Federal regulations at 42 CFR 447.203 and 447.204, implementing section 1902(a)(30)(A) of the Social Security Act (the Act), describe procedures for states and territories to follow in order to document that Medicaid payment rates are sufficient to enlist enough providers so that care and services are available under the state plan at least to the extent that such care and services are available to the general population in the geographic area. Through Access Monitoring Review Plans (AMRPs), states are required to analyze data and supporting information to reach conclusions on sufficient access for covered services provided under fee-for-service. Every three years, states must conduct the analysis for: primary care services (including those provided by a physician, FQHC, clinic, or dental care); physician specialist services; behavioral health services, including mental health and substance use disorder; pre- and post-natal obstetric services, including labor and delivery; and home health services. States are required to include additional services within the AMRPs when proposing to reduce rates or restructure payments in ways that may harm access to care and describe procedures to monitor access over three years once the reductions are approved. The AMRPs, and subsequent additions to the AMRPs, are developed in consultation with a state’s Medical Advisory Committee and subject to a 30 day public comment period prior to submission to the Centers for Medicare & Medicaid Services (CMS).
States submitted the first round of AMRPs to the CMS on October 1, 2016. The AMRPs are reviewed, but not formally approved, by CMS and are used to determine compliance with the Act as part of the State plan amendment review process. The AMRPs below are the “as submitted” plans received by CMS from states for the first submission period. CMS will update the documents as states amend them for purposes of analyzing and monitoring services subject to rate reductions.
Information contained below is gathered by CMS with assistance from States. If any information is incorrect, please send an email to MedicaidAccesstoCare@cms.hhs.gov.
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On November 2, 2015, CMS issued the Request for Information (RFI): Data Metrics and Alternative Processes for Access to Care in the Medicaid Program to inform the potential development of standards with regard to Medicaid beneficiaries’ access to covered services under the Medicaid program. CMS solicited information on four specific topic areas: 1) developing a core set of measures of access that all states would monitor and publicly report on in the state’s access monitoring review plan; 2) measuring access to long term care and home and community based services; 3) setting national access to care thresholds; and 4) establishing a process that would allow beneficiaries experiencing access issues to raise and seek resolution of their concerns. To help analyze the responses to the RFI, CMS engaged the Urban Institute to develop a report entitled “Proposed Medicaid Access Measurement and Monitoring Plan.” Through their efforts, the Urban Institute identified readily available data elements currently in use by CMS and states through other programs, initiatives, and resources that may be used to measure access to care, such as the Adult and Child Core Set, Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the Healthcare Effectiveness Data and Information Set (HEDIS). CMS is making the final report available as a technical assistance tool for states. The report is for informational purposes and the framework described within is not mandated.