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CMS Proposes Medicaid Care Access Rule

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The Centers for Medicare and Medicaid Services (CMS) has issued a draft of a regulation that could help state Medicaid programs show they are meeting patient care access requirements.

To meet the proposed standards, states might have to use commercial plan enrollee care access data from state databases, CMS databases, beneficiary surveys and other sources, CMS officials say in a Medicaid care access proposed rule that appears today in the Federal Register.

If implemented, the CMS proposed rule would have no direct effect on ordinary commercial health plans. The rule could affect commercial companies that manage state Medicaid plans, and the success or failure of Medicaid care access measurement efforts could affect the thinking of customers and plan managers in the commercial plan market.

CMS officials note that they want to offer state programs a high degree of flexibility to try new approaches to improving the quality of care and control the cost.

“We recognize that payment reductions or other adjustments to payment rates are legitimate tools to manage Medicaid program costs and achieve overall budget objectives,” officials say. “However, payment rate changes made without consideration of the potential impact on access to care for Medicaid beneficiaries or without effective processes for assuring that the impact on access will be monitored, may lead to access problems. Payment rate changes are not in compliance with the Medicaid access requirements if they result in a denial of sufficient access to covered care and services.”

Section 1902(a)(30)(A)

Medicaid is a public health program for the poor that is managed by the states and funded with a combination of state and federal money.

Section 1902(a)(30)(A) of the Social Security Act requires states to show that Medicare enrollees are

getting access to care that is comparable to the kind of care that members of the general population are getting.

The Patient Protection and Affordable Care Act of 2010 (PPACA) is supposed to greatly expand enrollment in Medicaid in 2014, and some Republicans in Congress asked while PPACA was being debated whether the new Medicaid enrollees would end up with any more access to medical care than they had when they were uninsured.

Several court cases have established conflicting standards for states that are trying to prove that their Medicaid programs are providing adequate access to care, officials say


In the proposed rule, CMS officials suggest that states could consider tracking enrollee care access indicators such as success in scheduling medical appointments – including after hours appointments, satisfaction with the availability of service providers within a reasonable distance from home, and knowledge about whether a particular service is covered by Medicaid.

To gauge the adequacy of the Medicaid provider, a state could look at indicators such as the number of providers with open panels who are accepting new Medicaid patients, the extent to which timely follow-up visits occur after an emergency visit or inpatient stay, and the time it takes for a provider who submits an application to participate in the Medicaid program to get permission to serve Medicaid enrollees, officials say.

Comments on the proposal are due July 5.

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