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The Centers for Medicare & Medicaid Services (CMS) has issued a final rule with comment period that aims to allow states and CMS to make better informed, data-driven decisions when considering whether proposed changes to Medicaid fee-for-service payment rates are sufficient to ensure that Medicaid beneficiaries have access to covered Medicaid services. The final rule also intends to strengthen CMS’ ability to review Medicaid payment rates to ensure they are consistent with efficiency, economy and quality of care, as well as ensure sufficient beneficiary access to care under the Medicaid program. CMS also issued a Request for Information (RFI) to gather input into additional approaches that it and states may consider to better ensure compliance with Medicaid access requirements. The RFI asks for comments on the potential development of standardized core set measures of access, access measures for long-term care and home and community-based services, national access to care thresholds, and resolution processes that beneficiaries could use when they have problems accessing essential health care services.
Background
In May 2011, CMS published the “Medicaid Program; Methods for Assuring Access to Covered Medicaid Services” proposed rule. That proposed rule outlined a standardized, transparent, data-driven process for states to document that provider payment rates are consistent with efficiency, economy and quality of care, and are sufficient to enlist enough providers to ensure care and services are available to Medicaid beneficiaries.
The final rule provides increased state flexibility, within a framework, to document measures supporting beneficiary access to services. In addition, the final rule does the following:
- Establishes new state procedures necessary for CMS approval of provider rate reductions or rate restructuring in ways that may negatively impact access to care. As part of these procedures, states will need to consider input from providers, beneficiaries and other stakeholders. In addition, states will need to analyze the effect that rate changes will have on beneficiary access to care. Specifically, states will need to review and analyze program data that has been developed consistent with an Access Monitoring Review Plan to determine that access is sufficient before submitting the proposed reduction or restructuring in provider payments to CMS. States will continue to have the discretion to set program rates and improve access to care through a variety of strategies.
- Requires states to submit Access Monitoring Review Plans. The plans must provide for state reviews of a core set of five services: primary care, physician specialists, behavioral health, pre- and post-natal obstetrics (including labor and delivery) and home health services. These services are highly utilized and are indicators of overall access to care in Medicaid programs. States may add additional services at their discretion, and must monitor access for any service for which payments have been reduced or restructured. The plans must specify data sources that will support a finding of sufficient beneficiary access and will address:
- The extent to which beneficiary needs are met;
- The availability of care and providers;
- Changes in beneficiary service utilization; and
- Comparisons between Medicaid rates and rates paid by other public and private payers.
- Requires states to implement ongoing mechanisms for beneficiary and provider input on access to care (through hotlines, surveys, ombudsman or another equivalent mechanism). States will need to promptly respond to the input citing specific access problems with an appropriate investigation, analysis and response.
The final rule becomes effective Jan. 4, 2016, at which time states must meet the requirements established through the provisions of the rule. During the 60-day comment period, CMS will accept comments from the public on the access review requirements, enabling states to begin preparing their initial review plan analysis and to assess whether adjustments to this provision are warranted. CMS will accept responses to the RFI through Jan. 4, 2016.
The final rule with comment and RFI are attached. CHA commented extensively on the May 2011 proposed rule and is in the process of reviewing the final rule and RFI.
