New Medicaid Proposed Rules Focus on Primary Care

Policy Points

• In its new proposed Medicaid rules, the Biden-Harris administration focuses on primary care and equity for beneficiaries, setting a maximum wait time for routine primary care and requiring states to enforce wait times and maintain provider directory accuracy, publish payment rates, and develop a public-facing webpage for required reports.
• The access standards in the proposed Medicaid rules may not be realistic based on current workforce shortages. Likewise, while reimbursement rates are a critical tool, rates alone are not sufficient to meet provider network goals.

Abstract

The Biden-Harris administration recently published two notices of proposed rulemaking (NPRMs): Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality. In both proposed rules, the administration makes clear its intention to focus on access to primary care as a pillar of the Medicaid program. Four key policies for primary care include (1) setting a 15-day maximum wait time standard for routine primary care, (2) requiring states to conduct secret-shopper surveys to enforce standard wait times and maintain accuracy of provider directories, (3) requiring states to publish payment rates for primary care, and (4) requiring states to develop a single web page for public transparency. The new Medicaid proposed rules highlight the importance of primary care through an emphasis on primary care wait times, network accountability, and transparency. However, the proposed policies may be insufficient to address underlying workforce constraints, and must be implemented with an eye to avoiding additional administrative burden on primary care providers. In general, the rules focus on supporting primary care and ensuring equity in access for Medicaid beneficiaries compared with populations that have other insurance types. The access standards in these rules — including wait time limits for routine primary care — may be helpful and worthwhile targets, but they are significant changes and may not be realistic based on current workforce shortages. The rules also emphasize rate sufficiency and transparency. While reimbursement rates are likely a critical tool to increase access, rates tend to be necessary but not sufficient to meet network goals. Transparency does, however, provide useful benchmarks and more readily allows for identification of disparities and resource needs.

Background

The Biden-Harris administration recently published two notices of proposed rulemaking (NPRMs) — Ensuring Access to Medicaid Services and Managed Care Access, Finance, and Quality. In both proposed rules, the administration makes clear its intention to focus on access to primary care as a pillar of the Medicaid program. The two rules aim to increase access, accountability, and transparency in Medicaid and the Children’s Health Insurance Program (CHIP) by setting ambitious standards for wait times, requiring significant additional rate transparency, and setting metrics for accountability. The administration has requested public comments to be submitted for the proposed rules by July 3, 2023.

Primary care is a critical component of a thriving health care system,^1,2 yet the recently published national primary care scorecard demonstrates the significant under-resourcing of primary care and variability of resources across payers and geographic regions. The scorecard finds that Medicaid spending on primary care has decreased over the last several years, falling from 5.3% of total health care spending in 2014 to 4.2% in 2020.³ As states struggle to address primary care shortages and improve access for all populations, this brief examines the proposed Medicaid access and managed care rules and explores their potential impacts on primary care.

A close reading of the proposed rules identifies four particularly significant policies:

1. Setting a standard maximum wait time of 15 days for routine primary care.
2. Requiring states to conduct secret-shopper surveys to enforce standard wait times and maintain accuracy of provider directories.
3. Requiring states to publish payment rates for specified services, including primary care evaluation and management services. Rates must be compared against Medicare, as well as across geographic regions, populations, and managed care entities.
4. Requiring states to develop a single web page that provides public access to required reports, including secret-shopper results and rate transparency reports.

Standard wait time limits

The administration has proposed a 15-day maximum wait time for routine primary care and OB/GYN services. Outpatient mental health and substance use disorder services wait times are set at no longer than 10 days. These standards would be enforced through managed care contracts, which cover 72% of Medicaid members.⁴ States not meeting the new standards would be required to submit a remedy plan and quarterly progress updates. Comments are being sought regarding whether fee-for-service Medicaid should also be included. Maximum wait time standards would go into effect approximately three years after the publication of the final rule.

