CMS’ proposed rule to streamline eligibility processes in Medicaid and the Children’s Health Insurance Program (“CHIP”) and solicitation of public comment on the creation of a national provider database impacts states, payers and providers. To inform the development of public comment, this article summarizes the primary elements of these recent agency issuances.
Medicaid Eligibility Notice of Proposed Rulemaking
On September 7, 2022, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed rule entitled “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 20222 and January 20213 Executive Orders to improve access to health coverage. As the title of the Proposed Rule suggests, CMS is focused on reducing burdens on individuals applying for Medicaid, CHIP, or Basic Health Program (“BHP”) coverage and making retention of coverage easier by reducing procedural hurdles.
The proposed changes would reduce churn in Medicaid coverage, increase predictability and stability in health plan enrollment, and support continuity of treatment. While the proposed rule impacts all Medicaid, CHIP and BHP enrollees, there are special provisions for the aged, blind and disabled populations and beneficiaries eligible for Medicare Savings Programs. If finalized, the regulatory changes would probably require eligibility-system, policy and potential state regulatory changes during the Public Health Emergency (“PHE”) unwinding period. The PHE is currently authorized through January 11, 2023,4 and if the PHE will not be extended, advance notice should be issued by Secretary of Health and Human Services Xavier Becerra around November 12, 2022.5
Parity in eligibility renewal standards for MAGI and non-MAGI populations. CMS proposes to extend the Medicaid eligibility renewal standards for modified-adjusted-gross-income (“MAGI”)-based eligibility groups to non-MAGI-based eligibility groups. This means that individuals who qualify for Medicaid because of age, blindness or disability would be subject to renewal determinations once every 12 months; have at least 30 days to return the state’s prepopulated form and any requested information; and not be required to attend an in-person eligibility interview. Additionally, states would be required to reconsider eligibility of an individual returning the prepopulated form within ninety days of termination.
Standardizing timeframes for individuals to respond to requests for additional information. Current regulations specify timeframes for state Medicaid agencies to render eligibility determinations and renewals but do not establish a standardized timeframe for individuals to provide requested additional information. The proposed rule would establish such timeframes, based on the date the request is postmarked or the electronic request 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 disability; and 30 days for current beneficiaries in the renewal process.7
Use of returned mail for loss of eligibility purposes. CMS proposes that States can no longer use returned mail or notification of an in-state or out-of-state forwarding address as evidence of ineligibility for Medicaid without conducting data checks (eg, health plan enrollee information) to validate eligibility status. States would be required to contact individuals via methods other than mail and take additional prescribed steps prior to termination.8
Streamlining enrollment in Medicare Savings Programs. The proposed rule supports streamlined and increased enrollment of low-income Medicare beneficiaries in Medicare Savings Programs (“MSP”) that, depending on the eligibility pathway, provide Medicaid coverage for payment of Medicare Parts A and B premiums and cost-sharing. To accomplish this, states would be required to start the MSP determination process based on Medicare Part D Low-Income Subsidy (“LIS”) data from the Social Security Administration and limit requests for information from individuals to complete the determination process. CMS also proposes regulations to conform MSP income and resource methodologies with those of the LIS program.9
CHIP proposals. In addition to several proposals to streamline CHIP eligibility and renewals, CMS proposes to eliminate the state option to impose a coverage lock-out period for non-payment of premiums.10
Public comment period. Public comments were due by November 7, 2022, and CMS is particularly interested in feedback for reasonable compliance timeframes for states to implement the proposed changes. For example, CMS seeks input on the feasibility of state compliance with the final rule’s provisions within 90 days, 6 months, or 12 months from the effective date.11 While the Office of Information and Regulatory Affairs has yet to publish the Fall 2022 Unified Agenda of Regulatory and Deregulatory Actions, the author foresees issuance of the final rule by Spring 2023.12
Request for Information on Creation of a National Provider Directory
On October 7, 2022, CMS issued a Request for Information (“RFI”)13 soliciting public comment on the creation of a standardized and interoperable National Directory of Health Providers and Services (“NDH”) to be developed and maintained by CMS.
CMS acknowledges the costs to providers, payers and patients and the burdens resulting from varying 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 across health insurance programs, and inaccuracies have been well-documented.14 CMS requests comment on the following:
- The platform and technical standards for the NDH to streamline validation, verification, and interoperability of provider-directory information, such as the HL7® Fast Healthcare Interoperability Resources (“FHIR”), Application Programming Interface (“API”) and integration of provider data from other CMS systems.
- Incentives and policies to support timely and accurate data reporting and use of the NDH.16
- Standardized provider-directory data elements, including information related to social determinants of health.17
- Considerations for implementation, including stakeholder engagement, technical and policy prerequisites and potential risks or challenges.18
Public comment period. Public comments are due by December 6, 2022, and commenters may selectively comment on the questions posed by CMS in the RFI.19
These two opportunities for public comment should be of interest to the broad healthcare stakeholder community. The Medicaid-eligibility rule, as proposed, removes procedural hurdles that can cause coverage disruptions or delays impacting continuity of healthcare services and health-plan enrollment in Medicaid-managed-care states. Inaccuracy of provider-directory information across coverage programs has been the subject of several studies and a long-standing administrative challenge for both payers and providers. Public input received on the many key areas set forth by CMS will inform agency actions regarding future rulemaking to establish a national provider directory.
1: Department of Health and Human 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 (September 7, 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 Coverage,” Federal Register Vol. 87, no. 68 (April 8, 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 (February 2, 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 the COVID-19 Response.” (January 21, 2022), https://aspr.hhs.gov/legal/PHE/Pages/Letter-to-Governors-on-the-COVID-19-Response.aspx.
6: See endnote 1 at pages 54780-54786.
7: See endnote 1 at pages 54786-54791.
8: See endnote 1 at pages 54791-54794.
9: See endnote 1 at pages 54763-54776.
10: See endnote 1 at pages 54813-54814.
11: See endnote 1 at pages 54760 and 54763.
12: The current Unified Agenda of 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 Healthcare Providers & Services,” (October 7, 2022), https://www.federalregister.gov/public-inspection/2022-21904/request-for-information-national-directory-of-healthcare-providers-and-servithese.
14: See, eg, Centers for Medicare and Medicaid Services, “Online Provider Directory Review Report,” (last visited 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 endnote 13 at pages 61023-61025.
16: See endnote 13 at page 61024.
17: See endnote 13 at pages 61025-61026.
18: See endnote 13 at page 61028.
19: See endnote 13 at page 61018.
© Copyright 2022. The views expressed herein are those of the author(s) and not necessarily the views of FTI Consulting, Inc., its management, its subsidiaries, its affiliates, or its other professionals.