notable changes, especially with respect to Medicaid provider taxes and state directed payments.</p><p>In addition, AHA members can still <a href="https://aha-advocacy.ispresenting.live/register/" target="_blank" title="AHA Virtual Advocacy Webcast registration">register</a> to participate virtually in AHA’s Advocacy Day briefing on June 17 at 10 a.m. ET.</p><h2>AHA Statement</h2><p>In a <a href="/press-releases/2025-06-16-aha-statement-senate-finance-committee-bill">statement shared with the media</a> this evening, AHA President and CEO Rick Pollack said, “We continue to review the Senate Finance Committee’s proposal. However, it appears that the provisions further undermine the ability for hospitals to provide care to Medicaid patients. This bill moves in the wrong direction.</p><p>“The magnitude of Medicaid reductions and changes to health insurance marketplaces will shift millions of Americans from insured to uninsured status.</p><p>“Additionally, the proposal further erodes the legitimate use of provider taxes and state directed payment programs that help bridge the gap of chronic and historic Medicaid underpayments.</p><p>“These harmful proposals will impact access to all patients who are served by our nation’s hospitals and health systems. These cuts will strain emergency departments as they become the family doctor to millions of newly uninsured people. Finally, the proposal will force hospitals to reconsider services or potentially close, particularly in rural areas.</p><p>“As the Senate continues its deliberation, we urge consideration of the far-ranging negative consequences to our nation’s patients and hospitals.”</p><h2>Key Provisions of Interest to Hospitals and Health Systems</h2><h3>Medicaid Provider Taxes (Section 71120)</h3><p>The legislation would freeze in place provider taxes states use to help fund their Medicaid programs as of the date of enactment, after which states could not increase either the amount of the tax or the base to which the tax applies (i.e., by adding new classes or items of services to be subject to the tax). In addition, beginning in fiscal year (FY) 2027 and continuing through 2031, states that have expanded Medicaid and have provider taxes above 3.5% will see their “hold harmless threshold” reduced by 0.5% annually until the threshold reaches 3.5% except for taxes on nursing homes and intermediate care facilities. This provision differs from that in H.R. 1, which did not include provisions that would reduce the safe harbor threshold for expansion states.</p><h3>Medicaid State Directed Payments (71121)</h3><p>The legislation would establish the payment limit for state directed payments (SDPs) at 100% of Medicare in expansion states and 110% of Medicare in non-expansion states. For SDPs approved before May 1, 2025, for the rating period occurring within 180 days of enactment, or with a completed preprint submitted before enactment, beginning with the rating period on or after Jan. 1, 2027, the total SDP amount would be reduced by 10 percentage points annually until the specified Medicare payment rate limit is achieved. In contrast, H.R. 1 did not require the annual reduction of grandfathered SDPs or appropriate funding for implementation.</p><h3>Medicaid Community Engagement Requirements (Section 71124)</h3><p>The legislation would require certain nonpregnant, nondisabled adult Medicaid beneficiaries to meet certain community engagement requirements (“work requirements”) beginning Dec. 31, 2026. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours/month. The legislation would exempt, among other groups, parents, guardians and caretaker relatives of children aged 14 or under, or a disabled individual. States would be permitted to receive temporary exemptions with Department of Health and Human Services (HHS) approval. The legislation would limit the types of entities that can contract with states to help implement this provision, effectively barring Medicaid managed care plans from assisting. The bill provides $200 million in FY 2026 grants for state implementation and $50 million for federal administration. In contrast, H.R. 1 exempted parents and caretakers of a disabled individual or dependent child (18 or under), did not explicitly prohibit contractors with financial interests, and provided $100 million for state implementation of the provisions.</p><h3>Increase Frequency of Redeterminations for Medicaid Expansion Enrollees (Section 71107)</h3><p>Consistent with H.R. 1, the legislation would require states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway, beginning in calendar year 2027.