Comments from Richard Besser, MD, on Access to Coverage and Care in Medicaid and CHIP

The following comments were submitted by President and CEO Richard Besser, MD, of the Robert Wood Johnson Foundation, in response to the Centers for Medicare & Medicaid Services (CMS) request for information regarding access to coverage and care in Medicaid and the Children’s Health Insurance Program (CHIP).

Objective 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

1. What are the specific ways that CMS can support states in achieving timely eligibility determination and timely enrollment for both modified adjusted gross income (MAGI) and non-MAGI-based eligibility determinations? In your response, consider both eligibility determinations and redeterminations for Medicaid and CHIP coverage, and enrollment in a managed care plan, when applicable. To support states’ work to achieve timely eligibility determination and timely enrollment for modified adjusted gross income (MAGI) and non-MAGI determinations, the Centers for Medicare & Medicaid Services (CMS) should:

• Issue guidance on key issues affecting timeliness, such as accepting attestations that are “reasonably compatible” with electronic sources (without requiring verification), including increasing the threshold for reasonable compatibility, and encouraging ex parte renewals, including allowing states to accept no information returned on income as verification of eligibility.
• Revise regulations to prohibit all interview requirements (rules currently prohibit face-to-face interviews for most non-elderly applicants).
• Encourage further streamlining/simplification of enrollment and renewal processes–for example, through the development and dissemination of a simplification toolkit. 
• Encourage states to amend state plans and processes, such as fully utilizing presumptive eligibility, expand use of real-time eligibility (automated processes with 24-hour turnaround for determinations), increase use of express lane eligibility, post-enrollment verification. 
  

Enforce, if necessary, determination and enrollment timeline requirements on state agencies.

2. What additional capabilities do states need to improve timeliness for determinations and enrollment or eligibility processes, such as enhanced system capabilities, modified staffing arrangements, tools for monitoring waiting lists, or data-sharing across systems to identify and facilitate enrollment for eligible individuals? Which of these capabilities is most important? How can CMS help states improve these capabilities?

Key capabilities for states include:

• Information sharing capabilities, such as:
  • The ability to use specific, reliable data sources, such as income information already verified by the Supplemental Nutrition Assistance Program (SNAP), as part of application and renewal processes
  • The ability to draw information from existing data bases instead of requiring applicants to verify eligibility
  • Established data use agreements with various institutions. CMS should play a role in easing the burden on state agencies to establish these partnerships and obtain the data.
• Client-focused eligibility systems, which prioritize high-need populations (people experiencing homelessness, people with limited internet access, people with limited English proficiency). CMS can set standards/improve the process for reviewing state eligibility systems.
• Security procedures that are more client-friendly than remote identity proofing.
• The ability to monitor and manage home and community-based services (HCBS) waiting lists. CMS should support states’ efforts to monitor access to HCBS while people are on waiting lists to help determine the level of unmet need. CMS could identify/disseminate best practices that states use in wait list monitoring and management to delay or prevent the need for institutional care.
  

3. In what ways can CMS support states in addressing barriers to enrollment and retention of eligible individuals among different groups, which include, but are not limited to: people living in urban or rural regions; people who are experiencing homelessness; people who are from communities of color; people whose primary language is not English; people who identify as lesbian, gay, bisexual, transgender, queer, or those who have other sexual orientations or gender identities (LGBTQ+); people with disabilities; and people with mental health or substance use disorders? Which activities would you prioritize first?

To support state efforts to address barriers to enrollment and retention of eligible individuals, CMS should:

