CMS streamlines Medicaid, CHIP
Final rule prohibits annual and lifetime limits on CHIP benefits
The Centers for Medicare & Medicaid Services finalized its rule overhauling the enrollment, cost-sharing and eligibility processes for Medicaid, the Basic Health Program, and the Children’s Health Insurance Program, or CHIP.
CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to purchase private insurance. The final rule prohibits annual and lifetime limits on CHIP benefits to improve access to care and aligning with Affordable Care Act standards, which the ADA previously supported.
Elizabeth Simpson, D.M.D., chair of the ADA Council on Advocacy for Access and Prevention, expressed support for the final rule, highlighting the importance of removing annual limits for CHIP beneficiaries.
“We commend CMS for releasing this rule and recognizing that Medicaid and CHIP beneficiaries still face barriers towards getting needed dental care,” she said. “Removing the annual limits for CHIP beneficiaries allows dentists to complete dental treatment plans without worrying about the costs towards families and helps improve the overall oral health of children.”
In a November 2022 letter to CMS, the ADA provided comments on the proposal by saying they “appreciate the recognition that children should not have limits placed on their dental benefits just as adults do not have annual or lifetime limits placed on benefits offered through their plans. The impact of these restrictions is mostly likely to be felt in those families the greater their poverty level.”
The ADA further stated “it has been observed that the greater a family’s poverty level, those with incomes less than 100% of federal poverty guidelines, the more likely children and adolescents were to have had caries and they also had twice the prevalence of untreated caries than with children and adolescents in families with incomes greater than or equal to 200% of [federal poverty guidelines]. We believe lifting these annual and especially lifetime limits on dental benefits within the CHIP program will help treatment of childhood caries as well as help adolescents when they face new treatment issues, including necessary dental and orthodontia care.”
Currently, 13 states place either an annual or lifetime dollar limit on at least one CHIP benefit, according to the rule. Twelve of these 13 states place an annual dollar limit on at least one CHIP benefit, including Alabama, Arkansas, Colorado, Iowa, Michigan, Mississippi, Montana, Oklahoma, Pennsylvania, Tennessee, Texas and Utah. A majority of these 12 states had an annual dollar limit on dental benefits for CHIP beneficiaries. Additionally, six of these 13 place a lifetime dollar limit on at least one CHIP benefit, including Colorado, Connecticut, Mississippi, Pennsylvania, Tennessee and Texas.
The final rule also eliminates waiting periods for CHIP. States will no longer be able to lock out CHIP beneficiaries for failure to pay premiums and implement pre-enrollment waiting periods.
Within the Medicaid program, “this rule aligns enrollment and renewal requirements for most individuals in Medicaid, establishes beneficiary protections related to returned mail; creates timeliness requirements for redeterminations of eligibility, makes transitions between programs easier, eliminates access barriers for children enrolled in CHIP by prohibiting premium lock-out periods and benefit limitations, and modernizes recordkeeping requirements to ensure proper documentation of eligibility determinations,” according to the final rule summary.
The regulations are slated to be effective 60 days from the rule’s publication in the Federal Register on April 2.
