Provider and patient advocacy groups urged the CMS to rescind its proposed repeal of the Medicaid access rule, arguing that it would reduce access to care and create financial hardship for both beneficiaries and providers.
The current Medicaid access rule requires states to monitor and document fee-for-service Medicaid payments and their impact on beneficiary access to care. The CMS is proposing to repeal that rule to ease the administrative burden for states with 85% or more of their beneficiaries enrolled in Medicaid managed care. The proposed rule would allow states to reduce reimbursement rates to fee-for-service providers without having to demonstrate to the CMS that the rate reductions won't reduce access to care.
"CMS's proposal would put beneficiary access to care at greater risk," wrote the American Hospital Association in comments to the rule. "We believe that it is paramount that burden reduction efforts selectively target those burdens that are harmful, duplicative or provide no value. This proposed rule fails to meet this criteria."
Providers and consumer advocates argue that waiving the rule will lead to significant cuts in state Medicaid reimbursements and decrease provider participation in the program, which will limit access and reduce the quality of care. The comment period closed Friday.
"Multiple data sources show that payment is the primary driver in determining physician participation in the Medicaid program, and the proposed rule could lead to increasingly insufficient Medicaid payment rates, seriously jeopardizing patients' ability to access health services," said the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Osteopathic Association and the American Psychiatric Association in a joint statement.
Groups opposing the rule also claim the change will disproportionately affect certain providers like safety-net hospitals and community health centers, as well as specific patient populations such as the disabled and people who are eligible for both Medicare and Medicaid.
"Medicaid is a health insurance program. Its purpose is to pay for medically necessary covered services for eligible individuals," wrote Georgetown University's Health Policy Institute officials. "Without providers who will serve them, Medicaid beneficiaries will not have access to the services they need."
"Given our high volume of Medicaid business, we are concerned about any rule and regulations dealing with payment for care to people on Medicaid and their access to care," said officials with the Ohio State University's Wexner Medical Center.
"The most vulnerable and at-risk population groups, such as the aged and disabled, remain in FFS Medicaid," wrote Dr. Rod Hochman, president and CEO of Providence St. Joseph Health.
Medicaid's so-called "equal access provision" says that payments must be "sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area."
Opposition groups say that Medicaid beneficiaries and providers have relied on the requirement to remedy complaints that state payments are insufficient to provide enough access to care. And because the Supreme Court ruled in 2015 that providers couldn't enforce the provision in federal court, the CMS is the only way for them to seek recourse. The CMS proposal would allow states with high numbers of managed-care participants in their Medicaid programs to submit a self-determined alternative analysis to the CMS. However, the agency hasn't outlined what the criteria for such an analysis might be.
"The AAMC asks that CMS publish detailed standards by which the agency will review a state's alternative analysis," said the Association of American Medical Colleges. "If CMS finalizes the proposal, the agency should, at a minimum, revise the requirements to ensure states must continue to seek input from beneficiaries and providers."
As states continue to face strong budgetary headwinds, they may see the removal of the CMS oversight as an opportunity to slash reimbursement payments. The proposed rule allows states to cut Medicaid payments by 4% during one fiscal year or up to 6% over two consecutive fiscal years with no reporting requirements.
"In states where provider payment rates are already low, often due to a lack of rate increases over many years, a four to six percent rate reduction would have a significant impact," argued CalOptima, a public health plan in California.
State Medicaid administrators, on the other hand, are generally supportive of the measure.
"The implementation of the Access Rule Monitoring and Remediation Process has created an uncompensated administrative burden on Medicaid programs. The proposed changes would alleviate a significant amount of the burden for Medicaid programs," Idaho Medicaid officials wrote.
But some state agencies would like to go even further. Arizona would like less oversight when it comes to cutting reimbursement rates for providers.
"AHCCCS is concerned the proposed rules continue to require information be submitted by the State in support of nominal rate adjustments. This approach is inconsistent with the stated aims of the rulemaking and does not provide an exemption in practice that will diminish the administrative burden," wrote the Arizona Health Care Cost Containment System, which administers Medicaid in the state.
Likewise, the state of Colorado asked that the CMS reduce the managed-care threshold in the proposed rule.
Provider and consumer advocacy groups wonder if any changes are necessary because the administrative cost of the current rule is low. The CMS said in the proposed rule that, "This proposed rule is not economically significant with an overall estimated reduced reporting burden of $3,633,289," or about $71,000 per state.