</p><h3>Modifying Retroactive Eligibility under the Medicaid and CHIP Programs (Section 71114)</h3><p>Consistent with H.R. 1, the legislation would limit the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date, as opposed to the current 90-day period.</p><h3>Medicaid Cost-Sharing Requirements for Certain Expansion Individuals (Section 71125)</h3><p>Consistent with H.R. 1, the legislation would require Medicaid expansion enrollees with incomes above 100% of the federal poverty level (FPL) to pay up to $35 in cost sharing per service. The provision would exclude certain services including primary care, pregnancy-related services, mental health or substance use disorder services. Total cost sharing may not exceed 5% of family income.</p><h3>Prohibition on Implementation of Certain Regulations (Sections 71101, 71102, and 71113)</h3><p>Consistent with H.R. 1, the legislation would prohibit the HHS Secretary from implementing certain rules, including the final staffing rule for nursing facilities, final Medicaid eligibility and enrollment rules, and final Medicare savings program eligibility and enrollment rule.</p><h3>Public Program Eligibility for Certain Non-citizens (Sections 71110, 71201 and 71301)</h3><p>The legislation would restrict eligibility for Medicare, Medicaid and premium tax credits for marketplace coverage for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants, and Compact of Free Association migrants lawfully residing in the United States. This expands on provisions included in H.R. 1.</p><h3>FMAP for Emergency Medicaid in Expansion States (Section 71102)</h3><p>Beginning Oct. 1, 2026, the legislation would limit the Federal Medical Assistance Percentage (FMAP) for emergency Medicaid services provided to unlawfully present aliens who, except for their immigration status, would qualify for expansion to the state’s traditional FMAP. In contrast, H.R. 1 did not include provisions limiting the FMAP for emergency Medicaid.</p><h3>Disallowing Premium Tax Credits during Periods of Medicaid Ineligibility due to Alien Status (Section 71302)</h3><p>Consistent with H.R. 1, the legislation would disallow undocumented immigrants who report income below 100% of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) to receive premium tax credits to purchase health insurance on the marketplaces.</p><h3>Requiring Marketplace Verification of Eligibility for Health Plan (Section 71303)</h3><p>Consistent with H.R. 1, the legislation would prohibit an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This would prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. Over half of all returning enrollees in 2025 enrolled through automatic reenrollment.</p><h3>Disallowing Premium Tax Credit in Case of Certain Coverage Enrolled in during the Special Enrollment Period (Section 71304)</h3><p>Consistent with H.R. 1, the legislation would prohibit individuals from receiving premium tax credits if they enroll in health coverage on the marketplace through a special enrollment period associated with their income.</p><h3>Eliminating Limitation on Recapture of Advance Payment of Premium Tax Credit (Section 71305)</h3><p>Mostly consistent with H.R. 1, the legislation would remove the repayment limits and require affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received. The Senate language includes a special rule for those with incomes that unexpectedly fall below 100% of federal poverty level so that they do not need to repay the full amount of their premium tax credits.</p><h3>Endowment Tax for Universities (Section 70415)</h3><p>The legislation would amend the excise tax rate for universities based on student endowments. The rates are as follows: 1.4% for student endowments ranging from $500,000-$750,000 (current law), 4% for student endowments ranging from $750,000-$2 million, and 8% for all student endowments above $2 million. In contrast, H.R. 1 had a maximum excise tax rate of 21% for student endowments above $2 million.</p><h3>Executive Compensation (Section 70416)</h3><p>The legislation would limit tax-exempt organizations’ ability to deduct compensation over $1 million.</p><h3>Charitable Contributions for Non-itemizers (Section 70424)</h3><p>The legislation would create a permanent deduction on charitable contributions for taxpayers who do not elect to itemize.</p><h3>Floor on Charitable Contributions (Section 70425)</h3><p>The legislation would impose a 0.5% floor on charitable contributions for taxpayers who elect to itemize for taxable years after Dec. 31, 2025.</p><h3>1% Floor on Deduction of Charitable Contributions Made by Corporations (Section 70426)</h3><p>The legislation would allow a deduction for corporate charitable contributions only to the extent that the aggregate of corporate charitable contributions exceeds 1% of a taxpayer’s taxable income and does not exceed 10% of the taxpayer’s taxable income.