• Pursue policy changes designed to reduce barriers to enrollment and retention, such as eliminating states’ option to establish waiting periods in CHIP. 
• Encourage states to take advantage of existing authorities to improve enrollment and retention, including:
  • Eliminating the five-year bar for children and people who are pregnant 
  • Utilizing the state plan amendment process to raise CHIP eligibility levels
  • Helping states utilize SNAP, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), tax, and other data to facilitate enrollment and retention through guidance developed in partnership with the Department of Agriculture, the Treasury Department, and other agencies
  • Encouraging all states to implement 12-month continuous eligibility for all children and youth
  • Approving and encouraging state 1115 demonstration proposals for continuous eligibility, including for people experiencing homelessness, leaving jail and prison, and other populations at heightened risk of losing coverage
  • Dissuading states from resuming excessive data checks to verify eligibility.  When misused or overused, data checks disproportionately affect marginalized communities who are most likely to experience changes in circumstances
  • Encouraging multi-year continuous eligibility for young children under demonstration waivers and
  • Encouraging states to ensure that Medicaid enrollees who are incarcerated have active Medicaid coverage as they return to the community.
• Encourage states to attend to the relatively high proportion of dually-eligible individuals who cycle in and out of Medicaid eligibility by: 
  • Requiring dual-eligible special needs plans (D-SNPs) to help members recognize and respond to redetermination notices
  • Developing and implementing beneficiary-friendly redetermination systems
    • Maximizing use of ex-parte renewals with dually-eligible populations
    • Extending protections offered to MAGI eligibility groups to dually-eligible individuals
    • Providing multiple avenues for beneficiaries and their representatives to respond to redetermination notices
    • Providing help via enrollment assisters.
• Allow or require D-SNPs to offer eligibility deeming periods.
• Provide states with guidance and timeframes for complying with existing or new policies. Areas that may require guidance include:
  • Applications and renewals should not require household members who are not applying for coverage, such as a parent who is applying for coverage for a child, to provide information about their immigration status or a Social Security number (SSN) 
  • States should not require people who are ineligible for SSNs to provide them even when they are seeking benefits for themselves
  • States should meet language access requirements in applications, renewals and related processes and ensure that application assistance is linguistically and culturally competent, including for individuals who speak less-common languages and members of the deaf community
  • Applications should not require a permanent address
  • Applications should not force people to identify only as male or female and  
  • States should inform people who don’t qualify for full coverage because of their immigration status about Medicaid payment for emergency services.

4. What key indicators of enrollment in coverage should CMS consider monitoring? For example, how can CMS use indicators to monitor eligibility determination denial rates and the reasons for denial? Which indicators are more or less readily available based on existing data and systems? Which indicators would you prioritize? 

Key indicators CMS should use or develop for monitoring enrollment barriers and inappropriate denials include:

• Three key indicators of program success—Equitable Access, Effective Delivery and Compassionate Integrity. The full list of indicators and questions that should be tracked to assess the effectiveness of program delivery can be found here.
• Waiting lists disaggregated by demographic categories.
• Case denials due to returned mail, which can inform the impact automatically-updated addresses through the United States Postal Service (USPS) could have on enrollment retention.
• Challenges related to Medicaid agency customer service through audit calls, including hold times, unanswered calls and whether agency officials treat enrollees and prospective enrollees with respect.
• Enrollment of populations spending down income to qualify for long-term services and supports ( LTSS), and how that may be affected by variations in state policy around post-eligibility treatment of income and the eligibility pathways potential LTSS consumers must follow.

Objective 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).

1. How should states monitor eligibility redeterminations, and what is needed to improve the process? How could CMS partner with states to identify possible improvements, such as leveraging managed care or enrollment broker organizations, state health insurance assistance programs, and marketplace navigators and assisters to ensure that beneficiary information is correct and that beneficiaries are enabled to respond to requests for information as a part of the eligibility redetermination process, when necessary? How could CMS encourage states to adopt existing policy options that improve beneficiary eligibility redeterminations and promote continuity of coverage, such as express lane eligibility and 12-month continuous eligibility for children?

