Medicaid Access Rule is Here: What You Need to Know

The Ensuring Access to Medicaid Services rule has been in the works for a while, but it was finalized this past spring and implemented in July. Here are five questions and answers about this rule for your clients, staff, and organization, with expert insights from Esme Grewal, Vice President of Government Relations at BrightSpring Health Services.

1. What is this rule?

The Ensuring Access to Medicaid Services final rule is designed to advance access to care and quality of care, as well as improve health outcomes for Medicaid beneficiaries across fee-for-service and managed care delivery systems, including home and community-based services (HCBS) provided through those delivery systems. According to the Centers for Medicare & Medicaid Services (CMS), “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.”

2. What are some of the requirements in the new rule?

There are several elements of the rule that will be important to follow over the coming years. For instance, states are required to establish a grievance system for HCBS delivered through fee-for-services. In three years, they are required to “report on their readiness to collect data regarding the percentage of Medicaid payments for homemaker, home health aide, personal care and habilitation services spent on compensation to the direct care workers furnishing these services. In four years, states must report on the percentage of Medicaid payments for these services spent on compensation to direct care workers. This is just an example of some of the major new changes Medicaid has made through this rulemaking.

3. What is the 80/20 requirement and what does that mean to I/DD providers?

The Ensuring Access to Medicaid Services rule includes a requirement that 80% of Medicaid payments for HCBS be designated for direct care worker wages. The provision won’t go into effect until 2030, but there are several steps states will need to take in conjunction with providers as it goes into effect. Grewal said, “This mandate ultimately does not impact most of the services provided to the I/DD population, particularly because it applies more specifically to Medicaid personal care, home health, and homemaker services and is not being applied currently to habilitation services, where many I/DD services would fall.” However, there are some components of the 80/20 wage mandate that do apply to I/ DD. For instance, she said, “There are reporting requirements that are essential to be aware of and, starting in July 2026, all states must begin publishing service payment rates (including habilitation) on a website that’s accessible to the general public. This is required to be updated every two years by the states.”

July 2026 is also the date states must publish the average hourly rate paid to direct care workers for personal care, home health, homemaker and habilitation services under Medicaid, which, Grewal said, “is the first time that we’ve seen anything like that.” The disclosure must also identify the number of Medicaid-paid claims and the number of enrolled Medicaid beneficiaries who were served that received one of those services within a calendar year. Grewal noted that CMS recently held its first public forum regarding the rule, and the agency will continue to issue additional information and guidance for states on how to comply with these rules.

4. What impact might the rule have on I/DD?

There are some benefits as well as potential challenges related to the final rule. On the plus side, it is designed to provide more transparency, which is very helpful for beneficiaries and family members. States should begin publishing in a very clear way all fee-for-service rates for these services as well as the average hourly rate they paid for care workers. “This is data that is powerful for any government program and something that’s been lacking in the Medicaid program,” Grewal explained. “This transparency will enable policymakers and others to compare states and see how and where programs are undersourced. This will hopefully result in additional funds to help states assist providers in their efforts to provide excellent services.”

However, Grewal cautioned that, if not provided in the correct context, the data won’t tell the whole story. For instance, she suggested, if a state posts the average hourly rate paid to direct care workers in the state, it could be insinuated providers are choosing to pay lower wages; so this data needs to be accompanied by information about how reimbursement rates work and the limited resources providers have. Grewal said, “We want to make sure that families are receiving that context with this information so they understand the challenges that providers of these services are facing in states across the country.”

5. What should I be doing to comply with this rule?

“I would highly encourage individuals to go directly to CMS and use their resources. The agency has been getting better and better about putting out materials that are easy to read and digest,” said Grewal, adding, “In this case, they’ve been putting out more materials to help everyone better understand what this rule is about and what requirements are coming down the pike.”

She noted that she expects to see states start to develop additional resources in the coming months, and there are still some issues that will need clarification. For instance, she said, “Several states as well as providers have asked for additional guidance on how to classify services and follow the intent of the rule because state programs are all very different. You might see the same I/DD services provided under different names in different states, for instance, and we need to understand how all the various requirements may touch I/DD programs. We expect additional clarity on how they’re qualifying all of these different services.”

In the meantime, she urged people to get a leg up by reading and using the information and resources provided by CMS and also referencing materials put out by the leading trade association for I/DD providers, the American Network of Community Options and Resources (ANCOR). CMS also just introduced a new training series on the rule, and she encouraged registration for this free online training.