Defending and strengthening Medicaid and the Youngsters’s Well being Insurance coverage Program (CHIP) is a vital precedence for the Biden-Harris Administration. Medicaid and CHIP present important well being care protection for over 80 million people and households, together with low-income adults, over 40 p.c of all youngsters in the USA, older adults, and folks with disabilities. Medicaid additionally covers 42 p.c of all births within the nation. Two-thirds of those births are to Black, Hispanic, or American Indian/Alaskan Native folks.
Along with offering protection of bodily well being care, Medicaid is the most important payer for long run companies and helps, together with residence and community-based companies (HCBS), which permit people with a spread of disabilities and must thrive and reside independently at residence or of their communities. Medicaid can be the largest payer for public psychological well being companies, together with for people with critical psychological sicknesses, substance use problems, or co-occurring problems.
Over the previous a number of months, our Facilities for Medicare & Medicaid Companies (CMS) groups, together with the Middle for Medicaid and CHIP Companies (CMCS), have met with a wide selection of stakeholders to hearken to their views about what works effectively in Medicaid, in addition to about what to enhance in this system. We now have heard from advocates, well being care and different security internet suppliers, and well being plans. We now have had working periods and particular person discussions with our companions within the states and territories. We now have heard concepts from our devoted employees. And most significantly, we’ve heard from people and households about their experiences with Medicaid and CHIP.
It’s clear from these discussions that Medicaid works. Masking almost 1 in 5 Individuals, Medicaid is the one largest well being protection program within the U.S., offering sturdy advantages with little to no out of pocket prices. Medicaid protection in and of itself is vital to well being fairness. It’s estimated that the Inexpensive Care Act’s (ACA’s) growth of Medicaid alone saved the lives of over 19,200 adults age 55 to 64 in simply the primary 4 years. In the course of the COVID-19 public well being emergency, Medicaid has been a lifeline for thousands and thousands who’ve been in a position to maintain well being protection and acquire wanted well being companies.
The Medicaid program can be a beacon of innovation and empowerment of native, on-the-ground voices to form how this system runs, state by state. It is among the most original and profitable federal-state partnerships, collectively funded by federal and state/territory governments and operated by 56 states and territories inside federal pointers. It additionally operates in shut collaboration with frontline suppliers and different companions, be they massive well being programs, particular person clinicians, residence well being staff, well being plans (who serve 70 p.c or extra of Medicaid members by way of complete managed care), advocates, or native organizations.
On the identical time, we’ve an amazing alternative to guard, strengthen, and develop Medicaid in numerous areas. Eleven years after the ACA, 4 million adults throughout 12 states nonetheless wouldn’t have entry to Medicaid. Thousands and thousands extra are presently eligible for Medicaid however battle to enroll and keep lined. Those that do preserve Medicaid protection might expertise challenges accessing suppliers and medical companies higher than these confronted by enrollees in Medicare or non-public insurance coverage, regardless of the statutory entry protections afforded to folks enrolled in Medicaid.
Lastly, our most urgent rapid precedence continues to be supporting states, suppliers, and different organizations on the continued COVID-19 pandemic response, together with encouraging uptake of COVID-19 vaccines for the Medicaid inhabitants throughout the age continuum.
Addressing these points and constructing a greater Medicaid program requires a transparent imaginative and prescient for the highway forward and shut working relationships throughout private and non-private companions. Right here, we start to put out a brand new imaginative and prescient for Medicaid and what we plan to perform beneath the Biden-Harris Administration.
Table of Contents
Strategic Priorities
Our proactive coverage agenda for CMCS focuses on three key areas: Protection and Entry, Fairness, and Innovation and Entire-person Care. Underneath every space, we’re dedicated to pursuing this coverage agenda for Medicaid and CHIP in actionable, measurable methods. These three key areas additionally align with the bigger imaginative and prescient for CMS as an entire and the company’s six strategic pillars.
