On March 23, 2018, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that would provide for a reduction of administrative burden with states that have high rates of Medicaid managed care enrollment. In the past, states with high enrollment have raised concerns regarding administrative burden when they have to determine whether Medicaid payments in Fee-for-Service systems are sufficient to enlist providers to ensure beneficiary access to covered care and services consistent with the statute.
Currently, states have to develop and submit to CMS an Access Monitoring Review Plan (AMRP) for Medicaid services every three years. This includes categories of services such as primary care, physician specialist, behavioral health, pre- and post-natal obstetric, and home health. The AMRP must identify a data-driven process to review access to address: 1) the extent to which beneficiary needs are fully met; 2) the availability of care through enrolled providers; and 3) changes in beneficiary service utilization. When states reduce rates for Medicaid services, they must add those services to the AMRP and monitor the effects of the rate reductions for three years. States must also undertake a public process and submit specific information regarding access to care when proposing to reduce or restructure Medicaid provider payment rates.
This proposed rule would provide an exemption to these requirements by proposing an 85% risk-based Medicaid managed care enrollment rate threshold, including comprehensive risk contracts. If states met that threshold, they would be exempt from having to develop an AMRP. This proposed rule would go even further by providing an exemption from all of the proposed procedures within the above thresholds even if the state hasn’t completed their side of the public process.
The proposed rule will also not look to require states to accurately predict the effect of Medicaid payment rate changes on access to care and instead submit an assurance that current access is consistent with the act and the baseline data supports this assurance. When states would meet this threshold, they would also be exempt from the requirements to consider the data collected through the AMRP and wouldn’t have to include documentation supporting compliance with the AMRP review. Nominal rate payment changes (4% one year, 6% two years) would not be subject to special provisions for rate reductions or restructuring procedures when submitting a State Plan Amendment (SPA) for changes.
Although the proposed rule would establish such thresholds, states are still obligated by statute to ensure Medicaid payment rates are sufficient to enlist enough providers to ensure beneficiary access to covered care and services is at least consistent with that of the same population in the general area, particularly when reducing or restructuring Medicaid payment rates through SPAs.
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