For decades, the AAP, its chapters and individual pediatricians have called for improved policies for Medicaid and the Children’s Health Insurance Program (CHIP), especially Medicaid parity with payment for Medicare.
Now, advocates are celebrating new proposals from the Centers for Medicare & Medicaid Services (CMS) that, if adopted, would improve access and transparency for care — whether provided through managed care plans or directly by states through fee-for-service arrangements.
The rules would boost accountability and ensure standardized data and monitoring for Medicaid and CHIP, which together cover more than 41 million U.S. children —"programs that are core to the financing and structure of U.S. pediatric health care,” AAP CEO/Executive Vice President Mark Del Monte, J.D., has noted.
Notices for the proposed rules — Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality — were released in late April and are open for comment through July 3. New policies could take effect later this year or over the next several years at varying times.
Consistent standards, requirements
CMS called the proposals “historic national standards.” They include:
- setting maximum appointment wait times (about two weeks for routine care),
- testing network adequacy via independent secret shopper surveys,
- requiring states to survey enrollees every year,
- disclosing provider payment rates online and
- mandating state web pages that show information such as quality data and access standards so enrollees can compare plans.
The rules are expected to improve how state Medicaid programs engage with enrollees.
Most of the proposed rules don’t affect providers directly. The maximum wait times, for example, fall on the plans to monitor.
Another provision states that for community-based and home services, at least 80% of fee-for-service and managed care Medicaid payments for personal care, homemaker and home health aide services would be required to be spent on direct care worker salaries.
Advocates weigh in
The proposed standards are “a very important step forward,” said James M. Perrin, M.D., FAAP, chair of the AAP Committee on Child Health Financing. He said the AAP had submitted detailed comments to CMS on improving access.
Longtime advocates are encouraged that some of their ideas were incorporated into the proposals.
“We’re pleased that CMS has taken this on,” said Dr. Perrin, who also heads a Medicaid Expert Advisory Panel. He said asking states to be more transparent in their payment rates is extremely valuable.
“We think it’s very important that both the states themselves and the managed care organizations have some transparency in the work that they’re doing for children,” Dr. Perrin said.
Others agreed.
“I think this really has the potential to be a game changer on behalf of our neediest kids,” said Suzanne K. Berman, M.D., FAAP, immediate past chair of the AAP Section on Administration and Practice Management.
“In the best scenario, we would see Medicaid rates naturally rise to the level of Medicare,” she added.
Dr. Berman practices in an underserved rural area of Appalachia in Tennessee, with no pediatric subspecialists nearby and the nearest children’s hospital 1½ hours away.
“Access to care for 75% of our county is something that I’ve been thinking about for a long time,” Dr. Berman said.
She takes new ideas from other states back to her statehouse and chapter pediatric council, which she chairs.
She said some providers don’t participate in Medicaid because they may earn only 60 or 70 cents on the dollar— or, with actual collections, 45 or 50 cents — a situation that’s unsustainable.
Dr. Berman said other Medicaid concerns are out-of-date provider listings, the length of time it takes to credential a new Medicaid provider and “PCP lock-in” — when providers in some states must verify that they are the primary care provider of record before beginning to treat a patient. If the record is wrong, it must be corrected and faxed that day or no payment can be made.
And while access can be a problem for families receiving Medicaid, access to Medicaid mental health providers is especially concerning.
“It’s not rare to have Medicaid plans take — and I’m not making this up — 12 to 18 months to credential a new mental health provider,” Dr. Berman said.
Enforcing network adequacy is critical, said Jesse Hackell, M.D., FAAP, chair of the AAP Committee on Practice and Ambulatory Medicine.
“If you’ve got one pediatric neurologist for a 16-county area that accepts Medicaid, there is no way you’re going to get the child in,” Dr. Hackell said. “So what I’m really hoping about in these rules is that … you can’t enforce a maximum wait time if you don’t have an adequate number of providers, and you can’t have an adequate number of providers if you don’t pay them adequately.
“We’ve always fought for a better payment because that would provide better access — so this is not new. But what’s new is it’s getting a response finally from CMS,” Dr. Hackell said.
Still, the devil is in the details, he said.
“The ultimate goal is making Medicaid at least as comprehensive as Medicare is for our seniors. Anybody who relies on government-provided health insurance should have the same access to care and the same coverage.”