State efforts to monitor and improve eligibility redeterminations should include the following policies and processes. CMS should encourage or, when appropriate, require states to pursue these approaches:

• Continuous eligibility, including through state plan option for children and waivers for adults.
• Refrain from conducting quarterly or mid-year data checks. 
• Maintain the prohibition on conditioning eligibility or renewals on work requirements, participation in community engagement activities, wellness programs, or personal responsibility requirements.
• Monitor redetermination processes for LTSS applicants, which may impact access to HCBS versus institutional care. CMS may find value in understanding both state and Medicaid managed LTSS health plan experience supporting beneficiaries and examining where redetermination processes and related policy create barriers and/or disparities in access to HCBS.
• Use of ex parte renewals. (For more detailed recommendations, see this resource.) CMS should ensure that states:
  • Gather and analyze data to determine why cases are not being renewed ex parte
  • Review their design documents to make sure their systems maximize opportunities for ex parte renewals
  • Take advantage of all useful data sources, especially information gathered for SNAP participation
  • Only verify eligibility factors subject to change
  • Include seniors and people with disabilities in ex parte renewals as regulations require.
• Maintain states’ option to use 1902(e)(14)(A) waiver authority to partner with MCOs to update beneficiary contact information.
• Improve how they communicate with enrollees, including notices, websites, use of text/email/phone, and seek updated addresses on returned mail from USPS and Departments of Motor Vehicles.
• Assess and improve algorithms in states’ automated decision-making systems by identifying–and correcting–data, analyses and assumptions that incorporate racial, gender, disability, age, and other biases.

2. How should CMS consider setting standards for how states communicate with beneficiaries at-risk of disenrollment and intervene prior to a gap in coverage? For example, how should CMS consider setting standards for how often a state communicates with beneficiaries and what modes of communication they use? Are there specific resources that CMS can provide states to harness their data to identify eligible beneficiaries at-risk of disenrollment or of coverage gaps?

To improve states’ communications with beneficiaries at risk of disenrollment, CMS should:

• Establish communication standards
• CMS could review/approve renewal letters to ensure they are at the appropriate reading level and are clear for people with limited literacy/numeracy 
• Require multiple communications in multiple modalities (mail, text, phone calls and email) ahead of redetermination deadlines 
• Provide states with model notices consistent with the principles from human-centered design
• Encourage or require additional communication strategies and improvement initiatives
• Require states to establish Medicaid consumer councils to provide feedback on communications and other program issues 
• Encourage states to use their website, social media and other platforms to educate enrollees and other stakeholders, including providers, managed care organizations, consumer groups and other advocates, about enrollment and renewal processes.

3. What actions could CMS take to promote continuity of coverage for beneficiaries transitioning between Medicaid, CHIP, and other insurance affordability programs; between different types of Medicaid and CHIP services/benefits packages; or to a dual Medicaid-Medicare eligibility status? For example, how can CMS promote coverage continuity for beneficiaries moving between eligibility groups (e.g., a child receiving Early and Periodic Screening, Diagnosis, and Treatment [EPSDT] qualified supports who transitions to other Medicaid services such as home and community based services [HCBS] at age 21, etc.); between programs (Medicaid, CHIP, Basic Health Program, Medicare, and the Marketplace); or across state boundaries? Which of these actions would you prioritize first?

To promote continuity of coverage, CMS should:

• Ensure that state eligibility workers, navigators and others assess individuals’ eligibility for all Medicaid eligibility categories, including condition-specific eligibility groups. Individuals who qualify for the Breast and Cervical Cancer program (BCCP), for example, have been denied traditional Medicaid coverage without being screened for BCCP. Prospective enrollees should not be responsible for knowing to ask about this and other eligibility pathways.
• Require states to provide Medicaid enrollees with information on and enrollment resources for marketplace coverage, such as clear and direct notices indicating potential eligibility for premium subsidies and special enrollment period (SEP) eligibility and what they must do to secure coverage, and how to get help (such as navigator assistance, the HHS call center, and patient advocacy groups).
• Improve the account transfer process by requiring states to provide telephone numbers, e-mail addresses, and other information that can be used for marketplace outreach.
• Align D-SNP deeming periods with Medicaid reinstatement and/or automatic re-enrollment time periods to promote continuity of coverage.
• Change the start date of marketplace coverage for people losing Medicaid so that individuals who apply the month they lose Medicaid can maintain uninterrupted coverage. 
• Increase the availability of enrollment assistance.

