The three rules build on the Biden administration’s goals to improve the quality of nursing home care and support older adults, people with disabilities, and care workers.
The Centers for Medicare & Medicaid (CMS), on Monday released three final rules that establish, for the first time, national minimum staffing requirements for nursing homes and national standards that will allow people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) to better access care when needed. It also improves home and community-based services.
“We’ve implemented significant changes across CMS programs to ensure eligible people can benefit from the critical lifeline afforded by health care coverage. Now, CMS has set its sights on an equally ambitious goal: making sure that coverage connects people to consistently high-quality care, regardless of where they live or receive care,” said CMS Administrator Chiquita Brooks-LaSure in the announcement. “That goal is ambitious, attainable, and rooted in the Biden-Harris Administration’s priority to ensure millions of people have access to affordable, quality health coverage and can stay healthy and thrive.”
The final rules:
ESTABLISH MINIMUM STAFFING STANDARDS FOR NURSING HOMES
The staffing requirements aim to improve care that residents receive and support workers by ensuring they have sufficient staff. More than 1.2 million residents receive care in Medicare and Medicaid certified nursing homes each day. CMS said adequate staffing is essential to providing an environment where residents receive safe, high-quality care while being treated with dignity. The agency received and considered more than 46,000 public comments on this rule and many of these comments highlighted how–without sufficient staff–residents do not receive necessary care including baths or trips to the bathroom, and experience preventable safety events, such as pressure ulcers and falls.
The final rule, which is scheduled to be published in the Federal Register on May 10, requires nursing homes participating in Medicare and Medicaid to:
- Provide residents with a minimum total of 3.48 hours of nursing care per day, which includes at least 0.55 hours of care from a registered nurse per resident per day and 2.45 hours of care from a nurse aide per resident per day.
- Have a registered nurse on site 24 hours per day, seven days per week to help mitigate preventable safety events and deliver critical care to residents at any time.
- Conduct a stronger annual facility assessment than is currently required to improve the planning and identification of the resources and supports that are needed to care for residents based on their acuity during both day-to-day operations and emergencies. This process will need to include participation from direct care workers and others.
- Develop a staffing plan to maximize recruitment and retention.
CMS will also require states to collect and report on the percent of Medicaid payments that are spent on compensation for direct care workers and support staff delivering care in nursing facilities and intermediate care facilities for individuals with intellectual disabilities. To increase transparency and accountability, CMS will publicly report the data reported by states, and states will also be required to report this data for each facility on a state-operated website.
To bolster the health care workforce, CMS said it is developing a $75 million national nursing home staffing campaign, including financial incentives for nurses to work in nursing homes.
For more on the staffing standards, see the fact sheet.
ENSURE ACCESS TO MEDICAID SERVICES
The “Access Rule,” which is scheduled to be published in the Federal Register on May 10, creates national standards that will allow people enrolled in Medicaid and CHIP to better access care when they need it. CMS said it also strengthens home and community-based services, which millions of older adults and people with disabilities rely upon to live in the community.
The agency said the rule will set minimum threshold standards for payments to the direct care workforce, create meaningful engagement with Medicaid consumers, and advance provider rate transparency.
In a fact sheet, CMS said it has actively sought to improve access to care and services for the people enrolled in the Medicaid program but has been limited by outdated regulations that need to be more comprehensive and consistent across all delivery systems and coverage authorities. The Access rule addresses critical dimensions of access across both Medicaid fee-for-service (FFS) and managed care delivery systems, including for home and community-based services. These improvements seek to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs with the goal of improving holistic access to care.
IMPROVE ACCESS TO CARE, ACCOUNTABILITY, AND TRANSPARENCY IN MANAGED CARE
The “Managed Care Rule,” which will be published in the Federal Register on May 10, will improve access to care for more than 70 percent of Medicaid and CHIP beneficiaries who are enrolled in a managed care plan. It will require a limit on how long enrollees must wait for an appointment and allow people to compare plan performance based on quality and access to providers.
In a fact sheet, CMS said the final rule strengthens standards for timely access to care and states’ monitoring and enforcement efforts; enhances quality and fiscal and program integrity standards for state directed payments; specifies the scope of in lieu of services and settings to better address health-related social needs; further specifies medical loss ratio requirements; and establishes a quality rating system for Medicaid and CHIP managed care plans.
STRONGER REQUIREMENTS WILL IMPROVE ACCOUNTABILITY, TRANSPARENCY, AND ACCESS TO COVERAGE
CMS said in the announcement that together, the Access and Managed Care rules create the strongest requirements yet for improving accountability, transparency, and access to health coverage in the nation’s largest health care program. They establish tangible, consistent standards for millions of children, families, adults, and people with disabilities regardless of the state in which they live.
The standards require states to:
Comply with national appointment wait time standards: States will enforce these wait time standards by conducting “secret shopper” surveys, which can help verify compliance with appointment wait time rules and correct provider directory inaccuracies.
Disclose provider payment rates: For the first time, states must reveal provider payment rates publicly.
Create a beneficiary advisory committee: Every state must establish a committee, which will allow for direct feedback to state Medicaid and CHIP programs on benefits and service delivery from the people who access it daily.
The Access Rule strengthens home and community-based services (HCBS) by requiring that at least 80 percent of Medicaid payments directly compensate direct care workers rather than cover “administrative overhead.” The rule also requires states to report how they establish and maintain HCBS wait lists, assess wait times, and report on quality measures. CMS said this policy allows states to consider small providers and providers in rural areas, promote training and quality, and ensure smooth implementation with additional data collection prior to full phase-in.
It also protects the health and safety of people who receive HCBS by improving states’ incident management systems and requires states to have a grievance process for all HCBS participants.
The Managed Care rule defines the scope of “in lieu of services and settings” services in managed care to better address enrollees’ health-related social needs (e.g., support for housing- and nutrition-related services). It also establishes a quality rating system for Medicaid and CHIP managed care plans–a “one-stop-shop” where beneficiaries can learn about eligibility for plans and compare them based on quality and other factors.