Biden-Harris Administration Takes Historic Action to Increase Access to Quality Care, and Support to Families and Care Workers

Nursing home minimum staffing standards promote resident care and safety

Medicaid and CHIP to have historic access standards, advance fair compensation for direct care workers

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today issued three final rules to fulfill President Biden’s commitment to support family caregivers, boost compensation and job quality for care workers, expand and improve care options, and improve the safety and quality of care in federally-funded nursing homes. The actions, announced during Care Workers Recognition Month and the Month of Action on Care, represent a transformational investment to support America’s families and workers.

The three rules announced today build on the President’s historic Action Plan for Nursing Home Reform and support of President Biden’s April 2023 Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers (Care EO). They also follow through on President Biden’s State of the Union commitments to improve the quality of nursing home care; support older adults, people with disabilities, and care workers; and strengthen the economy.

• “Minimum Staffing Standards for Nursing Homes” establishes, for the first time, national minimum staffing requirements for nursing homes to improve the care that residents receive and support workers by ensuring that they have sufficient staff.

• “Ensuring Access to Medicaid Services” (“Access Rule”) creates historic national standards that will allow people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) to better access care when they need it and also strengthens home and community-based services (HCBS), which millions of older adults and people with disabilities rely upon to live in the community.  This landmark final rule will set minimum threshold standards for payments to the direct care workforce, create meaningful engagement with Medicaid consumers, and advance provider rate transparency.

• “Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality” (“Managed Care Rule”) will improve access to care, accountability and transparency for the more than 70 percent of Medicaid and CHIP beneficiaries who are enrolled in a managed care plan. It will require a limit on how long enrollees have to wait for an appointment and allow people to compare plan performance based on quality and access to providers.

“Everyone should have equal access to the critical care they need. Our caregivers – those who are taking care of the ones we love – deserve our respect and full support. That’s why HHS has been at the center of the Biden-Harris Administration’s efforts to improve care and caregiving for Americans at all stages of their lives,” said HHS Secretary Xavier Becerra. “We are taking important steps to strengthen care provided through Medicaid and CHIP and establishing national staffing standards for nursing homes to enhance care for residents while improving conditions for workers. This will help ensure that millions of people have access to high-quality health care and that the dedicated workers who provide care to our loved ones are fully valued for their work.”

“We’ve implemented significant changes across CMS programs to ensure eligible people can benefit from the critical lifeline afforded by health care coverage. Now, CMS has set its sights on an equally ambitious goal: making sure that coverage connects people to consistently high-quality care, regardless of where they live or receive care,” said CMS Administrator Chiquita Brooks-LaSure. “That goal is ambitious, attainable, and rooted in the Biden-Harris Administration’s priority to ensure millions of people have access to affordable, quality health coverage and can stay healthy and thrive.”

Nursing Home Staffing Standards

Establishing minimum staffing standards for nursing homes is a critical step in the Biden-Harris Administration’s comprehensive approach to building a long-term care system where all older Americans can age with dignity.   Nursing home workers provide vital – although often undervalued – care for nursing home residents, assisting them with important daily tasks, such as bathing, dressing, mobility, and eating. These direct care workers, who are often women of color, typically earn low wages, rarely receive health and retirement benefits, and experience high injury rates. The Biden-Harris Administration believes that by improving working conditions and wages, improvements in the recruitment and retention of direct care workers will follow, enabling nursing staff to provide safer, higher quality care to all residents within nursing homes.

Over 1.2 million residents receive care in Medicare- and Medicaid-certified nursing homes each day. Adequate staffing is essential to providing an environment where residents receive safe, high-quality care while being treated with dignity. CMS received and considered more than 46,000 public comments on this rule from various stakeholders, including residents and their family members, workers, advocates, and the industry. Many of these comments highlighted how – without sufficient staff – residents do not receive necessary care including baths or trips to the bathroom, and experience preventable safety events, such as pressure ulcers and falls. Because of the final rule, nursing homes participating in Medicare and Medicaid will be required to follow designated nurse staffing standards:

• Provide residents with a minimum total of 3.48 hours of nursing care per day, which includes at least 0.55 hours of care from a registered nurse per resident per day, and 2.45 hours of care from a nurse aide per resident per day.
• Have a registered nurse on site 24 hours per day, seven days per week to help mitigate against preventable safety events and deliver critical care to residents at any time.
• Conduct a stronger annual facility assessment than is currently required to improve the planning and identification of the resources and supports that are needed to care for residents based on their acuity during both day-to-day operations and emergencies. This process will need to include participation from direct care workers and others.
• Develop a staffing plan to maximize recruitment and retention.

As part of the Biden-Harris Administration’s commitment to the long-term care workforce, CMS will also require states to collect and report on the percent of Medicaid payments that are spent on compensation for direct care workers and support staff delivering care in nursing facilities and intermediate care facilities for individuals with intellectual disabilities. To increase transparency and accountability, CMS will publicly report the data reported by states, and states will also be required to report this data for each facility on a state-operated website.

The Biden-Harris Administration is committed to bolstering the health care workforce and ensuring the contributions of workers across the long-term care sector are appropriately valued. CMS is developing a $75 million national nursing home staffing campaign to increase the number of nurses in nursing homes, thereby enhancing residents’ health and safety. Through this campaign, CMS will be providing financial incentives for nurses to work in  nursing homes.

Medicaid Access and Managed Care

The Access and Managed Care rules create the strongest requirements yet for improving accountability, transparency, and access to health coverage in the nation’s largest health care program. Building on Medicaid and CHIP’s already strong foundation, these two rules together create historic national standards that will allow people with Medicaid and CHIP to better access care when they need it, finalize payment standards for direct care workers providing HCBS, and will make provider rates more transparent. Adding to recent progress to streamline and strengthen Medicaid and CHIP enrollment and eligibility, today’s rules establish tangible, consistent standards for millions of children, families, adults, and people with disabilities regardless of the state in which they live.

For example, for the first time ever, states will be required to have national appointment wait time standards.  States will enforce these wait time standards by conducting “secret shopper” surveys, which can help verify compliance with appointment wait time rules and correct provider directory inaccuracies. States will also now be required for the first time to disclose provider payment rates publicly. Additionally, the rules will create a new beneficiary advisory committee in every state, which will allow for direct feedback to state Medicaid and CHIP programs on benefits and service delivery from the people who access it daily.

The Access Rule strengthens HCBS by requiring that at least 80 percent of Medicaid HCBS payments directly compensate direct care workers rather than cover “administrative overhead.” The rule also requires states to report how they establish and maintain HCBS wait lists, assess wait times, and report on quality measures. This policy would allow states to take into account small providers and providers in rural areas, promote training and quality, and ensure smooth implementation with additional data collection prior to full phase-in.

It protects the health and safety of people who receive HCBS by improving states’ incident management systems and requires states to have a grievance process for all HCBS participants.

The Managed Care rule defines the scope of “in lieu of services and settings” (ILOS) services in managed care to better address enrollees’ health-related social needs (e.g., support for housing- and nutrition-related services). Additionally, it establishes a quality rating system for Medicaid and CHIP managed care plans – a “one-stop-shop” where beneficiaries can learn about eligibility for plans and compare them based on quality and other factors.

For additional information on the rules issued today, please consult the CMS fact sheets on nursing home staffing standards, Access, and Managed Care.