In March, CMS proposed changes to the Medicaid Access Rule. That Rule, in effect only since 2016, establishes procedures that states must meet to demonstrate that they are complying with the Medicaid statute’s requirement that provider payment rates be sufficient to ensure Medicaid beneficiaries have access to care.   We recently shared our comments on the proposed changes.  We also wrote about how access to EPSDT services for children would be at risk because payment rate cuts to fee-for-service (FFS) providers of less than 4% over one year, and 6% over two, would no longer be subject to rigorous review for effects on access.

The proposed rate cut review exemption would apply in all states. There are 18 states where the FFS Medicaid population would be at even greater risk. This is because under the proposed rule, any state with 85% or more of its Medicaid beneficiaries enrolled in managed care organizations (MCOs) would be exempt from most of the Access Rule’s procedural requirements.  According to the Kaiser Family Foundation’s Medicaid Managed Care Tracker, the following states had 85% or more of their Medicaid beneficiaries enrolled in MCOs as of July 1, 2017:  Arizona, The District of Columbia, Florida, Hawaii, Iowa, Kansas, Kentucky, Louisiana, Maryland, Nebraska, New Jersey, New Mexico, Ohio, Oregon, Rhode Island, Texas, Utah, and Washington.

The proposed exemption would mean these states would not have to collect and analyze data relating to access to care in FFS Medicaid and publish the resulting analysis in an Access Monitoring Review Plan (AMRP), or apply that analysis and baseline data in determining whether a cut in FFS payment rates of any amount would impair access.  These states would also be exempt from the requirement that access be monitored for three years after any payment rate cut approved by CMS goes into effect.

Although most of the Medicaid populations in these exempt states are enrolled in managed care, the populations remaining in FFS Medicaid are not trivial.  We reviewed the AMRPs submitted to CMS by these 18 states to analyze the FFS population affected.  Our result are shown below.  There are at least 3.9 million FFS enrollees in these 18 states, including at least 660,000 children.  This is likely an undercount, as three out of the 18 states did not report FFS enrollment in the AMRPs.

FFS enrollment reported in AMRPs

We also found that children and the American Indian population have significant FFS enrollment in some states. Only eight out of 18 states reported a FFS child enrollment figure, but child enrollment was at least 17% of total FFS enrollment. This is higher in several states: children are 29% of FFS enrollment in New Jersey, 48% in New Mexico, and 52% in Texas. Three out of 18 states reported American Indian enrollment in FFS Medicaid. In the states that reported this data, the American Indian population is a significant share of the state’s FFS enrollment; it is 57% of FFS enrollment in Arizona, 99.8% of FFS enrollment in New Mexico, and 11% of FFS enrollment in Washington.

In proposing this exemption for states with high managed care, CMS does not explain why the remaining FFS populations in these states, and the providers that serve them, should not continue to have the protections of the Access Rule.  If implemented, these changes would lead to less transparency and accountability making it more difficult to assess whether or not states are fulfilling their responsibility to ensure access to care for all Medicaid populations.

Access Rule Comments