Medicare & Medicaid News
CMS issues rule to ensure Medicaid beneficiaries access to services
Response to Court decision that beneficiaries do not have private right of action to contest state-determined rates in federal courts
Oct. 29, 1025 - Today the Centers for Medicare & Medicaid Services (CMS) issued a final rule that it says allows 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.
Earlier this year, the Supreme Court decided in Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (2015), that Medicaid providers and beneficiaries do not have a private right of action to contest state-determined Medicaid payment rates in federal courts.
This, says a CMS fact sheet, places greater importance on CMS review to ensure that such rates are “consistent with efficiency, economy and quality of care” and ensure sufficient beneficiary access to care under the program.
The Court concluded that federal administrative agencies are better suited than federal courts to make these determinations.
To strengthen CMS review and enforcement capabilities, the final rule requires states to provide more information so that CMS can better monitor, measure, and ensure Medicaid access to care within fee-for service reimbursement methodologies.
In addition to the final rule, CMS is developing procedures to further bolster the administrative record that is used to document compliance with the final rule and ensure that there is consistent national application of its requirements.
CMS is also issuing a Request for Information to obtain input into additional approaches that it and states may consider to better ensure compliance with Medicaid access requirements.
CMS News Release:
“Maintaining beneficiaries’ access to care is vital to the health of our nation and health of those who may not otherwise have access to essential health care services,” said Vikki Wachino, deputy administrator of CMS, and director, Center for Medicaid and CHIP Services. “Through this rule, beneficiaries will have greater confidence in the services they receive from their Medicaid health care coverage.”
The goals of the final rule are fundamental to our health care system:
(1) measuring and linking beneficiaries’ needs and utilization of services with availability of care and providers;
(2) increasing beneficiaries’ involvement through multiple feedback mechanisms; and
(3) increasing stakeholder, provider, and beneficiary engagement when considering proposed changes to Medicaid fee-for-service payments rates that could potentially impact beneficiaries’ ability to obtain care.
To support these three goals, the final rule requires states to develop, the following -
> an access review plan that set out the data elements and other information to be used to ensure beneficiary access to mandatory and optional services;
> to establish new procedures to review the effects on beneficiary access of proposed rate reductions and payment restructuring; and
> to implement ongoing access monitoring reviews of key services, and additional services as warranted.
These provisions enhance meaningful access to health care services by putting beneficiaries back at the center of their care.
New Procedures for Rate Reductions and Payment Restructuring
The final rule establishes new procedures at the state level 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 perform an analysis of the effect that such rate change will have on beneficiary access to
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/restructuring in provider payments to CMS.
They will need to consider input from beneficiaries, providers, and other stakeholders within their analysis. States will also need to monitor the effect the changes have on access to care for at least three years after the changes are effective.
CMS says it is requiring these new monitoring procedures because the impact of rate changes on access to care may not be apparent at the time the changes are adopted. States will continue to have the discretion to set program rates and improve access to care through a variety of strategies.
Ongoing Access Review for Certain Services
In order to improve the data with which states and CMS monitor access, the regulation requires states to submit Access Monitoring Review Plans. 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.
The Access Monitoring Review 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. Additionally, 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.
Within the review plans, states will choose the appropriate measures, data sources, baselines and thresholds that take into account state-specific delivery systems, beneficiary characteristics and geography. The review plans will need to be reviewed and updated at least every three years.
CMS is requesting comments, through a 60 day comment period, on the access review requirements, including the service categories required for ongoing review, elements of the review, the timeframe for submission, whether we should allow exemptions based on state program characteristics (for example, high managed care enrollment), the provisions from which states could be exempted based on the specific program characteristics, and
alternatives to ensuring compliance with Medicaid access requirements for exempted services in lieu of the procedures described in this final rule with comment period.
Ongoing Beneficiary and Provider Feedback on Access to Care
Beneficiary experience in accessing Medicaid services and provider experience in delivering care are important indicators of whether access is sufficient and beneficiary and provider input will be particularly informative in identifying access issues. The final regulation 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