4. What are the specific ways that CMS can support states that need to enhance their eligibility and enrollment system capabilities? For example, are there existing data sources that CMS could help states integrate into their eligibility system that would improve ex-parte redeterminations? What barriers to eligibility and enrollment system performance can CMS help states address at the system and eligibility worker levels? How can CMS support states in tracking denial reasons or codes for different eligibility groups? 

To support states’ work to enhance their eligibility and enrollment system capabilities, CMS should:

• Support states’ work to revamp legacy systems through direct funding and expert technical assistance.
• Encourage states to connect to the USPS Change of Address Database.

Objective 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.

1. What would be the most important areas to focus on if CMS develops minimum standards for Medicaid and CHIP programs related to access to services? For example, should the areas of focus be at the national level, the state level, or both? How should the standards vary by delivery system, value-based payment arrangements, geography (e.g., sub-state regions and urban/rural/frontier areas), program eligibility (e.g., dual eligibility in Medicaid and Medicare), and provider types or specialties? 

Critical areas for access standards related to Medicaid and CHIP include:

• Improved regulatory guidance and oversight of MCO network adequacy, including new quantitative federal minimum standards for primary care, OB/GYNs and behavioral health.  These standards should specify time and distance and may also encompass other specialty services, and community-level services such as pharmacy and non-emergency medical transportation.
• A national core set of minimum standards and access measures. This would establish a mechanism for measuring access to care that is meaningful, enforceable and comparable across states and that would allow CMS to measure and compare performance in individual states relative to the nation as a whole. 
• CMS should develop minimum standards and monitor access for primary care, specialty care, behavioral health care, obstetric services, and home health services. 
• States should develop access standards and monitor access for children, including separate categories for pediatric primary care, pediatric specialty care, pediatric behavioral health services, and pediatric dental services.

2.  How could CMS monitor states’ performance against those minimum standards? For example, what should be considered in standardized reporting to CMS? How should CMS consider issuing compliance actions to states that do not meet the thresholds, using those standards as benchmarks for quality improvement activities, or recommending those standards to be used in grievance processes for beneficiaries who have difficulty accessing services? In what other ways should CMS consider using those standards? Which of these ways would you prioritize as most important? 

CMS monitoring activities should include:

• Monitoring whether and how waivers may impact the state’s ability to meet access standards and revoke waivers—such as waivers of non-emergency medical transportation (NEMT)—that are shown to limit access.  CMS should also monitor how waiver provisions may be positively affecting a state’s ability to meet or exceed access standards. 
• Direct testing of plan compliance with network adequacy standards, through secret shopper studies or other methodologies.
• Using national access standards to assess areas where state Medicaid programs are experiencing access gaps, as benchmarks for states to improve performance, and as the basis for compliance action for states that fail to meet the thresholds.
• Clarifying in written guidance that a state’s failure to provide reasonable access to a covered service is a violation of 42 USC 1396a(a)(3), which guarantees beneficiaries the right to a fair hearing when claims for assistance are not acted on with reasonable promptness. CMS should also clarify that fee-for-service ( FFS) Medicaid beneficiaries have a right to an expedited fair hearing in urgent cases.

3. How could CMS consider the concepts of whole person care1 or care coordination across physical health, behavioral health, long-term services and supports (LTSS), and health-related social needs when establishing minimum standards for access to services? For example, how can CMS and its partners enhance parity compliance within Medicaid for the provision of behavioral health services, consistent with the Mental Health Parity and Addiction Equity Act? How can CMS support states in providing access to care for pregnant and postpartum women with behavioral health conditions and/or substance use disorders? What are other ways that CMS can promote whole person care and care coordination?

