Access to Care

A new approach has been implemented that focuses on payment, standardization, enhanced oversight, and monitoring of access to care in Medicaid and the Children's Health Insurance Program. This replaces the old Access Monitoring Review Plans (AMRPs). The replacement was authorized by a 2024 rule by the Centers for Medicare and Medicaid Services.

Executive Summary

The Ensuring Access to Medicaid Services Final Rule helps make sure beneficiaries can access covered services. The Access rule hopes to improve health outcomes for Medicaid beneficiaries across fee-for-service (FFS) and managed care delivery systems, including home and community-based services (HCBS) provided. Improvements seek to increase transparency and accountability, standardize data and monitoring and create opportunities for states to promote active beneficiary engagement in their Medicaid programs. The final rule (CMS-2442F), along with the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439F), were established to reach this goal.

Here are the highlights of the provisions included in the final rule:

(A) Medicaid Advisory Committee and Beneficiary Advisory Council
The rule renamed and expanded the scope of the state Medical Care Advisory Committees (MAC) and will establish a Beneficiary Advisory Council (BAC) comprised of Medicaid beneficiaries, their families, and caregivers. Information about the MAC and BAC activities will be publicly available, including bylaws, meeting schedules, agendas, minutes, and membership lists, with at least two MAC meetings per year being open to the public, and will include a public comment period.

(B) Home and Community-Based Services
The rule strengthens oversight of person-centered service planning in HCBS. Standards for the incident management system will be met, and a grievance system for HCBS FFS will be established. The state will report on its readiness to collect data regarding the percentage of Medicaid payments for homemaker, home health aide, personal care and habilitation services spent on compensation to the direct care workers furnishing these services by 07/2027 and by 07/2028, will report on the percentage of Medicaid payments for homemaker, home health aide, personal care and habilitation services spent on compensation to the direct care workers furnishing these services. By 07/2030, the state will ensure a minimum of 80% of Medicaid payments for these services will be spent on compensation for the direct care workers furnishing these services, as opposed to administrative overhead or profit, subject to certain flexibilities and exceptions. The HCBS payment adequacy provision exempts the Indian Health Service and Tribal health programs subject to 25 U.S.C. 1641 from complying with its requirements. The state will report on waiting lists in section 1915(c) waiver programs; service delivery timeliness for personal care, homemaker, home health aide and habilitation services and will standardize the set of HCBS quality measures. The state will promote public transparency of the administration of Medicaid through public reporting of quality, performance and compliance measures.

(C) Fee-for-Service (FFS)
The State will publish all FFS Medicaid fee schedule payment rates on their website and will compare their rates for primary care, obstetrical and gynecological care and outpatient mental health and substance use disorder services to Medicare rates every two years. The State will publish the average hourly rate paid for personal care, home health aide, homemaker and habilitation services every two years. The State will demonstrate access sufficiency through an initial analysis when submitting a state plan amendment with a rate reduction or restructuring in circumstances that could result in diminished access for all services.

References:
Ensuring Access to Medicaid Services Final Rule (CMS-2442-F) | CMS

Contact Regarding:
AccessToCare@dhcfp.nv.gov

    Stakeholder Groups

    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.

    • Access to Care Monitoring Review Plan graphic

    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

      Nevada does 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 FFS arrangement:

      • Primary Care Services
      • Physician Specialist Services
      • Behavioral Health Services
      • Pre- and Post-Natal Obstetric Services, including Labor and Delivery
      • Home Health Services

      The ACMRP 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 market.

        Sources for more Information

        1. For the complete Federal Regulation governing access to care: www.ecfr.gov, link below. 42 CFR 447.203-447.205
        2. For the final rule with CMS comment period: The Federal Register, Department of Health and Human Services, CMS-2328-FC

        Exact Link: https://www.gpo.gov/fdsys/pkg/FR-2015-11-02/pdf/2015-27697.pdf, link below.

        1. General information about Center for Medicare & Medicaid Services: https://www.cms.gov, link below

        References

        CMS-2328-FC, Federal Regulation pg. 67582

          Contact Regarding CMS 2439-P and 2442-P

          Past Monitoring Review Plans (Coming Soon)

            Links