By Kelsey Waddill

– American Hospital Association (AHA) is concerned that the recent CMS proposal to relax the 2015 mandatory Medicaid access monitoring review plans will limit providers’ ability to confront Medicaid reimbursement failures and remove needed oversight of states’ access to care.

“By removing this important oversight function, CMS’s proposal would put beneficiary access to care at greater risk,” AHA wrote. “While the AHA shares CMS’s goal of reducing the regulatory burden on the health care system, we believe that it is paramount that burden reduction efforts selectively target those burdens that are harmful, duplicative or provide no value. This proposed rule fails to meet this criteria. It would leave the Medicaid program without a regulatory structure and process for the states and CMS to assess the adequacy of payment rates to ensure beneficiary access.”

AHA argued that the access monitoring review is the only platform that providers and beneficiaries still have to confront reimbursement failures. The Supreme Court’s decision in Armstrong v Exceptional Child Center, Inc. limited providers’ ability to take Medicaid underpayments to court.

Without the rule, providers will have no way to raise issue with reimbursements, which have proven to be a significant challenge in the past. The letter points to statistics from 2017 that demonstrate Medicaid payments totaled to 87 cents for every dollar of providers’ spending for Medicaid treatments.

“These data sources underscore the chronic underpayment in the Medicaid program and the need to monitor how payment affects access to care for vulnerable Medicaid populations,” AHA contended.

AHA also countered the states’ claim that the rule mainly served a small fee-for-service population, noting that, in 2017, 55 percent of Medicaid spending was under fee-for-service arrangements.

The association concluded that CMS should seek out stakeholders’ opinions on the best approach to access monitoring.

Under the proposed rule, states would no longer have to maintain and submit an access monitoring review plan.

For an access monitoring review plan, states provide data access to care that are subject to fee-for-service arrangements, including primary care services, physician specialist services, behavioral health services, pre- and post-natal obstetric services, and home health services. The plans are reviewed every three years.

However, the states would have to continue to provide sufficient Medicaid payment rates, which would be updated when making changes to the state’s Medicaid program through submitting a state plan amendment. CMS would provide criteria detailing what information would be required.

“This proposed rule would not remove, or otherwise limit, the states’ obligation to comply with the statute, but would allow states greater flexibility in the way in which they demonstrate such compliance,” the proposed rule stated.

CMS concluded that the proposed rule would cost state Medicaid and Medicare programs $1.2 million and would reduce the reporting cost by around $3.6 million, which the agency considers economically insignificant.

Prior to the current proposed rule, CMS attempted to make another proposed rule that would work toward the same end of lowering administrative burden while maintaining some oversight of states’ access to care. The rule was proposed in March 2018 but never advanced to finalization due to stakeholders’ comments.

CMS expressed the belief that the access monitoring review plans focused too heavily on fee-for-service systems and payment alterations, instead of truly addressing beneficiaries’ access to care.

To resolve this, CMS decided to create a workgroup of states and other stakeholders with four goals.

First, the group aimed to determine how to alter the present access to care requirements. Additionally, CMS and stakeholders sought the best way to ensure that beneficiaries had access to the appropriate care. The workgroup also looked to define effective enforcement practices and, lastly, the group would identify how to coordinate access monitoring for both fee-for-service and managed care.

AHA recommended that CMS expand its inquiries to provider and beneficiary stakeholders that are not tied to a state or the federal government.

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AHA: Proposed CMS Rule Hinders Medicaid Reimbursements –