Timely access to primary care is critical for the health and well-being of Medicaid members. Delays in access to primary care have been shown to increase avoidable emergency department utilization, as well as increase morbidity and mortality among patients with chronic conditions.⁵ Yet Medicaid members experience higher wait times for primary care than their commercially insured counterparts.6 The new rules would align Medicaid wait time standards with those set to be implemented for qualified health plans available through the Affordable Care Act marketplaces in 2025.^7,8

While published data on current Medicaid wait times are limited, available data suggest that Medicaid members often wait far more than the 15-day limit for routine primary care. For instance, in 2020, New Hampshire conducted a secret-shopper survey and found that average wait times ranged from 13 to 75 days depending on the managed care entity and averaged 36 days. In New Mexico, one-third of callers seeking primary care visits had wait times greater than 30 days if a provider could be reached at all.

The proposed rules would not allow telehealth services to count toward meeting wait time standards unless an in-person option is also offered. While consistent with qualified health plans, this policy differs from Medicare Advantage, where telehealth visits can provide credit toward meeting network standards. Telehealth services have been a critical tool in recent years to expand access to primary care and panel size despite workforce shortages, with Medicaid members remaining the highest utilizers of telehealth services.⁹ The Centers for Medicare & Medicaid Services (CMS) is seeking comments on the proposal to exclude telehealth-only appointments in meeting wait time standards.

With few tools outside of telehealth available to expand access to primary care, questions remain about the feasibility of meeting the newly proposed 15-day standard. CMS offers suggestions such as increasing payment, which is likely to be a critical component of decreasing wait times. However, higher reimbursement rates alone may be insufficient to significantly improve provider networks, with some states nearing 95% eligible provider participation rates.^10,11 States aiming to increase panel size or gain Medicaid participation may need to address the administrative burden associated with Medicaid participation. As states have moved toward managed care, providers must contract with multiple entities and bill multiple partners. A 2019 CAQH study found that providers maintained an average of 20.2 health plan contracts to cover their full patient population. The administrative burden associated with working with multiple entities is significant and may result in reduced provider participation.

Additionally, no limit is set for urgent primary care needs or sick visits. While routine primary care is essential, urgent/sick care visits may be more critical for the Medicaid population as these services are often the entry point for building long-term relationships with a primary care provider.

Secret-shopper surveys

Under the proposed rules, Medicaid managed care entities would be held accountable for wait time standards through an annual secret-shopper survey, in which a third-party entity posing as a Medicaid member calls primary care practices to determine the accuracy of provider directory information and the timing of the next available appointment. If the proposed rules are adopted, managed care entities would be considered compliant with standard wait times if 90% of callers are able to receive a routine primary care appointment within 15 days.

Importantly, CMS is focused on not only the wait time findings of the surveys, but also the data quality provided in the provider directories. Although there is currently no federal requirement to conduct secret-shopper surveys, many states already use secret-shopper surveys to identify provider network concerns, and data quality is a significant one. For instance, the 2020 New Hampshire survey found that one-third of primary care providers listed as in-network were not reachable by phone at all, and in New Mexico, only 15% of callers were able to reach and schedule a primary care appointment based on the data provided. Under the proposed rules, any data that appear to be outdated or inaccurate would be required to be updated immediately. However, with surveys only conducted annually, these updates would only be required once per year.

Accurate provider directories are essential for promoting access. However, primary care providers must prepare for the administrative burden, especially for providers that contract with multiple managed care entities and will need to report their updated information multiple times. Reporting processes will need to be streamlined to ensure that providers are able to keep up with increased demands.

Based on the findings of secret-shopper surveys, managed care entities and/or states not meeting the proposed standards for wait times and provider directory quality would be required to submit remedy plans. CMS has suggested remedies that may be included, such as increasing rates and outreach, expanding use of telehealth, and reducing administrative burden, as well as several remedies that may require state legislation or are outside the direct control of Medicaid agencies, such as expanding scope-of-practice laws and entering interstate compacts for provider licensure.¹²

Provider rates and payment analysis

The administration is requiring states to publish detailed rates for high-priority services, including primary care, OB/GYN, and outpatient mental health and substance use disorder services. States must also perform an analysis to compare rates with Medicare. Rates that differ by provider type, population served, or geographic location must be reported separately. Payment analyses must be reported within two years of publication of the final rule (or the first managed care rating period thereafter).

