Medicaid and CHIP provide health insurance coverage to more than 84 million people, including low-income children, families, seniors, pregnant people, and people with disabilities. While Medicaid has a proven track record of providing affordable, high quality health care, stakeholders have long sought better transparency and accountability with respect to access to services.

CMS recently finalized two key regulations: “Ensuring Access to Medicaid Services” (Access Rule) and “Medicaid, CHIP Managed Care Access, Finance, and Quality” (Managed Care Rule), aimed at improving access to care in Medicaid across delivery systems (fee-for-service and managed care) and authorities (state plan and waiver services). The rules are long and complicated, but once fully implemented, they will make meaningful improvements in access to care, data and payment transparency, and beneficiary engagement. Today we are posting the first two blogs in a series unpacking the new rules. This blog summarizes the Access Rule at a high level, and my colleague Leo Cuello recently summarized the Managed Care Rule. More detailed blogs will follow, so check back to learn more!

Now, let’s take a look at the Access Rule.

The Access Rule addresses three primary areas: (1) documentation of access to care and service payment rates, (2) Medicaid Advisory Committee and Beneficiary Advisory Council, and (3) home and community-based services.

(1)   Documentation of Access to Care and Service Payment Rates § 447.203

Prior Law

Under an access rule finalized in 2015, states were required to develop and submit to CMS an Access Monitoring Review Plan (AMRP) for certain Medicaid services paid for on a fee-for-service (FFS) basis. However, SMD letter #17-004 and a 2018 proposed access rule (never finalized), sent clear signals to states that rates could be reduced without consideration of the AMRP if the reductions were “nominal” or if the state had high managed care penetration rates, significantly weakening the AMRPs. In 2019, CMS proposed but never finalized a rule that would have rescinded the AMRP requirement. At the same time, CMS issued subregulatory guidance saying the agency would establish a new access strategy later. CMS has only posted the 2016 AMRPs.

New Final Rule

​​The Access Rule rescinds the AMRP requirements, improves FFS rate transparency, and creates a new, two-tiered system for reviewing state requests to reduce or restructure Medicaid FFS payment rates. The rate transparency provisions require states to:

• Post all Medicaid FFS payment rates on a publicly available website as of July 1, 2026;
• Analyze some Medicaid FFS payment rates (primary care, OB/GYN, outpatient mental health and substance use disorder services) relative to comparable Medicare rates for 2025 by July 1, 2026;
• Disclose some Medicaid HCBS FFS payment rates for 2025 by July 1, 2026.

The Access Rule establishes a two-tiered system for reviewing state requests to reduce or restructure Medicaid payment rates. Rate reductions could be approved under a streamlined process if the state can show: (1) aggregate Medicaid payments following the change would be at or above 80% of the comparable Medicare rate, (2) the cumulative effect of all reductions would result in no more than a 4% reduction in aggregate FFS Medicaid expenditures for each benefit category, and (3) the public process yielded no significant access to care concerns that the state could not reasonably address. If the state cannot show (1)-(3) above, additional analyses are required. Noncompliance with these requirements could result in CMS disapproving the state plan amendment (SPA) or withholding payment.

(2)   Medicaid Advisory Committee and Beneficiary Advisory Council § 431.12

Prior Law

States are currently required to have a Medical Care Advisory Committee (MCAC) to advise the state Medicaid agency about health and medical care services. The rules described high-level requirements related to the composition of the committee, the scope of topics to be discussed, and the support the committee could receive from the state in its administration. There are no rules currently in effect regarding the frequency of the MCAC meetings or their transparency.

New Final Rule

The Access Rule changes the name of the MCACs to the Medicaid Advisory Committee (MAC), reflecting the broader scope of topics the MACs would be able to address, such as: additional or changes to services; coordination of care; quality of services; eligibility, enrollment, and renewal processes; beneficiary and provider communications by the agency and MCOs; cultural competency, language access, health equity, and disparities and biases in the Medicaid program; and other issues. The rule would also require states to form a Beneficiary Advisory Council (BAC) made up of Medicaid beneficiaries or their representatives.

The recruitment and appointment processes for the MAC must be public and transparent, and 25% of the MAC membership will eventually need to be drawn from BAC members. The MAC will have to meet at least quarterly and the BAC will meet before each MAC meeting. MAC meeting minutes must be posted publicly and at least two MAC meetings must be open to the public with an opportunity for public comment. BAC meetings may be held privately at the discretion of the BAC. Finally, the MAC will be required to submit an annual report to the state that the state must post online. Unless a longer time frame is specified, states have until July 9, 2025 to comply with the MAC/BAC changes.

(3)   Home and Community-Based Services Part 441

Prior Law

While there have been quality and reporting requirements for Medicaid HCBS, the requirements vary across authorities and delivery systems and are often inadequate to provide the necessary information for ensuring that HCBS are delivered in a high quality manner that best protects the health and welfare of beneficiaries. Data differences have made it difficult to assess disparities in access, utilization, quality, and outcomes across demographic groups, and notable, high-profile instances of abuse and neglect have resulted from poor quality and inadequate oversight. Finally, inadequate payment rates and workforce shortages have hindered progress toward providing more care in community-based settings versus institutions.

New Final Rule

Under the new final rule, a series of changes would create a more uniform system for monitoring quality and improving oversight across HCBS authorities. The new rules will apply to § 1915(c) HCBS waivers and §§ 1915(i) state plan services, (j) personal assistance services, and (k) Community First Choice. The new rules will also apply under § 1115 demonstration projects unless specifically waived, and under FFS and managed care delivery systems.

States will be required to:

• Update functional assessments and person-centered plans at least once every 12 months;
• Establish grievance procedures for Medicaid beneficiaries receiving certain HCBS services in FFS (there are already grievance procedures applicable to managed care);
• Establish an incident management system to identify, investigate, and resolve critical incidents, including reports of abuse, neglect, and financial exploitation;
• Provide assurances that payment rates are adequate to ensure a sufficient direct care workforce;
• Collect and report data to monitor access (e.g., waiting lists, average amount of time between approval for and delivery of HCBS services, percent of authorized hours provided); and
• Report on core measures in the HCBS Quality Measure Set.

Stay tuned for more detailed posts on the FFS payment and MAC/BAC provisions.

[This is part of a blog series on two key federal regulations that aim to improve access to care for people enrolled in Medicaid and CHIP across delivery systems. Learn more about the “Ensuring Access to Medicaid Services” and “Medicaid, CHIP Managed Care Access, Finance, and Quality” rules here.]