</p><h2>Provisions Not Included in Senate Proposal</h2><ul><li>Delay to the cuts to Medicaid Disproportionate Share Hospital payments.</li><li>Increase Medicare payments for physicians.</li><li>Certain changes to health savings accounts.</li><li>Increase in the excise tax rate for tax-exempt private foundations.</li><li>Increase of the unrelated business taxable income of a tax-exempt organization by including the amount paid or incurred for any qualified transportation fringe benefit (provision included in House bill would have impacted non-profit hospitals’ ability to collect revenue from parking fees).</li><li>Provisions codifying the proposed Marketplace Integrity and Affordability rule.</li></ul><h2>Further Questions</h2><p>If you have further questions, please contact AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/06/Senate-Finance-Committee-Releases-Legislative-Text-for-Reconciliation-Bill.pdf" target="_blank" title="Click here to download the Legislative Advisory: Senate Finance Committee Releases Legislative Text for Reconciliation Bill PDF."><img src="/sites/default/files/inline-images/Page-1-Senate-Finance-Committee-Releases-Legislative-Text-for-Reconciliation-Bill.png" data-entity-uuid="c479588d-1ad4-4e00-9016-a9330165f5b4" data-entity-type="file" alt="Legislative Advisory: Senate Finance Committee Releases Legislative Text for Reconciliation Bill page 1." width="695" height="900"></a></div></div></div> Mon, 16 Jun 2025 23:00:00 -0500 CHIP /news/headline/2025-03-17-macpac-recommends-changes-medicaid-managed-care-external-quality-review-home-and-community-based <p>The Medicaid and CHIP Payment and Access Commission released its <a href="https://www.macpac.gov/publication/march-2025-report-to-congress-on-medicaid-and-chip/" target="_blank">March 2025 report</a> to Congress March 13. The first chapter makes three recommendations on improving the external quality review process in Medicaid managed care. Chapter two focuses on enhancing timely access to home- and community-based services. The final chapter analyzes the federal administrative requirements for HCBS programs and makes a recommendation on reducing states’ administrative burden.</p> Mon, 17 Mar 2025 15:51:31 -0500 CHIP /news/headline/2024-10-17-cms-allow-medicaid-chip-coverage-ihs-facilities-tribal-communities <p>The Centers for Medicare & Medicaid Services Oct. 16 <a href="https://www.cms.gov/newsroom/press-releases/biden-harris-administration-takes-groundbreaking-action-expand-health-care-access-covering">approved</a> section 1115 demonstration amendments which will allow Medicaid and Children's Health Insurance Program coverage of traditional health care practices provided by Indian Health Service facilities, Tribal facilities and urban Indian organizations. The amendments will benefit tribal communities in Arizona, California, New Mexico and Oregon. Studies show that traditional health care practices can improve outcomes for patients with various conditions, including mental health and substance use disorders, CMS said.</p> Thu, 17 Oct 2024 16:02:40 -0500 CHIP /news/headline/2024-09-26-cms-releases-guidance-states-meet-screening-diagnostic-and-treatment-requirements-under-medicaid-and <p>The Centers for Medicare & Medicaid Services Sept. 26 released <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/sho24005.pdf" target="_blank">guidance</a> on state compliance with the Early and Periodic Screening, Diagnostic and Treatment requirements under Medicaid and the Children's Health Insurance Program. The guidance explains statutory and regulatory EPSDT requirements and suggests best practices, such as increasing access through transportation and care coordination services, leveraging incentives, sanctions and contractual requirements in the Medicaid managed care programs, expanding the children-focused workforce, improving care for children with specialized needs (including children in the child welfare system and children with disabilities), and expanding families' awareness of their children’s rights under EPSDT requirements. The guidance also includes information, strategies and best practices to address the needs of children with behavioral health conditions.