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  • Washington Highlights

    CMS Issues Final Rule on Medicaid-Managed Care Access, Finance, and Quality

    Katherine Gaynor, Hospital Policy and Regulatory Analyst
    For Media Inquiries

    The Centers for Medicare & Medicaid (CMS) released a final rule on April 22, “Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality.” The AAMC previously submitted comments on the policies in the proposed rule [refer to Washington Highlights, June 30, 2023].

    The CMS finalized its proposal to establish the average commercial rate as the limit for provider payment levels for state-directed payments (SPDs) used for inpatient and outpatient hospital services, nursing facility services, and professional services at an academic medical center. The agency finalized their definition of an academic medical center to mean “a facility that includes a health professional school with an affiliated teaching hospital.” Additionally, the final rule will require states to ensure providers receiving SDPs to attest that they do not participate in any arrangement that holds taxpayers harmless for the cost of a tax, also referred to as “provider pooling.” The CMS, however, released a related informational bulletin stating that they will exercise enforcement discretion until calendar year 2028 for existing health care-related tax programs with certain hold harmless arrangements involving the redistribution of Medicaid payments.

    The final rule also establishes maximum appointment wait time standards, including 15 business days for routine primary care and OB-GYN services, and 10 business days for outpatient mental health and substance use disorder services. To ensure wait time standards are met, the CMS will require states to conduct annual secret shopper surveys with an independent entity to validate compliance and the accuracy of provider directories, to identify errors and providers that do not offer appointments.