The federal Medicaid agency took a significant step last week toward improving access to health services for Medicaid participants.  On October 29, the Center for Medicare and Medicaid Services (CMS) issued a long-awaited rule that directs states to ensure compliance with Medicaid access standards in the Affordable Care Act (ACA).

According to CMS, the purpose of the new rules is to enable it and the states to make better informed, data-driven decisions when considering whether proposed changes to Medicaid payment rates are sufficient to ensure that Medicaid beneficiaries have access to covered Medicaid services.

A blog post by Kelly Whitener of the Georgetown Center for Children and Families summarizes the new process for monitoring whether payment rates meet the ACA access requirement:

“The final rule requires each state to develop a medical assistance access monitoring review plan. The plan must be published and made available for public comment for at least 30 days prior to finalization and submission to CMS for approval. The plan must be established by July 1, 2016 and updated every 3 years.”

Any state that finds access problems would have to submit a correction plan within 90 days after discovering a problem. The rule also strengthens CMS’ ability to review Medicaid payment rates and ensure that they are consistent with efficiency, economy and quality and care.

The rule is final and takes effect on January 4, 2016. However, between now and then CMS is soliciting input on the portion of the rule that outlines the timetable for the access monitoring review plans. The agency is seeking comment on the service categories required for ongoing review, the elements of the review, and the timeframe for submission, as well as whether there should be an exemption process.

CMS also issued a request for information (RFI) on additional approaches the agency and states should consider to ensure better compliance with access requirements. Two examples include the potential development of a core set of access metrics and thresholds that can be applied nationally standardized core set measures of access, and establishing and a robust complaint resolution and appeals process. CMS will accept responses to the RFI through January 4, 2016.

The rule was initially drafted in 2011, but seemed to get sidetracked by a number of concerns about the best approach for balancing the state and federal roles. However, the completion of the rule became more important earlier this year when the U.S. Supreme Court ruled in Armstrong v. Exceptional Child Center, Inc. that Medicaid providers and beneficiaries don’t have a right to sue Medicaid agencies over low payment rates. The Court concluded that federal administrative agencies are better suited than federal courts to make these determinations.

The final rule is available on the Federal Register here.

Jon Peacock