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This rule addresses elements related to assuring access in Medicaid and/or the Children's Health Insurance Program (CHIP). These elements include processes that support the implementation of a comprehensive access strategy as well as payment processes, such as those related to specific payment systems.

Statement of Need:

In order to assure equitable access to health care for all Medicaid and CHIP beneficiaries across all delivery systems, access regulations need to be multi-factorial and focus beyond payment rates. Barriers to accessing health care services can be as heterogeneous as Medicaid and CHIP populations which can be measured through provider availability and provider accessibility to realized or perceived access barriers which can be measured through utilization and satisfaction with services. The final rule takes a comprehensive approach to improving access to care, quality and health outcomes, and better addressing health equity issues in the Medicaid program across fee-for-service (FFS), managed care delivery systems, and in home and community-based services (HCBS) programs.  These improvements seek to increase transparency and accountability, standardize data and monitoring, and create opportunities for States to promote active beneficiary engagement in their Medicaid programs, with the goal of improving access to care.

Summary of the Legal Basis:

Section 1902(a)(30)(A) of the Act requires states to "assure that payments are consistent with efficiency, economy, and quality of care and are 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." In addition, 2402(a) of the Affordable Care Act directs the Secretary to promulgate regulations ensuring that all states develop service systems that: (1) are responsive to the needs of beneficiaries receiving HCBS and enable them to maximize their independence; (2) provide necessary support and coordination for beneficiaries in need of such services and their caregivers; and (3) improve coordination and regulation of providers of such services to oversee and monitor functions, including a complaint system, and ensure that there are an adequate number of qualified direct care workers to provide self-directed services. Further, Section 1902(a)(4) of the Act is a longstanding statutory provision that, as implemented in part in regulations currently codified at 42 CFR 431.12, requires States to have a Medical Care Advisory Committee (MCAC) in place to advise the State Medicaid agency about health and medical care services.  

Alternatives:

In developing the policies contained in this rule, we considered numerous alternatives, including maintaining existing requirements. These alternatives are described in the rule.

Anticipated Costs and Benefits:

This rule is expected to result in potential costs for states to come into and remain in compliance. Estimates for associated costs are unknown at this time and may vary by state. Information about anticipated costs will be included in the rule.

Risks:

Risks of this rule are still under development and will be included in the final rule.