To promote whole person care and care coordination, CMS should:

• Require parity related to the Mental Health Parity and Addiction Equity Act (MHPAEA) in states with fee-for-service Medicaid programs to which MHPAEA does not apply. 
• Establish clear state guidelines and policies for reporting progress in Medicaid health plans’ compliance with federal and state MHPAEA laws.
• Promote strategies for reducing historical disparities in payment rates between behavioral and physical health services. For example, New Mexico Medicaid required the same rates for mental health visits and primary care visits in community health centers. 
• Promote Medicaid’s critical role in connecting people to services and supports that meet other social needs. Access to affordable housing and services is especially important to ensuring people with complex needs can live in community-based settings rather than institutions.
  • Share data and learnings from evaluations of state demonstration programs designed to increase Medicaid enrollees’ access services targeting health-related social needs.
• Continue to invest in increasing capacity among mental health, substance use disorder treatment, and housing service providers. Efforts to increase capacity should focus on increasing provider participation in Medicaid or increasing partnerships between these providers and existing Medicaid providers. 
• Make findings from the current SUPPORT Act demonstration project to increase Medicaid substance use disorder (SUD) treatment provider capacity available publicly and on an ongoing basis (not just at the conclusion of the demonstration) so that other states can benefit from them. 
• Work with states to ensure SUD provider assessments for IMD exclusion waivers have a wide scope and include not only inpatient and other high levels of care, but also providers of tenancy and other recovery supports. These assessments should include whether a state’s reimbursement rates adequately reflect the cost to deliver high quality care as well as plans for ensuring that any weaknesses identified are addressed. 
• Work with states to transition housing-related services, currently provided under 1115 demonstrations, to state plan coverage.  This transition will signal stable funding for service providers and expand the volume of people who are eligible for them. 

4. In addition to existing legal obligations, how should CMS address cultural competency and language preferences in establishing minimum access standards? What activities have states and other stakeholders found the most meaningful in identifying cultural and language gaps among providers that might impact access to care?

To promote cultural competency and language preferences, CMS should encourage more states to use their procurement policies with Medicaid health plans to advance health equity among Medicaid health providers. Through their contracting and payment policies, Medicaid health plans can influence health equity across a number of domains, including measurement of health equity and racial disparities in access and outcomes, the provision of services that address health-related social needs, workforce policies that expand capacity and diversity at the state level, and the provision of culturally and linguistically competent care that is consistent with the standards for culturally and linguistically appropriate services (CLAS). A number of state Medicaid programs have adopted the NCQA’s process to attain Distinction in Multicultural Health Care. This process provides guidelines for Medicaid health plans to work with their contracted health providers to advance health equity.

1 What are specific ways that CMS can support states to increase and diversify the pool of available providers for Medicaid and CHIP (e.g., through encouragement of service delivery via telehealth, encouraging states to explore cross-state licensure of providers, enabling family members to be paid for providing caregiving services, supporting the effective implementation of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits, implementing multi-payer value-based purchasing initiatives, etc.)? Which of these ways is the most important?

To support states’ work increasing and diversifying the pool of available providers, CMS should:

• Encourage states to implement programs to address sectors and positions that have received little attention to date. To increase and diversify the pool of available providers that can offer services that address the whole person, CMS should ensure that workforce efforts span across physical health, behavioral health, and long-term services and supports. 
• Encourage states to remedy the historic underinvestment in the safety net and behavioral health, such that reimbursement rates will allow adequate wages for delivery of those services. This has been done in a number of ways; for example, Colorado has established rate review committees to assess and set rates outside the immediate pressures of annual state budget cycles. New Mexico has established parity in prospective payment system rates for primary care and behavioral health visits in community health centers.

Objective 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.  

1. What should CMS consider when developing an access monitoring approach that is as similar as possible across Medicaid and CHIP delivery systems (e.g., fee-for-service and managed care programs) and programs (e.g., HCBS programs and dual eligibility in Medicaid and Medicare) and across services/benefits? Would including additional levels of data reporting and analyses (e.g., by delivery system or by managed care plan, etc.) make access monitoring more effective? What type of information from CMS would be useful in helping states identify and prioritize resources to address access issues for their beneficiaries? What are the most significant gaps where CMS can provide technical or other types of assistance to support states in standardized monitoring and reporting across delivery systems in areas related to access?