</p> Thu, 26 Sep 2024 14:03:10 -0500 CHIP /news/headline/2024-07-03-hhs-authorizes-five-states-provide-health-care-coverage-people-transitioning-out-incarceration <p>The Department of Health and Human Services July 2 <a href="https://www.cms.gov/newsroom/press-releases/hhs-authorizes-five-states-provide-historic-health-care-coverage-people-transitioning-out">announced</a> it will provide Medicaid and Children's Health Insurance Program coverage to incarcerated people in Illinois, Kentucky, Oregon, Utah and Vermont prior to release. The coverage, provided under the <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/smd23003.pdf">Medicaid Reentry Section 1115 Demonstration Opportunity</a>, will allow those states to provide coverage up to 90 days before an eligible person's expected release date. Coverage under the measure includes substance-use disorder treatment and treatment for certain behavioral health conditions. Other states participating in the program are California, Massachusetts, Montana and Washington.</p> Wed, 03 Jul 2024 15:03:39 -0500 CHIP /news/headline/2024-05-22-delaware-tennessee-become-first-states-provide-diapers-through-medicaid <p>The Centers for Medicare & Medicaid Services recently announced the approval of <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/de-dshp-dmntn-appvl-05172024.pdf">Delaware</a> and <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/tn-tenncare-iii-demo-aprvl-amndmnt-5.pdf">Tennessee</a> as the first states to provide diapers to children covered by Medicaid. The approvals were granted under section 1115 <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html">demonstrations</a>, which can be used to experiment or test new policies that are likely to assist in promoting Medicaid objectives. Delaware will be allowed to provide up to 80 diapers and one pack of baby wipes per week to mothers in the first twelve weeks postpartum, while Tennessee is authorized to provide 100 diapers per month for all children under age two enrolled in Medicaid or the Children's Health Insurance Program. </p> Wed, 22 May 2024 14:34:43 -0500 CHIP /news/headline/2024-05-10-cms-extends-unwinding-flexibilities-states-through-june-2025 <p>The Centers for Medicare & Medicaid Services May 9 announced <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib050924-e14.pdf">an extension</a> of unwinding flexibilities to support state efforts to protect the continuity of coverage in Medicaid and the Children's Health Insurance Program. States can continue to use certain waiver authorities to streamline eligibility redeterminations until June 30, 2025, adding a year to the previous deadline of June 2024. CMS said the extension for coverage renewals allows states to shift resources to help reduce processing times for applications. </p> Fri, 10 May 2024 14:17:47 -0500 CHIP /special-bulletin/2024-04-24-cms-finalizes-medicaid-access-and-payment-managed-care-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) released April 22 a <a href="https://public-inspection.federalregister.gov/2024-08085.pdf">final rule</a> focused on ensuring access to services for Medicaid and Children’s Health Insurance Program (CHIP) 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 (SDP) programs. CMS also published an <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib042224.pdf">Informational Bulletin</a> describing their plan to enforce provider attestation requirements beginning on Jan. 1, 2028. </p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><ul><li>Network Adequacy Metrics and Oversight:<ul><li>Establish maximum appointment wait times for primary care, obstetrics and gynecology services, and substance use disorder services.</li><li>Require states to use an independent entity to conduct secret shopper surveys to validate managed care plans’ compliance with applicable standards.</li><li>Require states to conduct an annual enrollee experience survey for each managed care plan.</li><li>Mandates states to conduct an annual payment analysis for certain services compared to Medicare payment rates.</li></ul></li><li>State Directed Payments:<ul><li>Require that SDP levels for hospital, nursing and professional services at academic medical centers not exceed the average commercial rate (ACR).</li><li>Streamline the application and approval process for certain SDP programs.</li><li>Prohibit the use of post-payment reconciliation processes for SDPs that are based on fee schedules.</li><li>Make explicit in regulation the existing requirement that SDPs must comply with all federal laws concerning funding sources of the non-federal share. </li></ul></li></ul></div></div><h2>AHA TAKE</h2><p>The AHA appreciates that CMS acknowledges the critical role hospitals play in state Medicaid financing and the importance of supplemental payments to sustain beneficiary access to care. In response to growing pressure and scrutiny of SDPs among federal oversight agencies, CMS contemplated a range of policy options in proposed rulemaking last year, some of which could have been devastating for the ongoing viability of certain hospital supplemental payment programs that support patient access to care, such as capping payments at Medicare rates or at an aggregate percentage of overall managed care spending. In response to feedback from AHA and the hospital field, we are pleased that CMS did not advance problematic proposals that could have significantly curbed SDP funding and reduced state flexibility to align payments with state quality and access goals. Instead, CMS finalized provisions that preserve existing SDP programs for the near future and permit ongoing state flexibility to make certain supplemental payments consistent with commercial rates where appropriate.