The Centers for Medicare and Medicaid Services (CMS) have proposed a new rule to improve patient care access, focusing on appointment wait times. The rule will require Medicaid-managed care organizations to adhere to national maximum standards for appointment wait times and conduct independent “secret shopper” surveys to monitor compliance. Additionally, the proposal includes a requirement for states to collect information about the patient experience through beneficiary surveys, a Medicaid and CHIP quality rating system, and better beneficiary engagement in Medicaid Advisory Committees. The proposals aim to improve healthcare coverage, quality, and access.
The Centers for Medicare and Medicaid Services (CMS) has proposed a new rule, the Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality Notice of Proposed Rulemaking (Access NPRM), aimed at improving patient care access and particularly addressing appointment wait times. Under this proposed rule, state Medicaid-managed care organizations and Children’s Health Insurance Plan (CHIP) plans will be required to adhere to national maximum standards for appointment wait times. Additionally, plans will be required to conduct independent “secret shopper” surveys to monitor compliance with the maximum allowed appointment wait times.
CMS Administrator Chiquita Brooks-LaSure stated that the proposed rule is aimed at bringing Medicaid or CHIP coverage and access together to reduce health disparities. The proposed rules create maximum allowed appointment wait times for primary care, obstetric/gynecological services, outpatient mental health services, substance use disorder services, and one state-selected service. The proposal aims to monitor compliance with appointment wait time standards through independent “secret shopper” surveys conducted by state Medicaid and CHIP agencies. The surveys will involve individuals calling Medicaid providers, requesting an appointment, and documenting the wait time.
CMS said that the proposals are aimed at improving not just healthcare coverage and quality, but access to care. A September 2022 study by Merritt Hawkins found that the average appointment wait time in 2022 was 26 days, which can be a detriment to both the patient experience and healthcare outcomes.
The proposed rule also includes a requirement for states to collect information about the patient experience through beneficiary surveys. If the proposals stay intact, managed care organizations will need to conduct enrollee experience surveys each year.
Furthermore, CMS has proposed a plan for a Medicaid and CHIP quality rating system for each state program. CMS pitched the idea of a “one-stop-shop” for Medicaid members to compare different plans, including details such as care quality, access to providers, covered benefits, covered drugs, cost, and other plan performance indicators.
Finally, the proposal calls for better beneficiary engagement in Medicaid Advisory Committees. CMS stated that Medicaid Advisory Committees should have a beneficiaries-only subgroup and include the voice of the beneficiary caregiver.
The proposed rule comes as the nation gets ready for a shift in healthcare coverage as the COVID-19 Public Health Emergency (PHE) ends on May 11. As part of the PHE’s sunset, the healthcare sector expects an influx of individuals losing Medicaid eligibility.
CMS emphasized the role Medicaid has played in enabling patient access to care, noting the number of individuals who have benefited from the program. “One in four Americans and over half of all children in the country are enrolled in Medicaid or CHIP, and the Biden-Harris Administration is committed to protecting and strengthening these programs for future generations,” said HHS Secretary Xavier Becerra in a CMS press release.