Data collection for purposes of access monitoring should:

• Address the three key dimensions of access: potential access, realized access, and health outcomes. 
• Account for the diversity of populations served by Medicaid and their differing needs. CMS should include general measures that apply to all the child and adult populations covered by Medicaid, but also include measures appropriate for subgroups, such as people receiving long-term services and supports who have unique needs.
• Reflect multiple settings. Data collected should provide information on access in both fee-for-service and managed care settings, as well as rural and urban areas.
• Reflect the broader environmental context. In monitoring access CMS should account for the broader environment that influences enrollees’ access to care, including federal and state policies, and social, economic and demographic factors that affect how Medicaid beneficiaries obtain and receive care.
• Provide timely information. To be useful for continuous quality improvement, the measures should provide information on the most current state of access to services as possible.
• Include widely accepted measures to encourage widespread adoption, which will facilitate benchmarking and comparisons across states.
• Be collected by plan, to identify and differentiate between plan level and statewide access barriers.

In addition, to improve data that supports health access and equity, CMS and OMB should: 

• Add race and ethnicity data fields to the two universal billing forms that are up for renewal next year—the UB-04 (also known as the CMS-1450), whose electronic version, the 8371 (Institutional) is used by institutional providers, and the CMS-1500 for non-institutional health services. These two forms document over 99% of all clinical encounters in the U.S., capturing information on patient demographics, diagnoses, treatment and provider identity. Today, CMS and the Office of Management and Budget (OMB) allow the addition of racial and ethnic identifiers to the forms, but do not require it. In those states that mandate their inclusion, the billing forms provide valuable insights into disparities in access, treatment, and health status.  CMS should ensure that those data elements are added to the 837I/CMS 1450 and to the CMS 1500 before their use is reauthorized next year.
• Work with and support states’ efforts to improve the data that informs its access monitoring approach. CMS may consider engaging states in measure selection and pilot testing improvements in data collection and analysis, such as improving the collection of race and ethnicity data.  States will need expert-level technical assistance and flexible funding that supports direct costs like system modifications as well as costs related to stakeholder engagement activities.

Finally, CMS should ensure federal data collection is a key component of Medicaid access monitoring.  In particular, the access monitoring effort would benefit from periodic fielding of a 50-state Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey aimed at both children and adults and administered by the federal government. The federal government has a long and successful track record of fielding high-quality surveys that produce estimates for all 50 states, including a one-time National Medicaid Adult CAHPS survey. 

2. What measures of potential access, also known as care availability, should CMS consider as most important to monitor and encourage states to monitor (e.g., provider networks, availability of service providers such as direct service workers, appointment wait times, grievances and appeals based on the inability to access services, etc.)? How could CMS use data to monitor the robustness of provider networks across delivery systems (e.g., counting a provider based on a threshold of unique beneficiaries served, counting providers enrolled in multiple networks, providers taking new patients, etc.)?

To measure access and monitor provider networks across delivery systems, CMS should:

• Adopt measures of care availability that include the number of providers available within a geographic area, the extent to which these providers participate in Medicaid, whether the providers are accepting new patients, and the accessibility or convenience of the provider’s office location. States should require managed care organizations (MCOs) to periodically supply this information, which they should be able to gather through provider surveys.
• Encourage states to  conduct regular secret shopper surveys, which would allow states to validate whether MCOs are meeting access standards. These surveys can effectively  spot issues in real-time and can be targeted to plans and/or particular provider types where problems have surfaced. 
• Require that states make enrollees, providers, advocates and other stakeholders aware of the expectation that enrollees should be able to receive care as well as the specific access standards on appointment availability, wait times, travel distances, and what they should do if care is not available. States should also regularly analyze the prevalence and content of grievances and complaints as part of their access monitoring strategy.

3. In what ways can CMS promote a more standardized effort to monitor access in long-term services and supports (LTSS), including HCBS, programs? For example, how could CMS leverage the draft HCBS measure set, grievances and appeals, or states’ comparisons of approved Person-Centered Service Plans to encounter or billing data in managed care or fee-for-service to ensure appropriate services are being received?

Which activities would you prioritize first?  

