The CMS wants to lower states' requirements for showing that their Medicaid fee-for-service payment rates are adequate to enlist enough providers to offer beneficiaries satisfactory access to care.
The rule proposed Thursday would rescind a 2015 Obama administration rule requiring states to file an access monitoring review plan and update it at least every three years.
The CMS said the proposed rule would save states money, and that it would issue a separate guidance reminding them that they must ensure beneficiaries have adequate access to care. The public will have 60 days to comment.
State officials had complained that the 2015 rule imposed excessive administrative burdens. They also said it wasn't needed given that most Medicaid beneficiaries across the country now are enrolled in private Medicaid managed-care plans, which must meet CMS network access standards.
"Rather than micromanaging state programs through complex federal mandates, CMS is easing the administrative burden on states while focusing on holding them accountable for delivering high-quality, accessible care to beneficiaries," CMS Administrator Seema Verma said in a written statement.
The proposal is the latest move in a long-running struggle to make sure Medicaid patients have adequate access to care despite the program's generally low payment rates to providers. The CMS currently is working on controversial revisions to the Obama administration's network adequacy and access standards for Medicaid managed-care plans.
Matt Salo, executive director of the National Association of Medicaid Directors, praised the new CMS proposal on state reporting requirements as "a sensible step forward" because the 2015 regulation wasn't working.
"We're all committed to meaningful access and to measuring that in ways that are outcomes-oriented," he said.
But other Medicaid experts warned that dropping the reporting requirements would make it more difficult to determine whether there are an adequate number of physicians and other providers available to serve patients in both the Medicaid fee-for-service and managed-care programs.
"They are eliminating the data that serves as an early warning system," said Sara Rosenbaum, a health law professor at George Washington University and former chair of the Medicaid and CHIP Payment and Access Commission. "Managed care is only feasible where there is an adequate supply of providers. If the network is illusory, you need to know that."
She and others worried about erasing the current reporting requirements without having an alternative system in place.
"We're concerned that CMS proposes to rescind the current reporting and monitoring scheme before having a comprehensive strategy in place to protect Medicaid enrollees, which should be developed with meaningful input from beneficiaries and their advocates," said Judy Solomon, a senior fellow at the Center on Budget and Policy Priorities.
The American Hospital Association said it has concerns about the proposed rule but wants to review it more closely before commenting. In its comments on the 2015 rule, the AHA raised concerns about states being able to cut Medicaid payment rates for hospital services following a U.S. Supreme Court ruling that year finding that providers cannot challenge state-set rates in federal court.
States are required by statute to pay Medicaid rates that attract enough providers so that services are at least as available to beneficiaries in each geographic area as they are to the general public.
To ensure that, the Obama administration required that states develop an access monitoring review plan for their Medicaid fee-for-service programs that analyzed the availability of primary-care providers, physician specialists, behavioral health providers, obstetric providers, home health and other types of providers.
States must consider the data collected through the access monitoring plan and solicit public input on the potential impact of any proposed cuts or restructuring of payment rates on access to care. They have to submit their proposed cuts and their impact analysis to the CMS for approval. The agency can take compliance action against states to remedy access issues.
Now the CMS wants to eliminate most of that process but continue requiring states to maintain documentation of payment rates and make that information available to the agency upon request.
As an added protection, the CMS said it would issue subregulatory guidance giving states flexibility to select the types of data they would use to demonstrate the sufficiency of payment rates.
"We expect that the guidance would remind states of their ongoing obligation to ensure sufficient payment rates," the agency said in the proposed rule.
It also said it is ramping up a "data-driven strategy to understand access to care" in the Medicaid program across the fee-for-service, managed care, and home-and-community based programs.
But Rosenbaum was skeptical.
"The battle over how to measure and ensure access and take steps to fix access problems has been an issue for Medicaid for its entire life," she said. "Now we seem to be moving away from any real, practical approach to even knowing where we have an access problem."
