CMS on Thursday issued a proposed rule that would eliminate existing requirements on how states assess access to care among fee-for-service (FFS) Medicaid beneficiaries and replace them with a more standardized approach that the agency hopes to develop with industry stakeholders.
Background: States raise concerns about Medicaid FFS monitoring requirements
Under a rule finalized in 2015, states are required to develop and submit an access monitoring review plan (AMRP) to the federal government, and update the plan at least every three years, for certain FFS Medicaid services. States under the final rule also must meet specific administrative requirements when they propose certain changes to Medicaid provider payments.
According to CMS, states have raised concerns about the requirements' administrative burdens and limits. In addition, CMS said states have questioned whether the final rule provided states with the most effective method for accurately assessing access to care in a state's Medicaid program, as states increasingly are shifting Medicaid FFS beneficiaries to Medicaid managed care programs that already are required to meet certain CMS network access standards.
CMS in 2018 proposed exempting states with at least 85% of their Medicaid beneficiaries in managed care programs from most of the final rule's access monitoring requirements. However, CMS did not finalize that proposed rule, saying "an overwhelming number of commenters raised concerns that the exemption thresholds were arbitrarily set without data to support them." CMS said it instead would seek "a new approach to understanding access and ensuring statutory compliance while [also] eliminating unnecessary burden on states.
Proposed rule details
CMS' new proposed rule seeks to replace the current regulations requiring states to conduct ongoing Medicaid FFS access reviews with a more comprehensive, outcomes-driven approach for monitoring access across FFS, managed care, and home- and community-based waiver program, , the agency said. CMS said that approach would be developed by workgroups and technical expert panels that include state and federal stakeholders.
The proposed rule states, "While the [current] AMRPs can serve as an overall structure for states to monitor access data … similar information can be presented by states through the [state plan amendment] (SPA) submission process to demonstrate compliance with the statute without the need to develop and maintain AMRPs as currently required under the regulations."
CMS said the current AMRP requirements will remain in place until the proposed rule is finalized, and the agency at that time will release guidance detailing how states can include data in their SPA submissions to demonstrate that their Medicaid FFS programs are meeting federal equal access standards. For instance, CMS in the proposed rule said it might require states to include data in their SPAs on:
- Available transportation in the geographic area;
- Direct comparisons of access for Medicaid beneficiaries to that of the general population in the geographic area;
- Ratios of participating providers to beneficiaries in the geographic area;
- Ratios of participating providers to total providers in the geographic area; and
- Rate comparisons.
CMS also issued guidance detailing its strategy to develop the more comprehensive approach to evaluating access to care in state Medicaid programs, and said it will seek input from stakeholders on how:
- CMS can improve current assessment and reporting requirements;
- CMS can ensure states are complying with statutory equal access requirements;
- CMS can most appropriately monitor Medicaid FFS and managed care programs; and
- States can most effectively ensure Medicaid beneficiaries have access to care.
CMS will accept public comments on the proposed rule for 60 days.
CMS Administrator Seema Verma said the proposed rule would help to ease states' administrative burdens. "Rather than micromanaging [s]tate programs through complex federal mandates, CMS is easing the administrative burden on states while focusing on holding them accountable for delivering high-quality, accessible care to beneficiaries," Verma said.
But some advocates raised concerns about the proposed changes, Modern Healthcare reports.
Judy Solomon, a senior fellow at the Center on Budget and Policy Priorities, raised concerns about CMS unveiling a plan to eliminate current monitoring and reporting requirements before a final plan is ready. "We're concerned that CMS proposes to rescind the current reporting and monitoring scheme before having a comprehensive strategy in place to protect Medicaid enrollees, which should be developed with meaningful input from beneficiaries and their advocates."
Sara Rosenbaum, a health law professor at George Washington University and former chair of the Medicaid and CHIP Payment and Access Commission, said the proposed rule would "eliminat[e] the data that serves as an early warning system. Managed care is only feasible where there is an adequate supply of providers. If the network is illusory, you need to know that."
However, the National Association of Medicaid Directors (NAMD), which CMS hopes will help to develop the new framework for assessing Medicaid access, said states likely will support the agency's move to replace the current requirements. Matt Salo, NAMD's executive director, said the proposed rule is "a sensible step forward," because the current requirements are not working.
Jack Rollins, a senior policy analyst at NAMD, said, "We look forward to working with CMS on the details of what that alternative approach may entail, per the informational bulletin they released alongside this proposed rule" (Meyer, Modern Healthcare, 7/11; Stein, Inside Health Policy, 7/11 [subscription required]; King, FierceHealthcare, 7/11).