CMS should consider the following access domains for LTSS programs:

• Access to person-centered planning. This is widely considered to be a vital component of an effective LTSS delivery system. We recommend that CMS look at the HCBS Experience Survey and the National Core Indicators Aging and Disability (NCI-AD) for a number of questions that could be used to determine access to person-centered planning. 
• Beneficiary perceptions of unmet need. The Administration on Aging within the Administration for Community Living explored how to measure need and unmet need, and indicated that national measures of unmet need may be available through surveys such as the National Health and Aging Trends Study.
• Availability of self-direction options. The availability of self-direction options, which empower people with disabilities to make decisions about the services they receive and the individuals who provide these services, is a component of access that is particularly critical to measure for people with disabilities.

4. How should CMS consider requiring states to report standardized data on Medicaid fair hearings, CHIP reviews, managed care appeals and grievances, and other appeal and grievance processes that address enrollment in coverage and access to services? How could these data be used to meaningfully monitor access?

To improve standardized data reporting and utilization, CMS should:

• Ensure that standardized data on Medicaid fair hearings, CHIP reviews, managed care appeals and grievances and other appeal and grievance processes related to enrollment and access, which could uncover critical barriers to access and coverage, are fully utilized. Access to these data are limited by state charges for these data and states’ heavy redactions. CMS should require states to make redacted fair hearing decisions easily available to the public. In addition, CMS should require states to regularly report:
• The number of fair hearing requests they receive
• The substantive basis for the requests in enough detail to identify the issue being raised and
• The time between request, hearing, and decision, and how the hearing was decided. 
• Require states to report similar information on CHIP reviewsRequire managed care organizations to report similar information on the grievances and appeals they receive. 
• States regularly review the information from the MCOs to detect problems enrollees are having in getting the care they need. 

5. How can CMS best leverage T-MSIS data to monitor access broadly and to help assess potential inequities in access? What additional data or specific variables would need to be collected through T-MSIS to better assess access across states and delivery systems (e.g., provider taxonomy code set requirements to identify provider specialties, reporting of National Provider Identifiers [NPIs] for billing and servicing providers, uniform managed care plan ID submissions across all states, adding unique IDs for beneficiaries or for managed care corporations, etc.)? 

Objective 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.

1. What are the opportunities for CMS to align approaches and set minimum standards for payment regulation and compliance across Medicaid and CHIP delivery systems (e.g., fee-for-service and managed care) and across services/benefits to ensure beneficiaries have access to services that is as similar as possible across beneficiary groups, delivery systems, and programs? Which activities would you prioritize first?

2. How can CMS assess the effect of state payment policies and contracting arrangements that are unique to the Medicaid program on access and encourage payment policies and contracting arrangements that could have a positive impact on access within or across state geographic regions? 

3. Medicare payment rates are readily available for states and CMS to compare to Medicaid payment rates, but fee-for-service Medicare rates do not typically include many services available to some Medicaid and CHIP beneficiaries, including, but not limited to, most dental care, long-term nursing home care, and home and community-based services (HCBS). What data sources, methods, or benchmarks might CMS consider to assess the sufficiency of rates for services which are not generally covered by Medicare or otherwise not appropriate for comparisons with Medicare? 

4. Some research suggests that, in addition to payment levels, administrative burdens that affect payment, such as claims denials and provider enrollment/credentialing, can discourage provider acceptance of Medicaid beneficiaries.2 What actions could CMS take to encourage states to reduce unnecessary administrative burdens that discourage provider participation in Medicaid and CHIP while balancing the need for program integrity? Which actions would you prioritize first? Are there lessons that CMS and states can learn from changes in provider enrollment processes stemming from the COVID-19 Public Health Emergency?  

• Encouraging states to provide multi-year continuous eligibility in early childhood, and 12-month continuous eligibility for all children and youth would reduce uncertainty and administrative burdens for providers that serve these populations, potentially encouraging greater Medicaid participation among pediatricians and pediatric specialists.

Other Feedback 

At the end of the RFI, there is an opportunity to provide any additional comments you have for this Request for Information that does not apply to one of the previous questions. 

The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.  Our comments reflect the perspectives of our grantees, who include policy experts, Medicaid advocates, academic researchers, and organizers with deep experience in the Medicaid and CHIP programs.

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