Update: Temporary Pause of Agency Grant, Loan, and Other Financial Assistance Programs
Medicaid
Updated Schedule: CMS Trainings on HCBS Provisions of the Medicaid Access Rule
The Centers for Medicare & Medicaid Services (CMS) has made updates to the training schedule for Home and Community-Based Services (HCBS) provisions of the Medicaid Access Rule. The new training session dates and tentative topics for each session can be found below. These dates and topics are subject to change.
- May 14, 2025, 3:00 pm ET: Timely Access, Waiting Lists, Person-Centered Planning Reporting Requirements & Minimum Performance Levels, and Website Requirements
- June 11, 2025, 3:00 pm ET: Institutional Rule Provisions*
*Nursing Facility and Intermediate Care Facilities for Individuals with Intellectual Disabilities Rate Transparency provisions finalized in CMS-3442-F: Medicare and Medicaid
You can learn more about the training series and register for upcoming sessions on the HCBS Provisions of the Medicaid Access Rule Training Series registration web page.
RCPA Shares Third Party Liability Member Survey
In an effort to gain a better understanding of providers’ ongoing needs and challenges in addressing third party liability (TPL) claims, RCPA is requesting that our members complete the following TPL Survey. This survey was designed to capture critical barriers so as to develop strategic pathways to ensuring access and equity.
In January 2024, Governor Shapiro announced that commercial insurers would be required to meet their obligations under Pennsylvania law to provide coverage for autism benefits by categorizing autism services as a mental health benefit. With this action, all autism services will be treated as mental health services, leading to greater mental health parity for those with autism spectrum disorders. The goal of the Shapiro Administration’s legislation is to improve much-needed access to services for individuals diagnosed with autism, a challenge that the Commonwealth has faced for decades.
As providers of mental health, autism services, and substance abuse disorders, our members treat a vast array of individuals who are insured by either commercial insurance, Medicaid insurance, or both. For those who have just Medicaid, billing is simple: providers bill the Medicaid payor, and they pay the claim. The same is true for those who have just commercial insurance if the provider is in network with the commercial insurance carrier.
Complications occur when an individual has both commercial insurance and Medicaid. Coordination of Benefits (COB) requires that the commercial insurance is billed first, and then Medicaid pays what is not covered. Services like the delivery of Applied Behavior Analysis (ABA) or Intensive Behavioral Health Services (IBHS) are two good examples of services that can fall into this category.
With this survey, we hope to gather information that will assist RCPA and members in addressing the barriers in insurance coverage for children, families, and individuals in Pennsylvania. We thank you for taking the time to complete the survey so that we can continue to seek solutions to access services in our communities.
If you have any questions, please contact RCPA Policy Associate Emma Sharp.
Health Component of CR: Medicaid Buy-In Bill Included
ADvancing States Shares Report on Trends in Equity for Older Adults Without Family Caregivers and Trends in Medicaid Waivers
Preparing States’ I/DD Systems for Implementation of the Medicaid Access Final Rule
Thursday, December 5, 2024
2:00 pm – 3:00 pm ET
11:00 am – 12:00 pm PT
Register Here
This spring, the Centers for Medicare & Medicaid Services (CMS) finalized the highly anticipated “Ensuring Access to Medicaid Services” rule (or the “Access Rule”) that, among other things, updates program standards and processes for Medicaid home- and community-based services (HCBS), including HCBS for people with intellectual and developmental disabilities (I/DD). Individuals with I/DD rely on Medicaid HCBS to support their independence and ability to live at home in their communities. The changes required by the Access Rule—and how states implement those changes—will have far reaching impact on state I/DD systems and the people they serve.
Join the Policy Information Exchange (PIE) for a discussion with state and provider experts who are thinking through their own approaches to Access Rule implementation. During the webinar, they will dive into the Access Rule’s impact on state I/DD programs, HCBS providers, and community partners, and individuals with I/DD and their families and caregivers. Specifically, they’ll discuss:
- New and updated requirements related to HCBS incident management and grievance systems, payment adequacy and transparency, access and quality reporting and disclosure.
- The implications for state I/DD systems—including challenges—as they plot a path to full implementation of the Access Rule within required timelines.
- Strategies for building effective and collaborative engagement with community partners, people receiving services, providers, case management entities, and direct care workers.
- Immediate steps that state I/DD systems should take now to assess their HCBS programs, processes, and IT infrastructure needs.
If you can’t make the live session on December 5, visit here to register for the free webinar now, and you’ll receive a link to view the program on demand.
