On January 4, 2016, the Center for Medicare and Medicaid Services (CMS) implemented sweeping new requirements for ensuring access to specific categories of Medicaid services. The final rule, released on November 2, 2015, and titled Medicaid Program; Methods for Assuring Access to Covered Medicaid Services, creates a very important vehicle for beneficiaries, service providers, their associations and advocacy organizations to have meaningful input in the construct of states’ fee-for-service Medicaid payment methodologies. Per the final rule, states must submit initial access review plans, including stakeholder feedback, to CMS by July 1, 2016.

The new regulation requires states to demonstrate compliance with the statutory requirement that Medicaid payments are sufficient to enlist enough providers to ensure access to covered services for beneficiaries is equivalent to that of the general population. This access requirement applies to fee-for-service payments and does not apply to managed care, waiver, or demonstration program payments.

The new regulation mandates baseline and follow-up reviews of access to core services in the areas of:

  • Primary care (physician, federally qualified health center, clinic, dental);
  • Specialty physician;
  • Mental health and substance use;
  • Obstetrics (prenatal, labor and delivery, postpartum); and
  • Home health.

Additional mandatory reviews are triggered when:

  • Payments are reduced or restructured;
  • New services are implemented; and
  • High levels of access complaints are received.

Further, access reviews must:

  • Describe the population including considerations for its care, service utilization, and payments, for adults, children and individuals with disabilities;
  • Measure whether beneficiary needs are fully met;
  • Document the providers reviewed are enrolled with Medicaid; and
  • Demonstrate access to care within a specific geographic area.

States must issue the initial access monitoring review plan by July 1st of 2016 and submit an update of a subset of service categories by July 1st every three years thereafter. The plan must be developed in consultation with the state’s medical care advisory committee and the data analysis and supporting documentation made available for public review and comment at least 30 days prior to its submittal to CMS.

When an access deficiency is identified, states are required to develop and submit a corrective plan to CMS within 90 days and must remediate the deficiency within 12 months. States that fail to take remedial action risk the loss of federal financial participation. To correct access issues, CMS suggests states can:

  • Increase payments;
  • Improve provider outreach, enrollment, and retention;
  • Enhance transportation;
  • Improve care coordination; and/or
  • Modify provider licensing and scope of practice policies.

In deference to unique state circumstances and in the interest of granting flexibility, CMS did not promulgate a specific format for the access review plans. Some data elements will be mandatory, however, including a comparison of Medicaid payments to other public and private insurance payments, by provider type and site of service. Suggested data elements include:

  • Time and distance standards;
  • Providers participating in the Medicaid program;
  • Providers with open panels;
  • Providers accepting new Medicaid patients;
  • Service utilization patterns;
  • Identified beneficiary needs; and
  • Logs of beneficiary and provider feedback.

CMS expects states to solicit stakeholder input during development of the access and remedial action plans as well as on an ongoing basis. States are required to establish a mechanism – surveys, ombudsman, or equivalent – to receive input from stakeholders and to log the volume and nature of this input and their responses to it. CMS will rely on this mechanism to understand access to care concerns and may, as a result, require states to monitor additional services. States are required to investigate, analyze and respond promptly to public input. Should stakeholder concerns not be adequately addressed by the state, they may be raised with CMS directly.

As previously noted, states must submit their initial access monitoring review plans to CMS by July 1, 2016. As part of this process, draft plans must be available for review and public comment at least 30 days prior to being finalized and submitted to CMS, and draft plans are expected within the next two to three months. Advocates, providers, and provider associations will want to become familiar with the access rule as they prepare to engage in the stakeholder input and public comment processes. On March 16, 2016, CMS posted a Frequently Asked Questions (FAQs) document about implementing the access rule that addresses both stakeholder input and public comment.