Resource Corner Blog

Navigating Through Medicaid Regulations, Updates and Stats


Traversing through Medicaid regulations and sub-regulations is not only tedious but often nebulous as Federal statutes aren’t the same in every state. Often those state statutes need interpreted because not every statute has regulations and not every regulation is spelled out in state statutes. For instance, according to the December 2019 meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC), new Medicaid regulations may be looked upon by some as “new” regulations when in fact they were simply codified.

The U.S. Code of Federal Regulations for Public Health, which includes Medicaid, lists updates to regulation chapters one, four and five. The first page looks simple enough, but click on a link and you get several pages of more links before you get to the needed information. Who has time for that?

We get it. There’s enough “dotting your i’s and crossing your t’s” tied with Medicaid billing, patient management and reimbursement without wading through pages and pages of regulatory changes.

Here’s your edge. Federal regulatory updates and related outlooks include:

  • Regulations defining permissible health care related taxes
  • Medicaid expansion developments
  • Section 1115 waiver activity by state
  • Enrollment and spending trends
  • Payment and delivery system reforms
  • Implications of the 2020 elections

Some proposed regulations are still taking comments before being rescinded, modified or finalized.

Regulations Still in the Comment Stage

Last November, CMS proposed The Medicaid Fiscal Accountability Rule (CMS-2393-P). This proposed regulation would increase transparency and oversight regarding state Medicaid payments.

  • Improved supplemental payment reporting
  • New regulatory definitions of base and supplementary payments
  • Reduce questionable financing mechanisms

Comments regarding the Medicaid Fiscal Accountability Rule closed on February 1, 2020 before going to the final phase of approval. This is one of those regulations that is important to watch as it affects how Medicaid monies are allocated on all levels. In one word, oversight.

Other 2020 legislative proposals to watch, according to the U.S. Department of Health and Human Services:

  • Increasing state Medicaid flexibility thereby alleviating Federal burden
  • Focusing eligibility on those with the most need
  • Reducing spending waste by new state financing options
  • Lowering prescription drug costs

These proposals aren’t just geared to financial outcome for each state’s Medicaid program, but to provide value and focus to those already on the program and those now eligible.

Medicaid Updates: What to Keep Your Eye on in 2020

The projected Medicaid National Health Expenditure through 2027 is 5.5 percent. Current estimates place insured individuals at 90 percent of the population and that will remain stable through 2027, but there’s still many people falling through the cracks as that remaining 10 percent is uninsured or under-insured.

Medicaid is 32 percent of the U.S. $1.3 billion budget for fiscal year 2020. This particular budget proposes to provide state flexibility as well as financially reconstructing the program’s financing and waste, putting the focus back on the elderly, the disabled, children, expectant mothers and those fight against the opioid crisis now that the SUPPORT Act is law. 

Medicaid expansion would cover nearly 4.5 million Americans and that is a major issue playing out this year as states decide about how to handle taxation and the Section 1115 waivers.

Enrollment and spending trends are ticking upward as are the needs of reforming both Medicaid payment and delivery.

Finally, how will the implications of the 2020 elections affect future Medicaid policy and regulations? Brian Marcotte, president and CEO of the National Business Group on Health, says that there won’t be much legislative healthcare action this year as it is an election year, so the focus will be on regulation and policy.

Federal Updates

According to the Federal Register’s Quarterly Provider Update for the first quarter of 2020, the Coordinating Care From Out-of-State Providers for Medicaid-Eligible Children With Medically Complex Conditions regulation (CMS 2324-NC) is updated.

  • The Federal Medicaid rate match under the ACA is 90 percent beginning this year, down from 93 percent in 2019.
  • Under the Healthy Kids Act (P.L. 115-120), beginning on October 1, 2019, and ending on September 30, 2020, the E-FMAP is increased by 11.5 percentage points, not to exceed 100 percent, for all states.
  • Projected National Health Expenditures by Payer for 2020 676 16.8 percent This trend looks to be pretty steady with little growth by 2027 for Medicaid and CHIP.
  • Section 1115 allows each state to test new Medicaid approaches

State Medicaid regulations are dependent on Federal regulations as states report their Medicaid costs each quarter so that the federal cost match for each particular state is met.

In Summary

The bottom line is that the hodgepodge of government-speak doesn’t speak for itself. Nothing is simple about staying on top of Medicaid proposed and approved regulations. TenEleven is one EHR with endless possibilities. With our on-demand, secure access to critical company data, we keep you competitive, compliant and up-to-date. Try the demo today.

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