Facilitators
- Alixandra Gould, Director, Manatt Health Strategies
- Anna Lansky, Senior Advisor, Manatt Health Strategies
Panelists
- Pete Cervinka, Acting Director and Chief Deputy Director, California Department of Developmental Services (DDS)
- Conor O’Dea, HCBS Policy Advisor, The Vermont Agency of Human Services
- Lydia Dawson, Vice President of Government Relations, ANCOR
OMHSAS Provides Updated Telehealth Guidance on “Four Walls”
On Friday, November 1, the Centers for Medicare & Medicaid Services (CMS) released an anticipated Final Rule titled “CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC),” which includes three new exceptions for the federal “four walls” rule. At present, the “four walls” rule prohibits Medicaid payment for clinic services when both the practitioner and individual receiving service are outside of the “four walls” of the clinic unless the services are being provided to unhoused individuals (such as through street medicine). The new exception for Indian Health Services and Tribal Facilities is required nationally. The exceptions for Behavioral Health Clinics and Rural clinics are optional. States who determine that their Behavioral Health Clinic and/or Rural Health Clinic populations served meet the four criteria established by CMS (see page 1323 of the final rule) must submit a Medicaid State Plan Amendment (SPA) and receive approval from CMS for these exceptions to be in place for their state.
The Office of Mental Health and Substance Abuse Services (OMHSAS) had been working toward a short-term state level solution to the four walls issue for both Outpatient Psychiatric Clinics and Drug and Alcohol Clinics. However, now that a long-term federal option has been made available, the team in OMHSAS will be pivoting to pursue this newly available federal exception for Behavioral Health Clinics. While OMHSAS is still in the process of developing a timeline for the new State Plan Amendment, their team will be working on this as a top priority, with the goal of having a SPA in place in early 2025.
It has been confirmed that OMHSAS will not be shifting their current enforcement policy around the four walls while they work through getting this waiver in place. RCPA will continue its collaboration with OMHSAS on the process as this move forwards. If you have any questions, please contact RCPA COO and Mental Health Policy Director Jim Sharp.
For additional information, please see the following:
- Full Final Rule
- CMS FAQ on the Final Rule
- Email for Questions Regarding OMHSAS Telehealth Policy
National Council Releases Five-Year Strategic Plan
ANCOR Shares Fact Sheet on Medicaid Enrollment and Eligibility Renewals for Individuals With I/DD
Legislation for Telehealth Flexibilities Introduced
Legislation for Telehealth Flexibilities Introduced:
HB 2560 To Address Psychiatry Time Requirements and “4 Walls”
RCPA is pleased to announce that yesterday, September 10, State Representative Tina Pickett (R-District 10) introduced House Bill 2560, which was referred to the House Health and Human Services Committee. The legislation is focused on addressing two critical telehealth considerations, including an update of the outpatient psychiatric outpatient time requirements and the Federal Medicaid payment standard known as the “4 Walls.” The latter would abrogate DHS 55 Pa. Code § 1153.52 Payment Conditions for Various Services and 55 Pa. Code § 5200.52 Treatment Planning. By addressing the “4 Walls” requirement, telehealth services by a practitioner can be delivered outside the physical outpatient clinics and will be categorized under licensed mobile mental health services.
On a parallel track, the Center for Medicare and Medicaid Services (CMS) has proposed a final rule exception that would eliminate the “4 Walls” requirements among several other actions. On September 9, 2024, RCPA submitted comments regarding the Medicaid Clinic Services 4 Walls Exceptions on behalf of our membership in support of the proposed exception to eliminate this Medicaid standard.
Additionally, the bill requires that providers who want to deliver telehealth services 100% must maintain a written agreement with a geographically proximate outpatient psychiatric clinic that operates a physical facility and provides in-person services at the outpatient psychiatric clinic within 40 miles or 60 minutes travel from the residence of the individual receiving services AND that the written agreement must include a provision that a referred individual must be seen by the geographically proximate outpatient psychiatric clinic within 10 days of the referral.
Finally, the bill addresses the required 50% psychiatric in-clinic time requirements of 55 Pa. Code Chapter 5200 for Psychiatric Outpatient Clinics. The proposed legislation outlines that required psychiatric time may be provided in person or by the use of telebehavioral health technology by psychiatrists, as specified by department regulations. Advanced practice professionals may also provide a portion of the psychiatric time, as specified by department regulations, either in person or by the use of telebehavioral health. Onsite supervision requirements can be performed by either a psychiatrist or an advanced practice professional. Lastly, the legislation permits DHS to issue waivers to fully remote providers so they can serve patients covered by private insurance.
The introduction of the bill represents a unified effort with OMHSAS, our partners in the Pennsylvania General Assembly, and stakeholders across the Commonwealth to enhance our system’s capacity to deliver services to those most in need. We ask that you join us in working with your legislators to pass this critical legislation.
RCPA will continue to update members as the legislation advances. If you have any questions, please contact RCPA COO and Mental Health Director Jim Sharp.
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