</p><p>Specifically, AHA appreciates that CMS codified provisions that establish the<strong> </strong>ACR as the upper payment limit for SDP programs and the provisions that offer states additional flexibility on the methodology for calculating the ACR. In codifying these provisions, CMS recognizes that hospitals treat all patients the same — regardless of coverage — and ensures that hospitals have appropriate resources to serve Medicaid patients. The AHA provided support for these provisions in comments on the proposed rule. The final rule also streamlines application and approval of certain existing arrangements, which reduces burden for state Medicaid agencies that continue with the critical mission of eligibility redetermination and ensures needed payments to safety net providers are not delayed or withheld due to administrative hurdles.</p><p>However, the AHA remains concerned about provisions that could restrict permissible financing approaches for Medicaid payments. Specifically, the finalized regulatory language regarding attestations could cause a chilling effect on financing mechanisms that states rely on to provide coverage to our most vulnerable communities. Implementing this entirely unnecessary policy will only create undue burden on both providers and states. As such, the AHA appreciates the delay in enforcement until 2028, but remains concerned that this policy could result in financing restrictions that have long-term consequences for coverage and access.</p><p>Finally, the AHA also applauds CMS’ efforts to strengthen network adequacy requirements and oversight of managed care programs. The finalized provisions will ensure that Medicaid managed care beneficiaries can access the services they need.</p><h2>SUMMARY OF KEY PROVISIONS</h2><p>The rule finalizes numerous changes to federal requirements for the Medicaid managed care program. The stated objective is to improve oversight of the program and ensure adherence to program integrity requirements. These regulatory changes span access improvements, network adequacy, provider payment, home and community-based services, quality reporting, <em>In Lieu of Service and Setting</em> (ILOS) requirements and SDP programs. The following summary focuses on those finalized provisions of particular interest to hospitals and health systems including implementation timeframes. </p><h3>Access and Network Adequacy</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>Maximum Appointment Wait Time Standard:</u> Establish appointment wait time standards for routine primary care,* obstetric/gynecological, and substance use disorder services* and a state selected service* (*adult and pediatric). Wait times would be comparable to ACA Marketplace standards.</td><td width="180">The first rating period on or after July 9, 2027.</td></tr><tr><td width="444"><u>Secret Shopper and Enrollee Experience Survey:</u> Require states to use an independent entity to validate managed care plan compliance with wait time standards and accuracy of provider directories. Also require states to conduct enrollee experience survey.</td><td width="180">The first rating period on or after July 9, 2027.</td></tr><tr><td width="444"><u>Annual Payment Analysis:</u> Require states to conduct and submit annual payment analysis that compares managed care plans’ payments for certain services as a proportion of Medicare’s payment rate, and for certain home and community-based services, the state’s Medicaid state plan rate.</td><td width="180">The first rating period on or after July 9, 2026.</td></tr><tr><td width="444"><u>State Remedy Plan and Public Website:</u> Require states implement a remedy plan for any managed care plan that needs improvement in meeting required access standards. Require states to maintain a single website that is readily identifiable to the public, easy to use and contains required information for public transparency.</td><td width="180"><p>Remedy plan: The first rating period on or after July 9, 2024.</p><p>Website: No later than July 9, 2025.