Medicaid has historically provided significantly less reimbursement to primary care providers than Medicare or commercial payers for the same services. In 2019, Medicaid fee-for-service rates for primary care were less than half of Medicare rates in six states, with commercial rates another 30% higher than Medicare.¹³ These proposed rules complement the recent Section 1115 demonstration approvals in Arkansas, Arizona, Massachusetts, and Oregon, which require states to demonstrate, as a condition for approval, that their rates for primary care, behavioral health, and OB/GYN services are at least 80% of Medicare rates or that rate gaps have narrowed for any services below this threshold.

Medicaid managed care payment rates have largely been unknown due to limited public reporting requirements. The proposed rule would require publication of managed care payment rates, signaling a significant shift in managed care oversight policy. Public reporting would increase transparency of payments made through managed care entities to promote evaluation of adequacy of rates to support robust provider networks. Newly proposed transparency requirements for payments made through managed care entities, and rate comparisons across populations and payers, will more readily allow identification of gaps and disparities for more prudent targeting of resources.

While transparency may aid in identification of gaps and needed resources, as states move toward value-based purchasing and capitated models for primary care, comparison across payers becomes challenging. The shift to align payers and move away from standard fee-for-service delivery systems may result in misleading comparisons based on CPT-code based payment analysis as described in the proposed rules. Additionally, transparency and standardization could result in pressure to move away from local negotiations for payment rates.

Single web page for accessibility

Under the proposed rules, states would be required to develop a single web page for publication of all required reporting, including the new wait time limits, results of secret-shopper surveys, and rate transparency reports. Web pages must be live approximately two years after the effective date of the final rule.

The administration aims to prioritize accessibility through the publication and promotion of accurate and timely data, including provider directory data, payment rates, and quality findings. Consistent publication standards would allow researchers and the public to use the information to compare accessibility outcomes, payment rates, and planned initiatives across state borders. These standards may help identify additional areas in need of resource investment through benchmarking, as well as new opportunities to improve accessibility.

Other policies in the proposed rules

State-directed payments

The administration has proposed new policies related to state-directed payments, a payment mechanism that has been increasingly used in managed care states to increase provider rates. The proposed policies aim to increase transparency and standardize monitoring and accountability requirements for these payments. Additionally, the rules would remove administrative barriers for certain payment proposals used to implement value-based arrangements. Rates would be capped at average commercial rates, and evaluations must be conducted every three years to demonstrate value. Per MACPAC, 29 states currently use directed payments to support physician reimbursement, but it is unclear how many of these states include payments for primary care. Transparency requirements proposed in this rule may provide more clarity on this question.

“In lieu of” services

Consistent with the recent Section 1115 demonstration approval in California, the administration further clarifies how states may use alternative services or service settings, termed “in lieu of” services (ILOS), to promote investments in certain health-related social needs. Primary care providers are often the first entry point for individuals with social needs. Yet, the lack of resources available to address these needs contributes to burnout among primary care clinicians.¹⁴ Emphasizing new approaches to address health-related social needs through ILOS may help primary care providers access additional resources to meet the needs of their patients.

Quality rating system for managed care

In addition to establishing a single web page for required reporting, CMS has proposed establishing a “one-stop shop” for Medicaid members to compare managed care options. Members would be able to compare provider networks (including primary care) according to performance on a variety of quality indicators. Additional transparency across managed care entities may provide members with more informed choice and the ability to select managed care entities that have a greater emphasis on outcomes related to primary care.

Discussion

The new Medicaid proposed rules highlight the importance of primary care through an emphasis on primary care wait times, network accountability, and transparency. However, the proposed policies may be insufficient to address underlying workforce constraints, and must be implemented with an eye to avoiding additional administrative burden on primary care providers. As a whole, the proposals send an important signal that primary care is of particular importance to the administration.

Setting national standards for wait times can be a meaningful driver of change, but current data suggest that 15-day targets may be challenging to meet, even over a three-year period. Similarly, reimbursement rate transparency can be a powerful tool to identify and provide pressure to correct underinvestment in primary care in Medicaid. Specifically, managed care entities have not historically been required to meet the same transparency standards as fee-for-service Medicaid. These proposed rules not only set numerous transparency requirements on managed care entities, but also hold the entities accountable for meeting these standards.

