CMS issues final rule designed to strengthen access to essential healthcare services for Medicaid beneficiaries

October 28, 2015

CMS released a final rule designed to improve the ability to measure and ensure meaningful access to covered services, and provide greater safeguards for beneficiaries who may otherwise experience great difficulty in receiving needed healthcare services. The intent of the final rule is to provide a framework to make better informed, data-based decisions that support more effective service delivery systems, service rate structures and provider payment methodologies that reflect the evolving Medicaid population. The goals of the final rule are:

  • Measuring and linking beneficiaries' needs and utilization of services with availability of care and providers;
  • Increasing beneficiaries' involvement through multiple feedback mechanisms; and
  • Increasing stakeholder, provider, and beneficiary engagement when considering proposed changes to Medicaid fee-for-service payments rates that could potentially impact beneficiaries' ability to obtain care.

The final rule requires states to:

  • Develop an access review plan that set out the data elements and other information to be used to ensure beneficiary access to mandatory and optional services;
  • To establish new procedures to review the effects on beneficiary access of proposed rate reductions and payment restructuring; and
  • To implement ongoing access monitoring reviews of key services, and additional services as warranted.

The rule also strengthens CMS' ability to review and ensure Medicaid payment rates are consistent with efficiency, economy and quality and care. The final rule becomes effective on January 4, 2016. In conjunction with the final rule, CMS released a request for information to solicit comments on additional approaches the agency and states should consider to ensure better compliance with Medicaid access requirements.