Working alongside states is crucial to executing this agenda, as is recognizing the operational, fiscal, and different realities on the state degree. We’re dedicated to offering the energetic communication, help, and instruments that states should be full companions in working and bettering the Medicaid and CHIP packages to advance these strategic focus areas. This contains actionable, well timed technical help and steering navigating cross-cutting insurance policies, and funding help the place acceptable. What’s extra, this partnership is just not restricted to states. CMCS may also pursue each avenue to have interaction with suppliers and different stakeholders, particularly folks and their households who’re lined by Medicaid and CHIP.
For all three focus areas, accumulating, understanding, and utilizing information is crucial, as is making this data clear to stakeholders. This contains prioritizing assortment of knowledge on race, ethnicity, language, incapacity standing and different components, and utilizing these information to establish disparities in entry, well being outcomes and high quality of care. We are able to additionally construct on present efforts to offer new and extra clear information on entry, high quality and expertise of care throughout each fee-for-service and managed care supply programs. And finally, we have to make it simpler for eligible folks to enroll in Medicaid and CHIP and maintain their protection. That’s why partnering with states to enhance information assortment and modernize eligibility and different programs is vital to making sure that each one people can entry and preserve their protection extra simply, whereas preserving program integrity. Which means ensuring we’re paying the precise supplier the correct amount for companies and folks lined beneath our packages—defending folks beneath care whereas additionally minimizing pointless burden on suppliers.
Focus Space 1: Protection And Entry
We’ll use each lever obtainable to guard and develop protection for all eligible folks and to undertake a broad view of entry to care that features supplier availability, high quality, culturally and linguistically competent care, and reductions in gaps in protection. This focus space can be guided by the CMS strategic pillar of constructing on the ACA, and increasing entry to high quality, inexpensive well being protection and care.
Defend Entry To Protection After The COVID-19 Steady Protection Requirement Ends
We’re extremely targeted on ensuring eligible folks preserve protection after the COVID-19 public well being emergency ends. Between the onset of the general public well being emergency and Might 2021, Medicaid and CHIP enrollment grew 15 p.c, from 71 million to greater than 82 million folks, the most important enhance over 18 months in this system’s historical past. That is partly on account of Congressional motion that ensured states would maintain folks with Medicaid enrolled at some stage in the general public well being emergency. As soon as this steady protection requirement ends, states can have 12 months to conduct eligibility renewals for everybody enrolled in Medicaid and CHIP; states should both renew enrollees’ Medicaid/CHIP protection or join them to low- or no-cost Market protection.
Maintaining eligible folks lined is a prime precedence for the Biden-Harris Administration. To help states with this effort, CMCS is working in shut partnership with the Middle for Shopper Info and Insurance coverage Oversight to launch a multi-pronged, cross-government collaboration. The aim is to assist states of their efforts to plan for the massive variety of eligibility redeterminations that will probably be required, reduce pointless losses of protection, and make sure that people who find themselves not eligible for Medicaid or CHIP can efficiently enroll in Market protection. Whatever the program for which persons are eligible, we need to make enrollment in inexpensive protection as simple as doable. We’re:
- Creating steering, planning instruments and different sources to help states of their planning efforts, together with steering launched in August offering states with 12 months (as an alternative of simply 6 months) to conduct redeterminations.
- Collaborating carefully with state Medicaid and CHIP businesses to plan and put together by way of common workgroups, all-state calls, and intensive individualized technical help.
- Partaking stakeholders (together with native community-based organizations, enrollment assisters, well being facilities and others) on an ongoing foundation in order that people enrolled in Medicaid and CHIP have help to finish the renewal course of, and dealing throughout CMS to enhance transitions for folks not eligible for Medicaid or CHIP to backed Market protection.
Well being plans, which already assist to ship care to 70 p.c of the Medicaid and CHIP inhabitants, are additionally vital companions in our efforts to maximise entry to protection after the general public well being emergency ends. We’ll work side-by-side with Medicaid managed care plans and well being plans on the Market to take each doable motion to assist folks and their households to keep up well being care protection.
