CMS Releases Medicaid Access Rule

The Centers for Medicare and Medicaid Services (CMS) has finalized a long-awaited Medicaid “access rule” that seeks to establish a transparent data-driven process for states to document whether Medicaid payments are sufficient to enlist providers to assure beneficiary access to covered care and services.  The final rule with comment period, entitled “Medicaid Program; Methods for Assuring Access to Covered Medicaid Services,” finalizes a proposed rule issued May 6, 2011. The rule only covers state plan services, so waiver programs and Medicaid managed care services are not affected; however, Home and Community Based Services (HCBS) offered through 1915 (i) or 1915 (k) state plan authorities are subject to this regulation. Although the regulation is final, CMS is seeking comment on whether future adjustments would be warranted to the provisions setting forth requirements for ongoing state reviews of beneficiary access.

Sufficiency requirement The rule requires that Medicaid payments “must be consistent with efficiency, economy, and quality of care and sufficient to enlist enough providers so that services under the plan are available to beneficiaries at least to the extent that those services are available to the general population.” States are required to consider, prior to the submission of any state plan amendment that proposes to reduce or restructure Medicaid service payment rates, the data collected, and the analysis performed, under a medical assistance access review plan (see below), input from beneficiaries, providers and other affected stakeholders on beneficiary access to the affected services, and the impact that the proposed rate change will have, if any, on continued service access. Any proposed state plan amendment affecting payment rates must include the most recent (no more than twelve months old) access monitoring review plan for the services at issue; an analysis of the effect of the change in payment rates on access; and a specific analysis of the information and concerns expressed in input from affected stakeholders.

The medical assistance access monitoring review plan The rule requires State Medicaid Agencies, in consultation with their state medical care advisory committee, to develop and continually update a medical assistance access monitoring review plan. The plan must be made available to the public for review and comment for a period of no less than thirty days prior to being finalized and submitted to CMS for review. The plan must include an access monitoring analysis that includes data sources, methodologies, baselines, assumptions, trends and factors, and thresholds that analyze and inform determinations of the sufficiency of access to care which may vary by geographic location within the state and will be used to inform state policies affecting access to Medicaid services, such as provider payment rates.

The plan and monitoring analysis must consider:

  • the extent to which beneficiary needs are fully met,
  • the availability of care through enrolled providers to beneficiaries in each geographic area, by provider type and site of service,
  • changes in beneficiary utilization of covered services in each geographic area
  • the characteristics of the beneficiary population (including considerations for care, service and payment variations for pediatric and adult populations and for individuals with disabilities); and
  • actual or estimated levels of provider payment available from other payers, including other public and private payers, by provider type and site of service.

The access monitoring review plan “must include an analysis of data and the state’s conclusion of the sufficiency of access to care that will consider relevant provider and beneficiary information, including information obtained through public rate-setting processes, the medical care advisory committees…, and other mechanisms (such as letters from providers and beneficiaries to State or Federal officials), which describe access to care concerns or suggestions for improvement in access to care.” States must also “have ongoing mechanisms for beneficiary and provider input on access to care (through hotlines, surveys, ombudsman, review of grievance and appeals data, or another equivalent mechanisms),” and “should promptly respond to public input through these mechanisms citing specific access problems, with an appropriate investigation, analysis, and response.”

For each of the services reviewed, by the provider types and sites of service described within the access monitoring analysis, the access monitoring review plan must include an analysis of the percentage comparison of Medicaid payment rates to other public and private health insurer payment rates within geographic areas of the state. The plan and analysis must, at a minimum, include

  • the specific measures that the state uses to analyze access to care;
  • baseline and updated data associated with the measures;
  • any issues with access that are discovered as a result of the review; and
  • the state agency’s recommendations on the sufficiency of access to care based on the review.

In addition, the access monitoring review plan must include procedures to periodically monitor access for at least three years after the implementation of a provider rate reduction or restructuring.

Timeframes Beginning July 1, 2016 the State agency must develop its access monitoring review plan by July 1 of the first review year, and update this plan by July 1 of each subsequent review period. For all of the following, the State Medicaid Agency must complete an analysis of the data collected, with a separate analysis for each provider type and site of service furnishing the type of service, at least once every 3 years:

(A) Primary care services

(B) Physician specialist services

(C) Behavioral health services (including mental health and substance use disorder)

(D) Pre- and post-natal obstetric services including labor and delivery

(E) Home health services

(F) Any services for which the state has proposed to reduce or restructure Medicaid                service payment rates

(G) Additional types of services for which the state or CMS has received a significantly          higher than usual volume of beneficiary, provider or other stakeholder access                    complaints for a geographic area

(H) Additional types of services selected by the state.

Remediation When access deficiencies are identified, the state must, within 90 days after discovery, submit a corrective action plan with specific steps and timelines to address those issues. While the corrective action plan may include longer-term objectives, remediation of the access deficiency should take place within 12 months. 

FMI: The final rule is available at