447.203 Documentation of Access to Careand Service Payment Rates

Posted: February 10th, 2016

Received from CMS: February 4th, 2016

§ 447.203 Documentation of access to careand service payment rates.

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(b) In consultation with the

medicalcare advisory committee under § 43

1.12of this chapter, the agency must developa medical assistance access monitoringreview plan and update it, inaccordance with the timelineestablished in paragraph (b)(5) of thissection. The plan must be publishedand made available to the public forreview and comment for a period of noless than 30 days, prior to beingfinalized and submitted to CMS forreview.

(1) Access monitoring review plandata requirements. The accessmonitoring review plan must include anaccess monitoring analysis thatincludes: Data sources, methodologies,baselines, assumptions, trends and

actors, and thresholds that analyze andinform determinations of the sufficiencyof access to care which may vary by

geographic location within the state andwill be used to inform state policiesaffecting access to Medicaid servicessuch as provider payment rates, as wellas the items specified in this section.The access monitoring review plan mustspecify data elements that will supportthe state’s analysis of whetherbeneficiaries have sufficient access to

care. The plan and monitoring analysiswill consider:(i) The extent to which beneficiaryneeds are fully met;(ii) The availability of care throughenrolled providers to beneficiaries ineach geographic area, by provider type

and site of service;(iii) Changes in beneficiary utilizationof covered services in each geographic

area.(iv) The characteristics of thebeneficiary population (includingconsiderations for care, service and

payment variations for pediatric andadult populations and for individualswith disabilities); and(v) Actual or estimated levels ofprovider payment available from otherpayers, including other public andprivate payers, by provider type and siteof service.

(2) Access monitoring review planbeneficiary and provider input. Theaccess monitoring review plan mustinclude an analysis of data and thestate’s conclusion of the sufficiency ofaccess to care that will consider relevant

provider and beneficiary information,including information obtained throughpublic rate-setting processes, the

medical care advisory committeesestablished under § 431.12 of thischapter, the processes described in

paragraph (b)(7) of this section, andother mechanisms (such as letters fromproviders and beneficiaries to State or

Federal officials), which describe accessto care concerns or suggestions forimprovement in access to care.

(3) Access monitoring review plancomparative payment rate review. Foreach of the services reviewed, by the

provider types and sites of service (e.g.primary care physicians in officesettings) described within the access

monitoring analysis, the accessmonitoring review plan must include ananalysis of the percentage comparison of

Medicaid payment rates to other public(including, as practical, Medicaidmanaged care rates) and private health

insurer payment rates within geographicareas of the state.

(4) Access monitoring review planstandards and methodologies. Theaccess monitoring review plan and

analysis must, at a minimum, include:The specific measures that the state usesto analyze access to care (such as, but

not limited to: Time and distancestandards, providers participating in theMedicaid program, providers with open

panels, providers accepting newMedicaid beneficiaries, serviceutilization patterns, identifiedbeneficiary needs, data on beneficiaryand provider feedback and suggestionsfor improvement, the availability oftelemedicine and telehealth, and othersimilar measures), how the measuresrelate to the access monitoring reviewplan described in paragraph (b)(1) of

this section, baseline and updated dataassociated with the measures, any issueswith access that are discovered as a

result of the review, and the stateagency’s recommendations on thesufficiency of access to care based on the review. In addition, the accessmonitoring review plan must includeprocedures to periodically monitoraccess for at least 3 years after theimplementation of a provider ratereduction or restructuring, as discussedin paragraph (b)(6)(ii) of this section.

(5) Access monitoring review plantimeframe. Beginning July 1, 2016 theState agency must:(i) Develop its access monitoringreview plan by July 1 of the first reviewyear, and update this plan by July 1 ofeach subsequent review period;

(ii) For all of the following, completean analysis of the data collected usingthe methodology specified in the access

monitoring review plan in paragraphs(b)(1) through (4) of this section, with aseparate analysis for each provider type

and site of service furnishing the type ofservice at least once every 3 years:(A) Primary care services (including

those provided by a physician, FQHC,clinic, or dental care).(B) Physician specialist services (forexample, cardiology, urology,radiology).(C) Behavioral health services(including mental health and substance

use disorder).(D) Pre- and post-natal obstetricservices including labor and delivery.(E) Home health services.(F) Any additional types of servicesfor which a review is required underparagraph (b)(6) of this section;(G) Additional types of services forwhich the state or CMS has received asignificantly higher than usual volumeof beneficiary, provider or other

stakeholder access complaints for ageographic area, including complaintsreceived through the mechanisms for

beneficiary input consistent withparagraph (b)(7) of this section; and(H) Additional types of servicesselected by the state.

(6) Special provisions for proposedprovider rate reductions orrestructuring—(i) Compliance withaccess requirements. The State shallsubmit with any State plan amendmentthat proposes to reduce providerpayment rates or restructure providerpayments in circumstances when thechanges could result in diminishedaccess, an access review, in accordance

with the access monitoring review plan,for each service affected by the Stateplan amendments as described under

paragraph (b)(1) of this sectioncompleted within the prior 12 months.

That access review must demonstratesufficient access for any service forwhich the state agency proposes toreduce payment rates or restructureprovider payments to demonstratecompliance with the accessrequirements at section 1902(a)(30)(A)of the Act.(ii) Monitoring procedures. Inaddition to the analysis conductedthrough paragraphs (b)(1) through (4) ofthis section that demonstrates access tocare is sufficient as of the effective dateof the State plan amendment, a statemust establish procedures in its accessmonitoring review plan to monitorcontinued access to care afterimplementation of state plan servicerate reduction or payment restructuring.The frequency of monitoring should beinformed by the public review describedin paragraph (b) of this section andshould be conducted no less frequently

than annually.(A) The procedures must provide fora periodic review of state determinedand clearly defined measures, baselinedata, and thresholds that will serve todemonstrate continued sustainedservice access, consistent with

efficiency, economy, and quality of care.(B) The monitoring procedures mustbe in place for a period of at least 3

years after the effective date of the stateplan amendment that authorizes thepayment reductions or restructuring.

(7) Mechanisms for ongoingbeneficiary and provider input. (i) Statesmust have ongoing mechanisms for

beneficiary and provider input onaccess to care (through hotlines,surveys, ombudsman, review ofgrievance and appeals data, or anotherequivalent mechanisms), consistentwith the access requirements and publicprocess described in § 447.204.(ii) States should promptly respond topublic input through these mechanismsciting specific access problems, with anappropriate investigation, analysis, andresponse.(iii) States must maintain a record ofdata on public input and how the stateresponded to this input. This recordwill be made available to CMS uponrequest.

(8) Addressing access questions andremediation of inadequate access tocare. When access deficiencies areidentified, the state must, within 90days after discovery, submit a correctiveaction plan with specific steps andtimelines to address those issues. Whilethe corrective action plan may includelonger-term objectives, remediation ofthe access deficiency should take placewithin 12 months.(i) The state’s corrective actions mayaddress the access deficiencies througha variety of approaches, including, butnot limited to: Increasing payment rates,improving outreach to providers,reducing barriers to providerenrollment, proving additionaltransportation to services, providing fortelemedicine delivery and telehealth, orimproving care coordination.(ii) The resulting improvements inaccess must be measured andsustainable.

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