</p></td></tr></tbody></table><h3>State Directed Payment Programs</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>Streamline Approval for Certain SDPs:</u> Removes regulatory barriers to help states use SDPs to implement value-based purchasing payment arrangements and include non-network providers in SDPs. Establishes submission timeframes for SDP preprints. Also eliminates written prior approval for SDPs that are minimum fee schedules set at the Medicare payment rate.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><u>Average Commercial Rate Limitations:</u> Requires that provider payment levels for SDPs for inpatient and outpatient hospital services, nursing facility services and the professional services at an academic medical center not exceed the average commercial rate.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><u>Prohibit Post Payment Reconciliation:</u> Prohibits the use of post-payment reconciliation processes for SDPs that are based on fee schedules.</td><td width="180">The first rating period on or after July 9, 2024.</td></tr><tr><td width="444">Prohibits the use of separate payment terms and requires that all SDPs be included in actuarially sound capitation rates.</td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2024.</p></td></tr><tr><td width="444"><p><u>Financing Restrictions:</u> Requires that states ensure each provider receiving an SDP attest that it does not participate in any arrangement that holds taxpayers harmless for the cost of a tax. CMS concurrently released an informational bulletin regarding CMS’ exercise of enforcement discretion until calendar year 2028 for existing health care-related tax programs with certain hold-harmless arrangements involving the redistribution of Medicaid payments.</p><p>Makes explicit in regulation the existing requirement that SDPs must comply with all federal laws concerning funding sources of the non-federal share.</p></td><td width="180"><p>Jan. 1, 2028</p><p>Additional CMS guidance on the exercise of enforcement discretion until CY 2028 can be found in the concurrently issued <a href="https://www.medicaid.gov/federal-policy-guidance/downloads/cib042224.pdf">Informational Bulletin</a>.</p></td></tr><tr><td width="444"><u>State Appeals Process:</u> Establish, through the U.S. Department of Health and Human Services Departmental Appeals Board, a process for states to appeal SDP disapprovals.</td><td width="180">The first rating period on or after July 9, 2024.</td></tr><tr><td width="444"><p><u>State Reports and Evaluations:</u> Requires provider-level reporting on actual SDP expenditures in the Transformed Medicaid Statistical Information System.</p><p><u></u></p><p>Require that states submit to CMS SDP evaluations every three years if the SDP costs exceed 1.5% as a percentage of total capitation payments.</p></td><td width="180">The first rating period on or after July 9, 2027.</td></tr></tbody></table><h3>Medical Loss Ratio</h3><table border="1" cellspacing="0" cellpadding="0"><thead><tr><th width="444"><strong>Provision</strong></th><th width="180"><strong>Implementation Date</strong></th></tr></thead><tbody><tr><td width="444"><u>MLR and Quality Expenditures:</u> Revises how quality expenditures are allocated for purposes of the medical loss ratio (MLR) calculation. These revisions to provider incentive payments and expense allocation reporting are intended to align with recent regulatory changes for Marketplace plans.</td><td width="180">Effective date of final rule.</td></tr><tr><td width="444"><p><u>MLR Specifications:</u> Requires managed care plans to provide medical loss ratios for each managed care plan.</p><p>Requires managed care plans to report identified or recovered overpayments to the state within 30 calendar days.</p></td><td width="180"><p>The first rating period</p><p>beginning on or after July 9, 2025.</p></td></tr></tbody></table><h3>Other Provisions</h3><p>The rule finalizes several provisions regarding use of ILOS<em> </em>in managed care settings. ILOS allows for managed care plans to offer ILOS as a substitute for a service or setting that is covered in the state plan; for example, some home- and community-based services or a medically-tailored meal. In general, the final rule provides greater specificity around what services qualify for ILOS and increased documentation. CMS also finalizes quality provisions that are designed to encourage greater public engagement and more transparency around state External Quality Review programs. </p><p>Lastly, the rule provides further direction and encouragement for states to establish a rating system for beneficiaries to compare managed care plans on quality and other factors.