Documentation of Access to Care and Service Payment Rates
Section 1902(a)(30)(A) of the Act requires that State plans “assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” Beginning in 2015, in order to demonstrate compliance, states were required to complete and make public access monitoring review plans (AMRPs) that analyzed and informed determinations of the sufficiency of access to care (which may vary by geographic location in the state) and were used to inform state policies affecting access to Medicaid services, including provider payment rates.
On April 22, 2024, CMS published, “Ensuring Access to Medicaid Services (CMS-2442-F)” (Access Final Rule, CMS 2442-F), effective July 10, 2024. The Access Final Rule rescinded the AMRP requirements previously in § 447.203(b)(1) through (8) and replaced these requirements with a streamlined and standardized process, described in § 447.203(b) and (c). The fee-for-service (FFS) payment provisions, located in Section II.C. of the Access Final Rule under “Documentation of Access to Care and Service Payment Rate, contain the following;
- Requires states to publish all FFS Medicaid fee schedule payment rates on a publicly available and accessible website.
- Requires states to compare their FFS payment rates for primary care, obstetrical and gynecological care, and outpatient mental health and substance use disorder services to Medicare rates, and publish the analysis every two years.
- Requires states to publish the average hourly rate paid for personal care, home health aide, homemaker, and habilitation services, and publish the disclosure every two years.*
- Requires states to establish an advisory group for direct care workers, beneficiaries, beneficiaries’ authorized representatives, and other interested parties to meet at least every two years, and advise and consult on payment rates paid to direct care workers for personal care, home health aide, homemaker, and habilitation services.*
- Requires states to demonstrate access sufficiency through an initial analysis when submitting a state plan amendment with a rate reduction, or restructuring in circumstances that could result in diminished access, for all services. If the state does not meet the requirements of the initial analysis, they must perform an additional, more extensive analysis.
*Note: These provisions pertain to HCBS but are part of the FFS payment documentation requirements.
For any additional questions regarding the FFS payment provisions of the Access Final Rule, email MedicaidAccesstoCare@cms.hhs.gov.
Guidance & Resources
- Ensuring Access to Medicaid Services – A Guide for States to the Fee-For-Service Provisions of the Final Rule
- Access: Rate Reduction/Restructuring Template (Note: As of July 9, this template is pending PRA approval by OMB, and states are not required to use it to meet the requirements of 42 CFR 447.203(c) until it has been approved. The 60-day notice published in the Federal Register on May 21, 2024 (89 FR 44685)).