On April 22, the Centers for Medicare and Medicaid Services (CMS) released two highly anticipated final rules that reshape the landscape for payment transparency and access to care in Medicaid and the Children’s Health Insurance Program (CHIP). The first rule — Managed Care Access, Finance, and Quality — focuses on improvements to Medicaid managed care, which serve nearly three-quarters of Medicaid enrollees. The second — Ensuring Access to Medicaid Services — focuses on fee-for-service (FFS) programs and improvements for home and community-based services (HCBS) across both FFS and managed care.
In this blog post, we focus on a few key provisions that align with CMS’s goals of promoting data transparency and standardization, enhancing care access and quality, creating opportunities for public and consumer input, promoting health equity, and standardizing across federally funded health programs. The final rules also define standards for access and quality in HCBS, which account for more than half of all Medicaid spending on long-term services and supports.
Promoting Payment Transparency and Assessing Rate Adequacy
Core medical services. Starting in 2026, states must begin publishing comparative analyses of their provider payment rates for outpatient behavioral health, primary care, and obstetrics/gynecology (ob/gyn) services. Specifically, states must compare their Medicaid FFS payment rates against Medicare FFS rates for comparable services, including any variations based on provider type, geography, or adult vs. pediatric patient. Managed care plans will not be required to disclose specific rates for specific services but must compare their total Medicaid and CHIP payments for each service category against what Medicare FFS would have paid for the same set of services.
Home and community-based services. For certain HCBS (i.e., home care and habilitation services), Medicaid managed care plans must similarly disclose their total payments and must compare that total against what Medicaid FFS would have paid for those same services. (Medicare does not cover comparable services.) For Medicaid FFS, states must publish HCBS rates in the form of a standardized hourly payment. In addition, starting in 2028, states must disclose the proportion of Medicaid HCBS payments for compensation to direct care workers, as opposed to overhead and other administrative costs for home care agencies. In 2030, states must ensure home care agencies spend at least 80 percent of Medicaid HCBS payments on worker compensation. This payment-adequacy requirement aims to address longstanding shortages in the direct care workforce.
Maximum Wait Times and Access Monitoring
Managed care. Starting in 2027, Medicaid and CHIP managed care plans must meet maximum wait times requirements for routine appointments in core service areas: outpatient behavioral health (10 business days), primary care (15 business days), and ob/gyn (15 business days), plus one additional service selected by the state. States will use “secret shopper” surveys to monitor compliance and verify the information in plans’ provider directories.
Fee-for-service rate changes. The final rule rescinds the requirement for states to publish a triennial Access Monitoring Review Plan. States found this requirement burdensome, and stakeholders said it was ineffective for identifying and addressing access issues. Instead, states must now conduct a more robust analysis when they seek federal permission to reduce or restructure their FFS provider payment rates. If the proposed rate change presents a risk to beneficiary access, it will entail greater scrutiny. This could be triggered, for instance, if the change would bring FFS rates below 80 percent of comparable Medicare rates or if public comments reveal significant concerns.
Enhanced Opportunities for Public Input, Especially for Beneficiaries
Advisory groups. By summer 2025, states must establish a Medicaid advisory committee, plus a beneficiary advisory council composed of people with lived experiences in Medicaid or CHIP and family members and caregivers. These groups will issue annual recommendations on issues like eligibility, coverage, provider payments, access, and quality. These groups have much stronger requirements for consumer participation and a broader purview than the current Medical Care Advisory Committees that they replace, which advise only on “health and medical care services.” In addition, a separate interested parties’ advisory group will make recommendations on payment and access for home care and other HCBS.
Other requirements. States must conduct annual experience surveys for managed care enrollees, establish a formal complaint or grievance system for HCBS consumers, and solicit public feedback on policies like appointment wait times in managed care.
Quality Measurement and Quality Improvement
Managed care quality rating system (QRS). The final rule includes a list of mandatory quality measures that states must use to assess plan performance in areas like evidence-based preventive services, timely behavioral health services, and consumer satisfaction. By summer 2028, states must establish a QRS website that allows people to easily compare managed care plans on these measures and other features such as the populations and services covered, provider networks, and drug formularies. States will later be required to report quality measure data stratified on race and ethnicity, sex, age, rural or urban status, disability, and language.
Home and community-based services. By 2027, states must implement a robust and standardized system for reporting and investigating critical incidents in HCBS to protect beneficiaries’ health and welfare. The final rules also strengthen HCBS program standards and reporting in areas such as person-centered service plans and wait lists. By 2028, states also must begin reporting on the HCBS Quality Measure Set, including stratification as described above.
Conclusion
Through these final rules, CMS aims to bolster access to care, improve care quality, and advance health equity. But any significant program reform comes with significant implementation effort and costs. To support implementation, CMS has committed to providing guidance documents and extensive technical support. Stakeholders will be closely watching — and participating in — implementation of these major new rules in the hope of seeing long-term impact on access and equity.