Shut The Protection Hole
There are almost 4 million folks with incomes under one hundred pc of the federal poverty degree (FPL) who reside in a state that has not expanded Medicaid. Thousands and thousands of individuals fall into the “protection hole”—they’re Individuals who qualify for neither Medicaid nor backed protection by way of the person Market as a result of they’ve revenue above their state’s Medicaid eligibility restrict however under the one hundred pc FPL minimal for backed Market protection. We all know that people who find themselves uninsured usually tend to delay care, have medical debt, and expertise larger charges of mortality. We additionally know they’re disproportionately folks of colour. Consequently, closing the protection hole is among the most essential actions we are able to take for well being fairness.We’re excited to help states which have not too long ago expanded Medicaid. Oklahoma expanded Medicaid on July 1, and as of November 9 the state has enrolled over 210,000 newly-eligible people. In October, Missouri kicked off its growth effort and estimates that an extra 275,000 persons are eligible to enroll. We stand able to associate with any state that has not already executed so to develop Medicaid and supply vital well being care protection for this inhabitants.
Improve And Strengthen Eligibility And Enrollment
Too usually, people who find themselves eligible for Medicaid or CHIP are deterred by pointless administrative crimson tape after they attempt to enroll or preserve their protection. In 2018, roughly 17 p.c of people that misplaced Medicaid or CHIP protection (shut to three million folks) re-enrolled inside three months.
We should make it simpler for eligible folks to enroll in and preserve Medicaid and CHIP protection. Our first aim is to enhance eligibility and enrollment information assortment and associated programs in order that states are ready to make sure all eligible folks can entry and preserve their Medicaid protection. The interval after the continual protection requirement ends is a chance to help states in creating long-term options to scale back administrative churn (the place people lose their Medicaid protection for administrative causes, versus being ineligible); examples embrace bettering the usage of administrative information for renewals (often called the ex parte renewal course of) and eliminating onerous documentation necessities. It additionally is a chance for CMS to have interaction well being plans about outreach and renewal efforts on the federal degree, and to encourage states to undertake digital outreach methods nationwide.
In the long term, we should associate with states to maneuver Medicaid off a largely paper-based method to partaking with enrollees. Adopting cellular, electronic mail, and different digital communication approaches will scale back how ceaselessly folks lose protection as a result of they didn’t obtain a vital Medicaid eligibility renewal letter within the mail. Lastly, the ACA simplified eligibility and enrollment insurance policies for non-disabled people beneath age 65; we’ll end what the ACA began by bringing those self same enhancements to our aged and disabled populations.
Defend And Increase Entry To Care
Medicaid is just not solely the most important single well being protection program within the nation but additionally gives dependable entry to care. Nevertheless, we are able to do extra to make sure that folks with Medicaid protection can depend on high-quality care after they want it. To this finish, we’ll discover insurance policies to create a uniform minimal customary for Medicaid and CHIP enrollees throughout the nation. There have been many previous efforts to enhance entry, to various levels of success. Shifting ahead, we purpose to outline a federal “ground” for well being care entry whereas persevering with to help state and native initiatives to enhance. This should be executed thoughtfully and in partnership with states. Our new technique will embrace a broad perspective to incorporate entry to enrollment and suppliers, in addition to linguistically and culturally acceptable look after each our fee-for-service and managed care supply programs, and for many who depend on vital HCBS to help their actions of each day dwelling.
Broaden Entry To HCBS
HCBS provides older adults and folks with disabilities the selection to remain of their properties and communities whereas receiving vital well being, purposeful and social helps, moderately than transferring to an institutional setting. With Medicaid as the first payor of HCBS within the nation, CMCS understands the challenges confronted by enrollees in search of HCBS, with super variation in entry and high quality throughout states and a nationally understaffed and underpaid workforce.
