Last November, the Centers for Medicare & Medicaid Services (CMS) proposed changes to its Medicaid Managed Care Rule. As I explained at the time, these proposals can be seen as part of a broader effort by the agency to weaken access protections for children, parents, and other Medicaid beneficiaries, not just in managed care, but also in fee-for-service. Because of the importance of managed care to children and parents enrolled in Medicaid—nationally, the large majority are enrolled in managed care organizations (MCOs) that are responsible for ensuring that they receive the services they need—Georgetown University’s Center for Children and Families (CCF) filed comments on the proposed changes.
The CCF comments focused primarily on the proposed dilution of the measure of MCO provider network adequacy. Since Medicaid MCOs rarely pay for services furnished to their enrollees by providers that do not participate in their provider networks, the key to access for MCO enrollees is whether an MCO’s provider network has enough providers participating who will actually treat the MCO’s enrollees so that those enrollees can get the services they need. In May 2016, after a thorough development process and public comment period, CMS issued a Managed Care Rule that required, at a minimum, that states establish time and distance standards for measuring MCO network adequacy (for example, how much travel time to the nearest participating primary care physician). Each state had the flexibility to determine its own time and distance minimum requirements for each provider group (e.g. primary care physicians, specialist, hospitals, etc.)
The 2016 Managed Care Rule was a comprehensive overhaul of prior regulations, involving many changes. To give state Medicaid agencies and MCOs time to adjust, requirements were phased in over more than three years; the network adequacy “time and distance” standard became effective for managed care contracts starting on or after July 1, 2018. Yet with less than six months of operational experience, in 2018 CMS proposed to eliminate the state-determined time and distance standard as a requirement and replace it with a requirement for any “quantitative” standard of the state’s own design. In our comments, we argue that the current time and distance standard contains more than enough flexibility for states to design requirements that reflect the characteristics of its provider markets and geographical challenges and should not be changed without far more operational experience.
We made a similar point in our comments on CMS’s proposed changes to the Access Rule, which measures beneficiary access to services in fee-for-service Medicaid. The Access Rule, issued by CMS in November 2015, after years of litigation, required states to measure and monitor access to care in the fee-for-services portions of their programs. The Rule phased in reporting and transparency requirements in three-year cycles, starting in 2016. Without having the operational experience of a full cycle, CMS proposed to exempt 18 states with high managed care enrollment from the requirements altogether. In our comments, we argued that this exemption was unwarranted and would leave 3.9 million Medicaid beneficiaries in those states, including 660,000 children, without the protections of the Rule.
On December 12, CMS notified OMB that it would rescind its proposed changes to the Access Rule. Although public comment on the proposed changes to the Access Rule was overwhelmingly negative, it is highly unlikely that the objections that CCF and others raised persuaded CMS to withdraw them. It is more likely that CMS is considering proposing more radical changes to the Access Rule, but only time will tell. I would be more than happy to stand corrected.
I would be even happier if the CMS Administrator, Seema Verma, would reconsider her apparent hostility to minimum access standards, whether in fee-for-service or managed care Medicaid. A basic objective of the Medicaid program is to ensure that beneficiaries have access to needed services. Administrator Verma should be promoting, not undermining, that objective. She could start by withdrawing the proposal to dilute MCO network adequacy standards.