Physicians and hospitals want the CMS to require state Medicaid agencies to do more to make sure beneficiaries have access to care than called for under regulations issued last fall.
A final rule published this past October outlines how Medicaid agencies must monitor access, particularly when they cut payment rates for physicians.
A draft version of the regulations was published in May 2011 as several states sought to reduce payments to providers in response to budget shortfalls fueled by the Recession.
The U.S. Supreme Court, in the meantime, ruled in March last year that beneficiaries and providers can't sue state Medicaid agencies over rate cuts. The CMS notes in the final rule that the decision puts even greater onus on the agency to make sure the programs pay providers enough to ensure access to high quality care.
The regulations require state Medicaid agencies to measure beneficiaries' health needs and the availability and use of services. They must conduct the assessment every three years and within a year of cutting rates to providers.
The CMS solicited additional feedback on measures, thresholds and appeals processes that would provide better information or procedures to ensure access. The agency received 79 comments by the Jan. 4 deadline.
Providers generally praised the effort but asked for additional measures to be tracked.
“The rule does not go far enough,” the American Medical Association said in a comment letter. “We do not believe the rule provides sufficient criteria for measuring access and urge that it be strengthened by requiring states to use specific and uniform data elements.”
For example, the AMA said, states should be required to track wait times for appointments by provider type and access to alternative office hours, such as those in the evenings and weekends.
The AMA also asked the CMS to require an analysis of Medicaid fee-for-service rates compared with Medicaid managed care rates.
Hospital associations, meanwhile, are unhappy that the CMS chose not to include many hospital services as core services under the rule.
“Doing so will allow states to continue to cut funds for hospital services with little federal oversight, exacerbating access to lifesaving treatment and basic hospital services,” the Arizona Hospital and Healthcare Association said in a letter.
Arizona has cut rates and other payments for hospital services repeatedly since 2008. The hospital association says Medicaid now pays its members less than 70% of the cost of the care they deliver.
State Medicaid agencies, however, still bristled at the creation of national thresholds for access to care.
“State Medicaid agencies are the experts on the Medicaid populations they serve and are in the best position to develop methodologies to ensure sufficient access to care,” the Texas Health and Human Services Commission said in a comment letter.
Sentiment was echoed by Pennsylvania's Department Of Health And Human Services, which noted that rural parts of that state are vastly different from the urban areas.
The rule applies only to fee-for-service Medicaid programs, but the CMS invited managed care plans to comment because similar measures were included in a Medicaid managed care rule published last summer.
The plans that responded pushed back on a requirement that states review access to care in responsive to unusually high numbers of complaints from beneficiaries.
Centene, for example, argued that such complaints are too subjective to warrant tracking.
The Minnesota Council of Health Plans, meanwhile, argued that addressing complaints in the context of the access reviews would duplicate appeals and grievance procedures already in place.
Joan Alker, executive director of the Georgetown Center for Children and Families, countered that state-based procedures may not be sufficient. The CMS, she said, should create a national process for Medicaid applicants, enrollees, providers and other stakeholders to raise and seek resolution of concerns about access.