</p><h2>FURTHER INFORMATION</h2><p>For additional detail, the <a href="https://www.cms.gov/newsroom/fact-sheets/medicaid-and-childrens-health-insurance-program-managed-care-access-finance-and-quality-final-rule">CMS Fact Sheet</a> on the final rule summarizes key provisions and the <a href="https://www.medicaid.gov/medicaid/managed-care/downloads/applicability-date-chart-mc.pdf">implementation chart</a> includes effective dates for applicable regulatory changes.</p><p>If you have further questions, please contact AHA at 800-424-4301. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/cms-finalizes-medicaid-access-and-payment-managed-care-rule-bulletin-4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-cms-finalizes-medicaid-access-and-payment-managed-care-rule-bulletin-4-24-24-2.jpg" data-entity-uuid data-entity-type="file" alt=" Cover Special Bulletin: CMS Finalizes Medicaid Access and Payment Managed Care Rule" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 13:55:29 -0500 CHIP /special-bulletin/2024-04-24-cms-finalizes-medicaid-access-and-payment-fee-service-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) released April 22 a <a href="https://public-inspection.federalregister.gov/2024-08363.pdf">final rule</a> focused on ensuring access to services for Medicaid beneficiaries in fee-for-service delivery systems in keeping with the Administration’s objectives to improve access for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. The finalized provisions are intended to increase transparency, improve accountability and ensure standardized data and monitoring. </p><div class="panel module-typeC"><div class="panel-heading"><h2>KEY HIGHLIGHTS</h2><ul><li>Medical Advisory Committee and Beneficiary Advisory Group: Renames and expands the scope of states’ Medical Care Advisory Committees (MAC) and requires that states establish a Beneficiary Advisory Group (BAG). The MACs and the BAGs are intended to promote transparency and accountability amongst the state, stakeholders and Medicaid beneficiaries related to the effective administration of the Medicaid program.</li><li>Fee-for-service Provider Payment Rate Transparency: Removes state access monitoring review plan requirements and replaces them with new payment rate transparency standards and documentation requirements. It also requires states to conduct a payment rate analysis for certain services every two years.</li><li>Home- and Community-Based Services: Strengthens safeguards and provides for a more coordinated administration of policies and procedures for individuals receiving Medicaid-covered home and community-based services. </li></ul></div></div><h2>AHA TAKE</h2><p>Ensuring access and coverage for Medicaid and CHIP populations is a key priority for the AHA and adequate provider payment is a critical component. We applaud CMS’ efforts to improve patient access to high-quality care in the Medicaid program and promote greater transparency and accountability, especially with respect to mitigating payment-related barriers to provider participation in the program. We also support CMS’ efforts to improve stakeholder and beneficiary engagement and improve access to home- and community-based services. </p><h2>SUMMARY OF KEY PROVISIONS</h2><p>The rule finalizes many of the proposed changes to ensure access to services for beneficiaries by promoting greater transparency and accountability in Medicaid fee-for-service (FFS). Central to these provisions is the statutory requirement that states must make FFS provider payments sufficient to enlist enough providers to ensure Medicaid beneficiaries have sufficient access to covered services. The following summary will focus on changes of particular interest to hospitals and health systems.</p><h3>Medical Advisory Committee and Beneficiary Advisory Group</h3><p>The final rule renames and expands the scope of state Medical Care Advisory Committees. The rule requires that states establish a MAC and a BAG, the core purpose of which is to provide advice and feedback on a state’s Medicaid program. The rule requires that Medicaid stakeholders comprise MAC membership, including consumer advocacy groups, beneficiaries, clinicians, health care administrators and other state agencies serving Medicaid populations. At least two MAC meetings per year are required to be open to the public and must include a public comment period. BAGs will be a stand-alone group of Medicaid beneficiaries, families and caregivers. States will be required to ensure transparency by posting MAC and BAG membership lists, meeting schedules, minutes, by-laws, recruitment processes and an annual report on MAC activities on its website.