We’re presently supporting states as they make investments $12.7 billion from the American Rescue Plan (P.L. 117-2) to enhance native HCBS companies and start funding in wanted structural modifications (go to CMCS’s web site to view states’ HCBS spending plans). We’ll proceed to work with Congress and different federal companions to advance HCBS enchancment and reform and to make continued investments on this space.
Moreover, in 2014, CMS printed the HCBS settings rule, which gives further protections to HCBS program individuals and ensures they’ve full entry to the advantages of neighborhood dwelling. The Biden-Harris Administration is dedicated to the settings rule and to working with advocates and beneficiaries to implement it.
Focus Space 2: Fairness
We’re devoted to measuring disparities and making focused, evidence-based investments in bettering well being fairness. Whereas Medicaid is a driver of well being fairness, the information inform us that vital racial disparities inside Medicaid persist. Advancing well being fairness is a key precedence for the Biden-Harris Administration and in addition a CMS strategic pillar. Well being fairness will probably be on the forefront of all coverage choices for Medicaid, not an afterthought.
Make Daring Investments In Fairness
On January 20, the Biden-Harris Administration introduced a “whole-of-government fairness agenda.” As the first supply of well being care protection for over one in three folks of colour, Medicaid and CHIP have well being fairness on the coronary heart of their missions. Nevertheless, as famous above, vital disparities stay for folks with Medicaid and CHIP. Advancing well being fairness will depend on our capacity to:
- Measure disparities in well being care entry, high quality, expertise and outcomes,
- Make evidence-based investments in equity-focused interventions, and
- Shut or scale back these gaps in well being fairness, together with by making funding and new federal investments linked to progress on decreasing well being disparities.
At first, we’d like correct information. We are able to’t repair what we don’t know, and we are able to’t measure progress with no baseline. Reporting on race, ethnicity, language, incapacity standing, and sexual orientation and gender id are inconsistent at finest—as are clear, constant and comparable stratification of vital high quality and consequence metrics throughout this system. CMS will work with states to enhance measurement of well being disparities throughout a core set of stratified metrics.
As well as, we acknowledge the perfect concepts and approaches for find out how to sort out well being disparities will come from voices and stakeholders on the bottom, not from CMS. We’re dedicated to partnering with states in order that well being fairness—and accountability for closing recognized disparities in entry, high quality and outcomes—is on the forefront of each coverage determination on the state degree, and on the prime of the precedence listing for each well being care supplier and well being plan. Which means working with states on evidenced-based interventions focused at decreasing well being disparities that maintain states and suppliers accountable to make sure continued progress on decreasing gaps in well being fairness.
A few of this work is already in progress. For instance, we’re presently encouraging all states to implement the 12-month postpartum protection possibility obtainable beneath the American Rescue Plan. We may also take a whole-person view when investing in acceptable, focused well being fairness interventions, and we’ll contemplate find out how to make investments in key populations with particularly massive disparities in well being outcomes (e.g., for maternal/post-partum well being, people concerned within the justice system, people with housing instability). Extra broadly, we’ll apply this lens of well being fairness to lots of the revolutionary discussions underway with states, together with part 1115 demonstrations and different Medicaid funding approaches.
Focus Space 3: Innovation And Entire-Particular person Care
Lastly, we’ll proceed to encourage innovation in value-based care, supply system reforms and whole-person care in Medicaid. Our method contains partnering with states to make sure the well being care system considers and helps the entire of an individual’s wants: bodily well being, behavioral well being, oral well being, long-term service and helps, and health-related social wants. We should deal with longstanding gaps in areas comparable to behavioral well being, in addition to discover how Medicaid can contribute to addressing health-related social wants (e.g., vitamin and homelessness or housing instability).
