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CMS Issues Medicaid Access to Care Guidance

The Centers for Medicare & Medicaid Services (CMS) issued a Nov. 16 letter to state Medicaid directors providing guidance on implementation approaches for access requirements within Medicaid fee-for-service (FFS).

The guidance follows a 2015 final rule with comment period that directed states to ensure that Medicaid FFS beneficiaries have access to health care services comparable to those of a given area’s general population. The rule included new requirements for access review, notice, and feedback when states change rates for certain services.

Through this guidance, CMS intends to reduce regulatory burden on states by clarifying certain Medicaid reimbursement rate reductions that are deemed not to have a significant impact on access, and, therefore, will not require additional review by CMS, including:

  • reductions necessary to implement CMS federal Medicaid payment requirements;
  • reductions where the payment rates remain at or above Medicare and/or average commercial rates; and
  • reductions that result from changes implemented through the Medicare program, where a state’s service payment methodology adheres to the Medicare methodology, such as adoption of new Medicare payment systems and consistency with value-based purchasing initiatives.

CMS also outlined examples of nominal payment changes that could be difficult for states to determine whether the changes may result in diminished access. The agency instructs states to follow the public process, as outlined in the regulation, and to document the process. States are not required to submit the access analysis or formal monitoring plan in their state plan amendment (SPA) if no probable access concerns are identified. The guidance also provides additional clarification for states with high Medicaid managed care penetration. Lastly, CMS reiterated the agency’s commitment to reviewing SPAs in a timely manner.

Contact Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

Rachel Schwartz is a former policy associate at America's Essential Hospitals.

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