</p><h3>Fee-for-service Provider Payment Rate Transparency</h3><p>CMS finalizes its proposal to remove state access monitoring review plan requirements and replaces them with new payment rate transparency standards and documentation requirements. The final rule requires that states publicly disclose and regularly update Medicaid FFS payment rates for all services on a state’s website. The final rule also requires states to publish an analysis that compares Medicaid and Medicare payment rates for critical services every two years, including primary care, obstetrical and gynecological care, and outpatient behavioral health services.</p><p>States are required to demonstrate that any state plan amendment that proposes to reduce provider rates or restructure provider payments would not put access at risk. An access analysis is required if any of the following conditions are not met.</p><ul><li>Aggregate Medicaid payments are at or above 80% of the most recently published Medicare payment rates.</li><li>Payment rate reductions result in no more than a 4% reduction in FFS expenditure for each benefit category.</li><li>Public process has not identified access concerns.</li></ul><p>If these conditions are not met when a state proposes a rate reduction or restructuring, states must provide detailed information to CMS for the agency to evaluate the proposed payment changes. Such information would include a comparison of relevant Medicaid and Medicare payment rates. Also, states would need to provide data on participating providers, beneficiaries receiving services and analysis related to services affected by rate reduction or restructuring, as well as estimates on how change would affect access.</p><h3>Home- and Community-Based Services</h3><p>The rule finalizes provisions intended to strengthen safeguards and better coordinate policies and procedures for individuals receiving Medicaid-covered home and community-based services (HCBS). Under the rule, states are required to:</p><ul><li>Establish a grievance system for FFS HCBS programs. Ensure that at least 80% of Medicaid payments for personal care, homemaker and home aide services be spent on compensation for the direct care workforce.</li><li>Publish average hourly rates for personal care, home health care, homemaker and habilitation services every two years.</li><li>Create an advisory group to advise on direct care worker provider rates. </li><li>Report publicly on waiting lists for HCBS waiver programs and standardized sets of quality and compliance measures.</li></ul><p>CMS will align the new requirements across the various HCBS Medicaid authorities found in 1915 (c),(i),(j), and (k) as well as 1115 demonstration authority.</p><h2>Further Information</h2><p>For additional detail, the <a href="https://www.cms.gov/newsroom/fact-sheets/ensuring-access-medicaid-services-final-rule-cms-2442-f#:~:text=The%20Ensuring%20Access%20to%20Medicaid,HCBS)%20provided%20through%20those%20delivery">CMS Fact Sheet</a> on the final rule summarizes key provisions and the <a href="https://www.medicaid.gov/medicaid/access-care/downloads/applicability-date-chart-ac.pdf">implementation chart</a> includes effective dates for applicable regulatory changes.</p><p>If you have further questions, please contact AHA at 800-424-4301. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/04/cms-finalizes-medicaid-access-and-payment-fee-for-service-rule-bulletin4-24-24.pdf" target="_blank"><img src="/sites/default/files/2024-04/cover-cms-finalizes-medicaid-access-and-payment-fee-for-service-rule-bulletin-4-24-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Special Bulletin: CMS Finalizes Medicaid Access and Payment Fee-for-service Rule" width="NaN" height="NaN"></a></div></div></div> Wed, 24 Apr 2024 13:24:25 -0500 CHIP /news/headline/2024-04-19-massachusetts-medicaid-demonstration-expands-services-continuous-eligibility <p>The Centers for Medicare & Medicaid Services April 19 approved an <a href="https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ma-masshealth-ca-04192024.pdf" target="_blank">amendment</a> to a Massachusetts Medicaid and Children’s Health Insurance Program demonstration to add health-related social needs services; expand Marketplace subsidies and cost-sharing assistance; provide pre-release services to eligible incarcerated beneficiaries; and expand continuous eligibility to 24 months for older adults experiencing homelessness and 12 months for other adults. According to the <a href="https://www.mass.gov/news/masshealth-receives-federal-authority-to-expand-eligibility-for-individuals-and-lower-insurance-costs-for-massachusetts-families" target="_blank">state</a>, the amendment covers up to six months of post-hospitalization/pre-procedure housing as a health-related social needs service.</p> Fri, 19 Apr 2024 13:53:53 -0500 CHIP