Some want to opt out of a CMS rule effective this week that's meant to ensure Medicaid beneficiaries have adequate access to care. State officials say the rule is outdated and a waste of administrative resources. But scofflaws could see their federal funds withheld if they don't comply.
Last year, the CMS finalized a rule requiring states to assess how easy it is for fee-for-service Medicaid beneficiaries to receive primary care and pre-and post-natal obstetric services and see specialists and behavioral health experts, among other services.
The CMS felt that there are adequate provider network standards for managed-care beneficiaries so they are excluded. The agency gave states until Oct. 1 to submit their plans for review. The rule was first proposed in 2011, and states say it won't make a big impact on the current population. Of the 75.2 million beneficiaries now in Medicaid, 73% are now in private plans, up from 55% in 2013 according to PwC.
States with at least 90% beneficiaries in managed care, like Florida, say there's no point in spending the time to conduct the assessment of its Medicaid population. In the final access rule, the CMS estimated it could take states as long as 15,000 hours to develop the plans.
“We have a tiny fee-for-service population,” said Justin Senior, deputy secretary of the Division of Medicaid in Florida at the 2016 Medicaid Health Plans of America last week. “We're having to do as much work under the access rule as we are to comply with the managed Medicaid rule. It doesn't make any sense.”
Senior said that at any given time there are between 15,000 and 30,000 fee-for-service beneficiaries in his state compared with the more than 3 million in managed care. Beneficiaries not in managed care in his state Medicaid program include those who have other healthcare coverage, persons eligible for refugee assistance, and Medicaid recipients who are residents of a developmental disability center.
Tennessee was successful in getting a pass from complying with the rule as the agency saw the fee-for-service enrollees generally had other forms of coverage such as Medicare, according to Medicaid spokeswoman Sarah Tanksley. The state had just 319 people in fee-for-service as of August, compared to 1.5 million in managed care.
Others haven't been as successful.
Iowa officials asked for a delay in submitting its plan because it is also developing new time and distance standards required by the managed-care rule. The CMS declined their request, according to state Medicaid spokeswoman Amy Lorentzen McCoy. The state has 29,000 fee-for-service beneficiaries, compared with 595,592 in managed care.
The CMS has said it will not offer a blanket exemption to all states with few people in fee-for-service as it felt access to care needed to be guaranteed for this population as well. For the most part, states with small fee-for-service populations interviewed for this story said they would comply.
Providers are against exemptions and say they don't think administrative burden is a reason enough not to comply with the rule.
“It's more burdensome for a patient to not have access to care,” said Ivy Baer, senior director of regulatory and policy at American Medical Colleges.
Others pointed out that children who qualify for Medicaid based on complex medical needs are more likely to be enrolled in fee-for-service.
“They are a vulnerable beneficiary population served by Medicaid who would likely benefit from the access review requirements,” said Gillian Ray, a spokeswoman for Children's Hospital Association.
Experts echoed provider sentiments. “Even small Medicaid populations are entitled to accessible care,” said Sara Rosenbaum, professor of health policy at George Washington University.
