#final rule

Just announced this morning, CMS has finalized two hotly debated proposed rules into final rules. The final rules involve the SNF staffing mandate proposed last year and the Medicaid Access Rule, requiring 80% of payments for Medicaid HCBS programs go to compensation for direct care workers. The Medicaid Rule follows the original proposed rule while the staffing mandate INCREASES the number of…

Happy Hump Day!  Only 12 more shopping days until Christmas! In mid-November, CMS issued a final rule titled: “Medicare and Medicaid Programs; Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities; Medicare Providers’ and Suppliers’ Disclosure of Private Equity Companies and Real Estate Investment Trusts“. The final rule is…

Somewhat buried within the Home Health Final Rule (PPS) was an update on a CMS initiative to identify hospice agencies requiring additional regulatory oversight for poor care performance (poor quality, unsafe care practices). Back in 2021, CMS began the Special Focus initiative and in the 2024 Hospice Final Rule, CMS indicated that the recommendations for the program would be in the Home Health…

Back a few weeks ago I did a post summarizing the 2024 Final PPS Rule for Skilled Nursing Facilities. Recall, these rules come out yearly, updating payment rates and other provisions impacting payment and some, impacting policy. Typically, the initial or proposed rule starts in spring and then after comments, etc., becomes final during the summer, at least for programs that have follow the…

For early August, this is a semi-busy week with health policy stuff and upcoming econ data on inflation. Congress is on recess but that doesn’t mean that there isn’t a fair amount of activity in-play that will impact the health care industry, some positive, some negative. Likewise, this is the start of the presidential election cycle and while it seems all political news is scandal and…

Early in April, CMS released the 2024 Medicare Advantage/Part D Final Rule and within, there are a number of interesting policy shifts that could benefit providers. The rule addresses a common practice that has been frankly, often abused by Med Advantage plans – prior authorizations or more commonly known as, “prior auths”. The crux is authorization provisions created delays in care and…

USDA’s Agricultural Marketing Service (AMS) administers the National Organic Program (NOP) as authorized by the Organic Foods Production Act of 1990 (OFPA).  The USDA organic regulations, which were published on December 21, 2000, and became effective on October 21, 2002, govern the production, handling, labeling, and sale of organically produced agricultural products.  On August 5, 2020, in…

The Medicaid Final Rule, CMS-2408-F, was finalized this November. The new rule implements recommendations from the Notice of Proposed Rule Making from last November. Provisions from the policy will begin taking effect as early as December 14, 2020.

According to Medicaid enrollment data from 2018, 66 million individuals are enrolled in managed care, making managed care arrangements the primary delivery system for Medicaid benefits. To assist these programs, the rule reduces administrative burdens on Medicaid managed care plans and provides states more flexibility to determine capitation rates and appropriate payment rates.

These regulations were last finalized by the Obama administration in 2016. Shortly after the Trump administration transitioned in, the administration started a "full review of managed care regulations to prioritize beneficiary outcomes and state priorities." The administration sent letters to state governors for input on how to more effectively manage the Medicaid program and improve health outcomes.

In response, states indicated that the 2016 regulations added cost and additional administrative burdens to Medicaid programs. With the support of state Medicaid directors and the National Association of Medicaid Directors (NAMD), CMS determined the problematic areas from the 2016 regulations. In the Notice of Proposed Rule Making in 2018, the group suggested ways to improve federal oversight, state flexibility, beneficiary protections, fiscal integrity, and the delivery of quality care.

According to CMS, "This rule finalizes many of those proposals and helps ensure that state Medicaid and CHIP agencies are able to work efficiently and effectively to design, develop, and implement Medicaid and CHIP managed care programs that best meet each state's local needs and populations."

CMS-2408-F makes changes in the following managed care regulations: setting actuarily sound capitation rates, pass-through payments, state-directed payments, network adequacy standards, risk-sharing mechanisms, quality rating system appeals and grievances, and requirements for beneficiary information.

However, the new rule does not entirely revise the 2016 regulations. The most notable revisions occur in capitation rates and payments, network adequacy standards, requirements for beneficiary information, and quality ratings and oversight.

Capitation Rates and Payments 

States are authorized to set capitation rate cell ranges instead of a single rate per cell. States are prohibited from changing capitation rates based upon the amount of federal aid for a population that would raise federal expenses. States cannot add or revise risk-sharing mechanisms after the beginning of a rating period. The rule establishes two minimum fee schedules for directed payment arrangements from health plans to providers. States shifting a population from FFS to managed care are allowed to make supplemental pass-through payments for up to 3 years.

Network Adequacy Standards

States are no longer required to create and enforce enrollee travel time and distance standards. Alternatively, states can set a quantitative adequacy standard.

Requirements for Beneficiary Information  

Mandated taglines are only necessary for materials that are essential to acquiring services instead of all written materials. Provider directories are to be updated every three months rather than monthly. Managed care plans can issue notice of provider terminations to the later of 30 days before the effective date of the termination or 15 days after the receipt or issuance of a termination notice.

Quality Rating System (QRS) 

The rule only requires that states alternative managed care quality rating systems (QRS) attain information comparable to the CMS QRS when it is feasible. States can now extend the definition of disability in relation to health disparities within their quality strategy, however, they are not obligated to. On a yearly basis, states must publish which plans are exempt from external quality review.