RFK Jr. indicates policy changes on surprise billing, rural healthcare, Medicaid

Increased surprise billing payer requirements, rural healthcare support and Medicaid changes — including work requirements — drew support in written comments from the nominee to lead federal healthcare programs.

Robert F. Kennedy Jr. answered a series of follow up questions from senators after his two confirmation hearings in late January. His responses came shortly before the Feb. 4 Senate Finance Committee approval, 14-13, of his nomination. A vote by the full Senate is expected as soon as this week.

 The No Surprises Act was enacted in December 2020 during the first Trump administration and implemented by the Biden administration. But the Biden administration did not implement all of its provisions.

“If confirmed, I look forward to implementing President Trump’s No Surprises Act, including the provisions of the law that were never implemented under the Biden administration,” Kennedy wrote the senators.

Unimplemented provisions of that law include:

• Adding information to insurance cards, including deductibles and out-of-pocket maximum limits
• Sending enrollees advance notices before a service that includes estimated costs
• Requiring plans to establish a process to update and verify provider directories
• Requiring plans to continue paying for services if a patient changes plans with a different network of providers

In response to multiple questions on how he would address the challenges facing rural healthcare providers, including rural hospitals, Kennedy wrote “rural health care is in crisis in this country and that is catastrophic for our entire country.

“I support President Trump’s agenda to look holistically at the various ways our federal programs currently support rural health and where those can be improved to meet our mutual goal of ensuring access to high quality care in rural areas.”

Kennedy wrote that rural providers could benefit from changes to policies on the use of graduate medical education, AI, telehealth and other innovations that “support access to care in these areas.”

Medicaid

Kennedy was generally vague in his responses to many questions on any planned Medicaid policy changes. When he was asked about whether he supported Republican congressional proposals to cut Medicaid spending in various ways, he simply noted Congress decides Medicaid funding levels.

Kennedy wrote he plans “to ensure that the Medicaid program is well administered, effective, and available for the most vulnerable beneficiaries, and that the states are given the flexibility to pursue innovative approaches that fit the needs of their citizens.”

Sen. Raphael Warnock (D-Ga.) asked Kennedy whether he would oppose Republican legislative efforts to cap state directed payments (SDPs) in Medicaid at the Medicare equivalent rate. A 2024 Biden administration rule allowed SDPs to provide funding as high as average commercial rates. Warnock said rolling back SDPs to Medicare rates would cut more than $1 billion from SDPs to hospitals in Georgia.

Kennedy did not respond to his plans for SDPs but said he aims to “work with the CMS administrator and team to review regulations and current policies to ensure compliance with the law.” Some conservatives have questioned the legality of various Medicaid payments.

Hospitals have garnered an increasing share of revenue from SDPs, which was projected to reach a cumulative $110 billion in 2024, up from a cumulative $69 billion in February 2023.

One Medicaid flexibility sought by some states is to add requirements that able-bodied adults obtain jobs, training or education, which is termed “community engagement.”

“Encouraging community engagement allows more families to realize the American dream and has been shown to contribute positively to both physical and mental health,” Kennedy wrote. “If confirmed, I will work with states to implement innovative approaches that both promote holistic health and foster community engagement.”

Among a preliminary list of potential federal budget savings from congressional Republicans was a proposal to establish universal Medicaid work requirements, which would save an estimated $100 billion over 10 years.

Medicare

On Medicare coding, Kennedy said he plans to “work with the CMS administrator to take a holistic look at the Medicare program to ensure that it is working to keep our nation’s seniors healthy and reduce the rate of chronic disease.”

“The most important drivers of chronic disease are not related to Medicare coding, however, it is important for Medicare coding and payment to incentivize high quality care for Medicare beneficiaries,” he wrote.

Kennedy did not directly respond to questions about whether he would continue Medicare drug negotiations the Biden administration began in 2024 under the Inflation Reduction Act. Although he did write that would “follow the laws” on the issue.

He also plans to work with Congress “to identify other levers to lower prescription drug prices for all Americans.”

In response to a question about Medicare and Medicaid payment rates for ambulance services, Kennedy wrote that plans to investigate why the Biden administration discontinued Emergency Triage, Treat and Transport (ET3) model through the CMS Innovation Center. The Biden administration ended that Medicare model in December of 2023 — two years earlier than planned — due to what it described as lower than expected participation and interventions compared to initial projections. 

Asked about Medicare’s hospital at home program, Kennedy described it as “an innovative approach to providing access to care services in the setting that works for patients.” He planned to implement such programs, as allowed by Congress.

On telehealth, Kennedy said “innovative modes of care delivery, such as telehealth, will maximize quality and access to care for Medicare beneficiaries.”

In response to multiple questions from Sen. Elizabeth Warren on problems with the Medicare Advantage (MA) program, Kennedy noted he has “heard a number of concerns about the Medicare Advantage program throughout this process.”

Kennedy said he aims to ensure MA “provides seniors with improved health outcomes and benefits while remaining financially sustainable.”

EMTALA

Democratic senators pressed Kennedy on abortion policies, including whether he would continue the Biden administration’s EMTALA guidance that hospitals must provide abortions if they are needed to preserve a patient’s life or health. The Biden administration’s Department of Justice sued Idaho over its concern that the state’s abortion restrictions violated EMTALA.

Kennedy noted HHS is responsible for evaluating complaints about EMTALA violations.

“I believe the department can simultaneously enforce EMTALA and respect the many state laws protecting the unborn and the right of conscience in healthcare,” Kennedy wrote. “If confirmed, I look forward to working with CMS as well as Congress to ensure that both can be achieved.”