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Monitoring access under fee for service

In MACPAC’s June 2022 report, we made a series of recommendations to create a new and more robust system for monitoring access to care for Medicaid beneficiaries that would allow for comparisons across states and delivery systems.

Although managed care is now the dominant delivery system in Medicaid, monitoring access under fee for service (FFS) remains important, with almost half (45 percent) of national Medicaid benefit spending covering services provided under FFS arrangements in fiscal year 2020. Populations that remain in FFS Medicaid, such as children and adults with disabilities, are among the most vulnerable beneficiaries, and ensuring their access to services is particularly important given their high health needs.

The use of FFS varies by state; some states operate mainly under FFS while others operate primarily or exclusively in a managed care environment. Even states that operate mainly under FFS may use features similar to managed care, such as medical homes and case management services. Further, the populations that remain in FFS Medicaid, such as children and adults with disabilities, are among the most vulnerable beneficiaries, and ensuring their access to services is particularly important given their high health needs.

Access requirements in Medicaid fee for service

The key requirement to ensure access to Medicaid services under FFS is commonly known as the equal access provision. Specifically, § 1902(a)(30)(A) of the Social Security Act requires that Medicaid provider payment rates be “consistent with efficiency, economy, and quality of care,” and “sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.”

Historically, compliance with the equal access provision requirement to “enlist enough providers” had been assessed primarily through the adequacy of provider payment rates. In some instances, payment rates were determined to be too low to ensure equal access to Medicaid services primarily as the result of lawsuits filed by providers and beneficiaries. However, on March 31, 2015, in Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (2015), the Supreme Court ruled that Medicaid providers and beneficiaries do not have a private right of action to contest state-determined Medicaid payment rates in federal courts. The Supreme Court decision underscored CMS’s primary role in ensuring access to care. On November 2, 2015, CMS published a final rule with comment describing how states must monitor and report on access to care under FFS to comply with the equal access provisions. This rule provided states with more guidance and expanded on the 2011 proposed rule, including, in response to the Armstrong v. Exceptional Child Center, Inc. decision, providing states with processes to review the effect of changes to provider payment rates.

Current access monitoring practices in fee for service

States are required states to submit access monitoring review plans which must be updated at least every three years. (Initial plans were due October 1, 2016; updated state AMRPs, which were due in October 2019, are not yet publicly available.) The access monitoring review plan applies to five categories of services: primary care services, physician specialist services, behavioral health services, prenatal and postnatal obstetric services, and home health services. The state must also monitor additional services for which the state or CMS has received a significantly higher than usual call volume of access complaints from beneficiaries, providers, or other stakeholders.

The final rule also requires a recent access review be submitted with any state plan amendment (SPA) proposing a reduction or restructuring of payment rates that could result in diminished access. States must monitor the effects of the rate change for at least three years. The rule includes additional parameters to assess whether access is sufficient. Within 90 days of identifying an access issue, states must submit a plan of corrective action listing specific steps and timelines to address the issues within 12 months.

A chapter in MACPAC’s March 2017 report included an initial review of the draft state AMRPs from 49 states and found that the approach to monitoring access and establishing benchmarks for sufficient access varied across states. Most states reported baseline data for the five required types of services and some also included data pertaining to services for which access issues had been identified, such as dental and transportation services. Baseline data were reported from a variety of sources, such as utilization data from claims, self-reported access measures from beneficiary surveys, and provider enrollment figures. States also differed in the extent to which they included demographic or other enrollee characteristics that would allow them to monitor access for the populations served through FFS arrangements.

Learn more by reading these report chapters and briefs: