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Federal law requires state Medicaid program to establish methods and procedures to ensure that Fee for Service (FFS) Medicaid beneficiaries can access services to at least the same extent as the general population in the same geographic area.
In 2015, 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, placing greater importance on the Centers for Medicare and Medicaid Services (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.
On November 2, 2015, the CMS published a final rule that implements the equal access provision that requires state Medicaid agencies to develop, update, publish and submit to CMS a medical assistance access monitoring review plan. The final rule require state Medicaid agencies collect and analyze data to demonstrate sufficient access to care by examining enrollee needs, the availability of care and providers and the utilization of services. Beneficiary experiences are to be a primary determinant of whether access is sufficient. The Access to Care Monitoring Review Plan (ACMRP) must consider the following items:
- The extent to which beneficiaries' needs are met;
- Availability of care through enrolled providers to beneficiaries in each geographic area, by provider type and site of service;
- Changes in beneficiary utilization of covered services in each geographic area;
- Characteristics of the beneficiary population (including considerations for care, service and payment variations for pediatric and adult populations, as well as individuals with disabilities; and
- Actual or estimated levels of provider payment available from other payers, including other public and private payers, and by provider type along with the geographic area of service.
Effective April 8,
2016 the new rule requires states to develop review plans and update them at a minimum of every three years. States must make plans available to the public for at least 30 days, including review and feedback from Medical Care Advisory Committee (MCAC), finalize and submit to CMS for review. The first review is due October 1,
2016 which falls on a Saturday therefore, Nevada must have the review plan submitted by September 30,
The State of Nevada, Division of Health Care Financing and Policy (DHCFP) team is currently in the implementation stage and has started soliciting and collecting feedback from a number of identified stakeholder groups.
The new rule also creates new requirements when submitting Medicaid state plan amendments (SPA). Whenever states submit a SPA to CMS to reduce or restructure provider payment, they must submit an access review for each service affected by the SPA and indicate how states will monitor access to each affected service for at least three years.
Currently, the final rule excludes access reviews from Medicaid Managed Care (MCO) arrangements however this could change once CMS has released the new MCO regulations. The possible logic behind this exclusion is that proposed Medicaid managed care regulations, to be issued around June 1st of this year (2016), will contain relevant provisions regarding both payment and network adequacy. CMS has stated that equal access standard applies only “to state payments to providers and not to capitated payments managed care entities.” (CMS 2328-FC, Fed reg. 67582)
State of Nevada Access to Care Monitoring Review Plan
not currently have an automated mechanism in place when developing and
providing comparable access to that which is provided to non-Medicaid enrollees,
and in accordance with 42 CFR 447.203. The DHCFP
is developing an ACMRP for the following service categories provided under a
- Primary Care Services
- Physician Specialist Services
- Behavioral Health Services
- Pre- and Post-Natal Obstetric Services, including
Labor and Delivery
- Home Health Services
will include data-driven processes by which the DHCFP documents and monitors access
to care. Documentation and monitoring
will focus on the five specific categories; the extent to which beneficiary
needs are fully met, the availability of care through enrolled providers,
utilization of Medicaid services, changes in beneficiary service utilization
and a comparison of Medicaid rates and rates paid by other payers in the
Sources for more Information
- For the complete Federal Regulation governing access to care:
www.ecfr.gov, link below. 42 CFR 447.203-447.205
- For the final rule with CMS comment period: The Federal Register, Department of Health and Human Services, CMS-2328-FC
https://www.gpo.gov/fdsys/pkg/FR-2015-11-02/pdf/2015-27697.pdf, link below.
- General information about Center for Medicare & Medicaid Services:
https://www.cms.gov, link below
CMS-2328-FC, Federal Regulation pg. 67582