While transparency can set benchmarks and provide pressure, rate transparency alone may be insufficient to address provider network gaps. Administrative burden is a significant cause of low provider participation rates in the Medicaid program, especially in managed care states where providers may be required to contract with multiple entities to serve their Medicaid populations. This rule indirectly incentivizes states and managed care entities to reduce these burdens through accountability measures for wait times and the secret-shopper survey. However, workforce shortages may be more challenging for Medicaid to address. For the rules to be as effective as possible, standards should be feasible, and the parties that face incentives to improve their performance should also be the parties with levers to achieve performance improvement.

In general, the rules focus on supporting primary care and ensuring equity in access for Medicaid beneficiaries compared with populations that have other insurance types. The access standards in these rules — including wait time limits for routine primary care — may be helpful and worthwhile targets, but they are significant changes and may not be realistic based on current workforce shortages. The rules also emphasize rate sufficiency and transparency. While reimbursement rates are likely a critical tool to increase access, rates tend to be necessary but not sufficient to meet network goals. Transparency does, however, provide useful benchmarks and more readily allows for identification of disparities and resource needs.

Primary care providers and other interested parties aiming to influence the target wait times and definitions of primary care or provide additional feedback should do so before this opportunity ends on July 3, 2023.

Notes

1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/
2. Park B, Gold SB, Bazemore A, Liaw W. How evolving United States payment models influence primary care and its impact on the quadruple aim. J Am Board Fam Med. 2018;31(4):588-604. https://www.jabfm.org/content/31/4/588
3. Jabbarpour Y, Petterson S, Jetty A, Byun H. The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care. Milbank Memorial Fund and Physicians Foundation. February 22, 2023. https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/
4. Hinton E, Raphael J. 10 Things to Know About Medicaid Managed Care. KFF. March 1, 2023. https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/
5. Prentice JC, Pizer SD. Delayed access to health care and mortality. Health Serv Res. 2007;42(2):644-662. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955366/
6. Gotlieb EG, Rhodes KV, Candon MK. Disparities in primary care wait times in Medicaid versus commercial insurance. J Am Board Fam Med. 2021;34(3):571-578. https://www.jabfm.org/content/34/3/571
7. Center for Consumer Information and Insurance Oversight, Centers for Medicare & Medicaid Services. 2023 Final Letter to Issuers in the Federally-Facilitated Exchanges. April 28, 2022. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-2023-Letter-to-Issuers.pdf
8. Centers for Medicare & Medicaid Services. HHS Notice of Benefit and Payment Parameters for the 2024 Final Rule. April 17, 2023. https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule
9. Assistant Secretary for Planning and Evaluation, Office of Health Policy. National Survey Trends in Telehealth Use in 2021: Disparities in Utilization and Audio vs. Video Services. Issue Brief HP-2022-04. February 1, 2022. https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf
10. MACPAC. An Update on the Medicaid Primary Care Payment Increase. March 2015. https://www.macpac.gov/wp-content/uploads/2015/03/An-Update-on-the-Medicaid-Primary-Care-Payment-Increase.pdf
11. Neprash HT, Zink A, Gray J, Hempstead K. Physicians’ participation in Medicaid increased only slightly following expansion. Health Aff (Millwood). 2018;37(7):1087-1091. https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.1085
12. Centers for Medicare & Medicaid Services, Department of Health and Human Services. Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality. 88 Federal Register 28092-28252. May 3, 2023. https://www.federalregister.gov/documents/2023/05/03/2023-08961/medicaid-program-medicaid-and-childrens-health-insurance-program-chip-managed-care-access-finance
13. Zuckerman S, Skopec L, Aarons J. Medicaid physician fees remained substantially below fees paid by Medicare in 2019. Health Aff (Millwood). 2021;40(2):343-348. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00611
14. Kung A, Cheung T, Knox M, et al. Capacity to address social needs affects primary care clinician burnout. Ann Fam Med. 2019;17(6):487-494. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6846269/