CMS Issues Final Rule on Adequacy of Medicaid Payments to Providers

Legislation | November 23, 2015

The Centers for Medicare & Medicaid Services (CMS) released a final rule that provides guidance for states about creating a clear and evidence-based process to ensure Medicaid payments are adequate to attract enough providers to assure access to services for beneficiaries.

CMS aims to achieve the following 3 goals as a result of this rule:

  1. Linking beneficiaries’ needs and utilization of services with availability of providers.
  2. Enhancing beneficiaries’ participation through multiple feedback opportunities.
  3. Increasing stakeholder, provider, and beneficiary engagement when considering proposed changes to Medicaid fee-for-service payments rates that might impact beneficiaries’ ability to obtain services.

The rule requires state Medicaid agencies to develop an access monitoring review plan that takes the following into account:

  • Extent to which beneficiaries’ needs are met.
  • Availability of services through enrolled providers by geographic area, provider type, and site of service.
  • Changes in beneficiary utilization of services in each geographic area.
  • Characteristics of the beneficiary population.
  • Levels of payment available from other public and private payers. 

In line with other recent CMS guidance, states are required to have ongoing mechanisms for beneficiary and provider input on access to services and report on how the state responds to collected feedback. 

Public comments are being accepted for §447.203(b)(5) that addresses the access monitoring review plan time frame and the specific services to be covered. Comments are due by January 4, 2016.

Of particular interest to LeadingAge members, home health services are on the list of services specifically covered, along with services for which the states or CMS have received a higher volume of access complaints and any additional services selected by the states.

CMS is also seeking feedback on whether and what core access measures, thresholds, and access resolution techniques would be useful to ensure access to care for Medicaid beneficiaries.

A request for information on data metrics and alternative processes for access to care in the Medicaid program is open for responses through January 4, 2016. One of the specific areas sought for input is measuring access to long-term care and home- and community-based services. 

LeadingAge submitted comments on the request for information.