The Centers for Medicare and Medicaid Services (CMS) recently published a proposed rule that would require states to implement a standardized review process to ensure compliance with Medicaid access requirements. This is an important requirement since, historically, during times of economic crisis states have reduced rates to providers without having to justify the reductions, which have led to harmful effects on Medicaid enrollees’ access to care.
The proposal relies on a framework recently developed by the Medicaid and CHIP Payment and Access Commission (MACPAC) and focuses on 3 areas: enrollee needs; the availability of care and providers; and service utilization. States would have flexibility to determine the appropriate measures to demonstrate and monitor access to care within each category. The proposal would apply only to Medicaid services paid through a state plan under fee-for-service, not services provided through managed care arrangements. It would not apply to the Children's Health Insurance Program (CHIP).
Whenever a state proposed provider rate reductions or restructuring, it would have to conduct an "access review" based on MACPAC's 3-part framework. Medicaid payment rates also would be reviewed in relation to standard Medicare payment rates, commercial payment rates, and provider costs. Following any payment reductions or restructuring of rates, states would be required to develop monitoring procedures to assess any negative impacts on access to care. The rule would allow a state to electronically publish any state plan amendments that involve payment rate changes.
Comments on the proposed rule are due July 5.