Medicaid may also set a brand new aim of transitioning the overwhelming majority of Medicaid beneficiaries into accountable care relationships by 2030. These efforts will probably be executed in shut partnership with the Middle for Medicare and Medicaid Innovation, in alignment with our collective imaginative and prescient for value-based care, in addition to with the Middle for Medicare and the Medicare-Medicaid Coordination Workplace for making care extra accessible for people dually eligible for Medicaid and Medicare. This focus space additionally overlaps with the CMS strategic pillar to drive innovation to sort out our well being system challenges and promote value-based, person-centered care.
Set up Part 1115 Coverage Rules And Standards
Part 1115 of the Social Safety Act authorizes the Secretary to approve experimental, pilot, or demonstration tasks which are more likely to promote the targets of Medicaid and CHIP. In keeping with the priorities of the Biden-Harris Administration, we’re working to develop a transparent set of 1115 demonstration coverage ideas to make sure that federal Medicaid insurance policies help fairness and monetary stewardship constantly throughout states. We imagine that part 1115 demonstrations will help foster:
- Enhanced or expanded protection for Medicaid beneficiaries and uninsured people;
- Improved entry to look after Medicaid beneficiaries and uninsured people;
- Improved high quality and fairness and lowered well being disparities;
- A powerful, sustainable well being security internet;
- Worth-based care supply and fee innovation that improves high quality, fairness, and whole-person care (together with addressing health-related social wants), and
- Elevated entry to HCBS, substance use dysfunction companies, and psychological well being companies.
We’re keen to have interaction with states on this subject, and encourage states to suggest revolutionary part 1115 demonstrations that advance the targets of the Medicaid and/or CHIP packages.
Carry Behavioral Well being Care Up To Parity With Bodily Well being
Medicaid presently accounts for one-third of all spending on behavioral well being. Nonetheless, behavioral well being has seen a perennial underinvestment and is simply too usually siloed from the remainder of the medical system. Preliminary proof suggests a pointy enhance within the variety of adults reporting adversarial psychological well being situations and substance-use problems through the COVID-19 pandemic in comparison with what has been reported in prior years. When community-based care is unavailable, the quickest solution to get behavioral well being care is commonly by way of the emergency division (ED). In the course of the pandemic, some hospitals are experiencing as a lot as a 300 p.c enhance in pediatric ED visits for behavioral well being situations, which solely underscores the necessity to develop acceptable community-based habits well being care.
As our nation, and the individuals who depend on Medicaid and CHIP, come out of the pandemic, entry to behavioral well being care is vital to closing the fairness hole. We’re dedicated to partnering with states lastly to deliver behavioral well being companies (each psychological well being and dependancy remedy) as much as parity with bodily well being companies. That is an ongoing effort. For instance, $15 million in Medicaid funding was not too long ago awarded to states for community-based cellular disaster intervention companies, and we’re working in direction of steering to all states on find out how to implement cellular disaster companies. We’re additionally partnering throughout the Division of Well being and Human Companies to strengthen our behavioral well being security internet. Working in collaboration with states and with our companions at Substance Abuse and Psychological Well being Companies Company (SAMHSA), Facilities for Illness Management and Prevention (CDC), the Administration for Youngsters and Households (ACF), and others, we’re dedicated to making sure that evidenced-based, data-driven behavioral well being coverage and investments are applied throughout our packages.
Future Of Medicaid And CHIP
Greater than 80 million persons are enrolled in Medicaid and CHIP for his or her well being care protection. Whereas these packages have executed immeasurable good for hardworking households throughout our nation, there may be nonetheless a lot extra we are able to do. We now have alternatives throughout all parts of our packages to guard and strengthen service supply to our members. This work calls for our consideration and funding. CMS serves the general public as a trusted associate and steward, devoted to advancing well being fairness, increasing protection, and bettering well being outcomes. Via our concentrate on protection and entry, fairness, and innovation, we’re dedicated to executing on this imaginative and prescient.
We stay up for the thrilling highway forward in direction of stronger, higher Medicaid and CHIP packages.