CMS Requesting Information on Access to Coverage and Care in Medicaid and CHIP

Last month, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) entitled Access to Coverage and Care in Medicaid and CHIP.  CMS is seeking input on topics related to healthcare access in Medicaid and the Children’s Health Insurance Program (CHIP).  This includes enrollment in coverage, maintaining coverage, and access to services and support. For the full list of questions included in the RFI click here. The comment deadline is April 18, 2021.  NCUIH urges UIOs to respond to this RFI to provide feedback to CMS regarding the barriers to access to coverage and care in Medicaid and CHIP in AI/AN communities.

CMS Strategic Vision for Medicaid and CHIP and Role of this RFI

This RFI is one of CMS’ first steps in developing a comprehensive access strategy for Medicaid and CHIP.  CMS has established three key areas for its strategic visions for Medicaid and CHIP: (1) coverage and access, (2) equity, and (3) innovation and whole-person care. CMS will use the feedback from this RFI to inform its future policy, monitoring, and regulatory approaches in all three key areas of the strategic vision.

CMS has set forth five objectives to be addressed in the RFI.

1. Medicaid and CHIP reaches people who are eligible and who can benefit from such coverage.
   • CMS is interested in identifying strategies to ensure that individuals eligible for Medicaid and CHIP are aware of coverage options and how to apply for and retain coverage. Eligible individuals should be able to apply, enroll in, and receive benefits in a timely and streamlined manner that promotes equitable coverage.
2. Medicaid and CHIP beneficiaries experience consistent coverage.
   • CMS is seeking input on strategies to ensure that beneficiaries are not inappropriately disenrolled and to minimize gaps in enrollment due to transitions between programs. These strategies are particularly important during and immediately after the COVID-19 Public Health Emergency (PHE) and can include opportunities that promote beneficiaries’ awareness of requirements to renew their coverage as well as states’ eligibility assessment processes, which can facilitate coverage continuity and smooth transitions between eligibility categories or programs (e.g., students eligible for school-based Medicaid services are assessed for Supplemental Security Income (SSI)/Medicaid eligibility at age 18, or youth formerly in foster care are assessed for other Medicaid eligibility after age 26).
3. Whether care is delivered through fee-for-service or managed care, Medicaid and CHIP beneficiaries have access to timely, high-quality, and appropriate care in all payment systems, and this care will be aligned with the beneficiary’s needs as a whole person.
   • CMS is seeking feedback on how to establish minimum standards or federal “floors” for equitable and timely access to providers and services, such as targets for the number of days it takes to access services. These standards or “floors” would help address differences in how access is defined, regulated, and monitored across delivery systems, value-based payment arrangements, provider type (e.g., behavioral health, pediatric subspecialties, dental, etc.), geography (e.g., by specific state regions and rural versus urban), language needs, and cultural practices.

4. CMS has data available to measure, monitor, and support improvement efforts related to access to services (i.e., potential access; realized access; and beneficiary experience with care across states, delivery systems, and populations).
   • CMS is interested in feedback about what new data sources, existing data sources (including Transformed Medicaid Statistical Information System [T-MSIS], Medicaid and CHIP Core Sets, and home and community based services (HCBS) measure set), and additional analyses could be used to meaningfully monitor and encourage equitable access within Medicaid and CHIP programs.
5. Payment rates in Medicaid and CHIP are sufficient to enlist and retain enough providers so that services are accessible.
   • Section 1902(a)(30)(A) of the Social Security Act (the “Act”) requires that Medicaid state plans “assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” Section 1932 of the Act includes additional provisions related to managed care. Section 2101(a) of the Act requires that child health assistance be provided by States “in an effective and efficient manner….” CMS is interested in leveraging existing and new access standards to assure Medicaid and CHIP payments are sufficient to enlist enough providers to ensure that beneficiaries have adequate access to services that is comparable to the general population within the same geographic area and comparable across Medicaid and CHIP beneficiary groups, delivery systems, and programs. CMS also wants to address provider types with historically low participation rates in Medicaid and CHIP programs (e.g., behavioral health, dental, etc.). In addition, CMS is interested in non-financial policies that could help reduce provider burden and promote provider participation.

Need to Address Uninsured Rates Among American Indians and Alaska Natives

Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country.  The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of revenue for facilities like UIOs which provide healthcare to AI/ANs.  As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  While UIOs had hoped to see an increase in Medicaid funds in light of Congress’ authorization for eight quarters of 100% Federal Matching Assistance Percentage for UIOs, this has so far failed to result in higher rates of reimbursement for UIOs.

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