Although federal law requires that Medicaid (Medi-Cal in California) payment rates be sufficient to enlist enough providers so that patients have meaningful access to care, there hasn't been a process for states to demonstrate that they are meeting these requirements. Since 2011, the Centers for Medicare and Medicaid Services (CMS) has been working on federal guidelines for states to demonstrate that they are in compliance with the federal access requirements.

The result of this work is the recently published final rule, “Medicaid Program; Methods for Assuring Access to Covered Medicaid Services,” which is currently open for public comment. The rule requires, among other things, that states perform an independent assessment of access before implementing a rate reduction. Although generally supportive of CMS’ commitment to modernizing the current regulations in an effort to reflect the current Medicaid environment, the California Medical Association (CMA) believes that the rule could go further to provide a meaningful improvement in access to care.

Over the years, when the state of California faced budget cuts, one of the first programs impacted was California’s Medi-Cal program. The decrease in funding for the Medi-Cal program was a clear indication that rates are often subject to fluctuation and instability based on the ever-changing political and budgetary climate. CMA believes that public transparency and accountability in the rate-setting process would help to provide more consistent access to care to the Medi-Cal population.

CMA recently submitted comments on the Medicaid access rule, encouraging CMS to extend the rule by:

• Amending its regulations to permit an appeals process for providers and beneficiaries: (1) to dispute approval of state plan amendments and (2) to challenge the consistency of rates under an approved state plan;


• Implementing evidence-based regulatory policy and prohibiting states from reducing rates when there are access problems;


• Clarifying that the rule does not affect the longstanding processes and policies, including judicial interpretations of the regulations, governing the state plan amendment approval process;


• Requiring that federal reviews must also take place to ensure that access is being met in the Medicaid program; and


• Adding the effect of rates on emergency department and in-patient hospitalization costs to the data elements required for the access monitoring review plan.

Click here to read CMA’s comments.

Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmadocs.org.