Comments criticize CMS plan to cut Medicaid care access monitoring
Letting states cut Medicaid without reviewing access to care could hurt hospitals and physicians, cause facilities to close and result in uncompensated care increases, according to comments on the proposed rule.
In March, CMS put forward a plan letting states bypass the Obama era network adequacy rule. The proposal would not require states to perform an analysis on how payment cuts are affecting access to care unless they cut Medicaid reimbursements by at least 4% a year or at least 6% in two consecutive years.
Comments from healthcare officials said the change could especially hurt rural hospitals and force facilities to take lower rates without any recourse.
Medicaid has been a battleground for healthcare policy in recent years. Several states are applying for waivers that would allow them to reduce their rolls through work requirements or mandatory premiums. A few states are still debating whether to expand Medicaid under the Affordable Care Act, and on the left side of the spectrum, California is considering a plan to provide coverage for undocumented adults.
The proposed rule follows the Trump administration’s plan to reduce regulations. CMS said its goal is to avoid micromanaging the state Medicaid programs and instead hold states accountable for results.
Currently, as part of the network adequacy rule, states must show a data-driven way to review care access. If states reduce Medicaid rates, they must add to the review plan and analyze the effects for three years. CMS’ proposed rule would also exempt states with an overall Medicaid managed care penetration rate of 85% or more from most access monitoring requirements. States meeting the threshold would attest to that fact at the start of each year. There are currently 17 states that meet the criteria.
Casey Dungan, senior vice president of the Tennessee Hospital Association, wrote that rural hospitals with few large employers and a high percentage of Medicaid and Medicare patients can’t afford to leave the managed care networks and have no leverage to negotiate higher rates.
“Hospitals in all communities see a number of Medicaid patients in their emergency departments and will fulfill their obligation to serve them without respect to cost or ability to pay," Dungan wrote. "If a hospital remains out of network with a managed care organization in the state, it will still continue to see a large number of patients in the emergency department but will receive punitively low rates or no payment at all.”
The Virginia Hospital & Healthcare Association said the state's Medicaid program has reimbursed between 64 cents and 79 cents on the dollar recently. The low reimbursement rate is “already negatively impacting access to care, particularly in rural Virginia, where some hospitals have shut down services, such as obstetrics. Some of these providers specifically cite the low reimbursement rate for deliveries as the primary driver for shuttering these services.”
The American Academy of Family Physicians wrote that the organization opposes the proposal because it will “almost certainly lower the level of access monitoring in those states … Since this proposed rule impedes the federal government from confirming compliance with access to care for patients enrolled in Medicaid, the AAFP cannot support it.”
A number of California hospital groups also sent joint comments that opposed an exemption from the access standards. “Such an exemption eliminates safeguards that were put in place under the current rule to promote a more transparent data-driven process for states to document whether Medicaid payments are sufficient to enlist providers to assure beneficiary access to covered services,” they wrote.