CMS strengthens access to essential health care services for Medicaid beneficiaries

Meaningful access to health care services is crucial for the 72 million Americans who rely on the Medicaid program for coverage. As our nation  moves towards better sharing and utilizing of information to improve health access, treatment, and outcomes, it is critical for us to work together to ensure continued access to preventive, primary, and specialty service that are needed to maintain the health and well-being of our most vulnerable populations.

The Centers for Medicare & Medicaid Services (CMS) today released a final rule that not only improves our ability to measure and ensure meaningful access to covered services, but also provides greater safeguards for beneficiaries who may otherwise experience great difficulty in receiving needed health care services. The intent of this final rule is to provide a framework for us to use to make better informed, data-driven decisions that support more effective service delivery systems, service rate structures, and provider payment methodologies that reflect our unique and evolving Medicaid population.

Building upon comments on the 2011 proposed rule, this final rule signifies another step forward in strengthening the delivery of health care services provided under the Medicaid program.

“Maintaining beneficiaries’ access to care is vital to the health of our nation and health of those who may not otherwise have access to essential health care services,” said Vikki Wachino, deputy administrator of CMS, and director, Center for Medicaid and CHIP Services. “Through this rule, beneficiaries will have greater confidence in the services they receive from their Medicaid health care coverage.”

The goals of the final rule are fundamental to our health care system: (1) measuring and linking beneficiaries’ needs and utilization of services with availability of care and providers; (2) increasing beneficiaries’ involvement through multiple feedback mechanisms; and (3) increasing stakeholder, provider, and beneficiary engagement when considering proposed changes to Medicaid fee-for-service payments rates that could potentially impact beneficiaries’ ability to obtain care.

To support these three goals, the final rule requires states to develop an access review plan that set out the data elements and other information to be used to ensure beneficiary access to mandatory and optional services; to establish new procedures to review the effects on beneficiary access of proposed rate reductions and payment restructuring; and to implement ongoing access monitoring reviews of key services, and additional services as warranted. These provisions enhance meaningful access to health care services by putting beneficiaries back at the center of their care.

The final rule also strengthens CMS’ ability to review and ensure Medicaid payment rates are consistent with efficiency, economy and quality and care. This aligns with the recent Supreme Court Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (2015) decision, which concluded that federal administrative agencies are better suited than federal courts to make these determinations. The court ruling placed greater importance on review and enforcement capability at the federal level; thus, improving our ability to monitor, measure, and ensure access to care within fee-for-service payment methodologies.

The final rule becomes effective on January 4, 2016, at which time states must meet the requirements established through the provisions of the rule. During the 60-day period, CMS will accept comments from the public on the access review requirements. This will enable states to begin preparing their initial review plan analysis and to assess whether adjustments to this provision are warranted.

In conjunction with the final rule, CMS today released a request for information to solicit comments on additional approaches the agency and states should consider to ensure better compliance with Medicaid access requirements. This includes comments on the potential development of standardized core set measures of access, access measures for long-term care and home and community based services, national access to care thresholds, and resolution processes that beneficiaries could use in facing challenges in accessing essential health care services. CMS will accept response to the request for information through January 4, 2016.

The final rule with comment and request for information are available on the Federal Register at https://www.federalregister.gov/public-inspectionstarting October 29, 2015 and can be viewed at https://www.federalregister.gov starting November 2, 2015.

For more information, visit http://www.medicaid.gov/medicaid-chip-program-information/by-topics/acce...  

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