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CMS seeks input for final rule and request for information on essential health care services for Medicaid beneficiaries

November 2, 2015

The Centers for Medicaid and Medicaid Services (CMS) recently released a final rule with comment aimed at enhancing the delivery of health care services provided under the Medicaid program. The final rule—Methods for Assuring Access to Covered Medicaid Services, provides a framework for CMS to make better informed, data-driven decisions when considering whether proposed changes to Medicaid fee-for-service payment rates to ensure that Medicaid beneficiaries have access to covered Medicaid services.

The primary goals of the final rule are:

  • Measure and link beneficiaries’ needs and utilization of services with availability of care and providers;

  • Increase beneficiaries’ involvement through multiple feedback mechanisms;

  • Increase stakeholder, provider, and beneficiary engagement when considering proposed changes to Medicaid fee-for-service payments rates that could potentially impact beneficiaries’ ability to obtain care.

To support the goals of the final states are required to meet these requirements:

  • Develop an access review plan that set out the data elements and other information to be used to ensure beneficiary access to mandatory and optional services;

  • Establish new procedures to review the effects on beneficiary access of proposed rate reductions and payment restructuring;  

  • Implement ongoing access monitoring reviews of key services, and additional services as warranted.

The services to be addressed in the state’s access review plan include:

  • Primary care services

  • Physician specialty services

  • Behavioral health services

  • Pre- and post-natal obstetric services

  • Home health services

  • Services about which the state receives a significantly higher than usual volume of access complaints

The final rule becomes effective on January 4, 2016. This will enable states to begin preparing their initial review plan analysis and to assess whether adjustments to this provision are warranted.

In conjunction with the final rule, CMS released a request for information (RFI)—Data Metrics & Medicaid Access to Care RFI (CMS-2328-NC), to solicit comments on additional approaches the agency and states should consider to ensure better compliance with Medicaid access requirements. CMS is seeking feedback on whether and what core access measures, thresholds, and access resolution processes would be useful in ensuring access to care to Medicaid beneficiaries.

Comments for both the provisions of the final rule on which comments are sought and for the RFI should be submitted electronically through Comments must be received by January 4, 2016 at 5 pm ET. Leave comments for the final ruleMethods for Assuring Access to Covered Medicaid Services and leave comments for the RFIData Metrics and Alternative Processes for Access to Care in the Medicaid Program.

Additional Resources:

Methods for Assuring Access to Covered Medicaid Services (CMS-2328-FC) Final Rule and Request for Information (RFI): Press release

Last modified on 05/18/2023

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