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Date ArticleType
11/1/2015 Payment/Reimbursement
CMS Issues Final Rule on Methods for Assuring Access to Covered Medicaid Services


On October 29, the Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment (see below) that will impact the process by which CMS and states make changes to Medicaid fee-for-service payment rates.

Specifically, the final rule puts additional structures in place that are intended to make rate development more data-driven 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. Note the regulation only (emphasis added) applies to Medicaid fee-for-service state plan benefits. Therefore, the Medicaid rates paid for services rendered under waivers, including Section 1115 and 1915(b) and (c) waivers, as well as rates paid under any managed care arrangement (state plan or waiver), are not impacted by the rule.  

This rule finalizes a proposed rule that was issued in May of 2011 and is especially important due to the Supreme Court’s decision in Armstrong v. Exceptional Child Center, Inc. that Medicaid providers do not have a cause of action to challenge a state’s Medicaid reimbursement rates.  Below is additional information about the final rule. AHCA will release a more detailed summary of what is included in this regulation, as well as assess the areas of this rule where it is possible to submit comments and respond to CMS’ Request for Information. If you have questions or suggestions, please contact Caroline Haarmann at chaarmann@ahca.org. To view the final rule, click here and click here to view the Request for Information (RFI) associated with the rule.

New Process for Rate Reviews
The final rule includes new procedures states must implement and follow in order to receive approval of provider rate reductions or rate restricting that could have a negative impact on access to care. This will include reviewing and analyzing program data that has been developed consistent with an Access Monitoring Review Plan to determine that access is sufficient before submitting the proposed reduction/restructuring in provider payments to CMS. States will be required to consider input from providers, beneficiaries, and other stakeholders within their analysis. In addition, states must monitor the effect the rate changes have on access to care for at least three years after the changes go into effect.

Ongoing Access Review for Certain Services
In order to improve the data with which states and CMS monitor access, states will be required to submit Access Monitoring Review Plans to CMS. States will have flexibility in choosing appropriate measures, data sources, baselines, and thresholds that take into account state-specific delivery systems, beneficiary characteristics, and geography. These review plans must be reviewed and updated at least every three years. The Access Monitoring Review Plans must provide for state reviews of a core set of five services, due to their high utilization rate: primary care, physician specialists, behavioral health, pre- and post-natal obstetrics (including labor and delivery), and home health services. States may add additional services at their discretion, and must monitor access for any service for which payments have been reduced or restructured. In addition, if states or CMS receive a significantly high number of complaints about access to care for additional services, states will need to add them to their review plan.

Ongoing Beneficiary and Provider Feedback on Access to Care
The final rule requires states to implement ongoing mechanisms for beneficiary and provider input on access to care (e.g., hotlines, surveys, ombudsman). States will need to promptly respond to the input citing specific access problems, with an appropriate investigation, analysis, and response.

Opportunity to Comment and Accompanying Request for Information (RFI)
CMS is requesting comments, through a 60 day comment period, on various elements of the access review requirements and, separately, feedback on whether and what core access measures, thresholds, and access resolution processes would be useful in ensuring access to care to Medicaid beneficiaries. CMS also seeks input into measuring access to long term care and home and community based services.