• AAFP Fights for Patient Access to Covered Medicaid Services

    CMS Proposed Rule Gets a 'Thumbs Down'

    May 21, 2018 09:00 am News Staff – In a May 16 letter(3 page PDF) to CMS Administrator Seema Verma, the AAFP took a stand against a CMS proposed rule that would amend the process for states to document whether Medicaid payments in fee-for-service (FFS) systems are sufficient to enlist physicians and other providers to ensure beneficiary access to covered care and services.

    The proposed rule was published in the March 23 Federal Register.

    In the letter, which was signed by AAFP Board Chair John Meigs, M.D., of Centreville, Ala., the AAFP told CMS that to ensure access to Medicaid covered services, efforts must be made to raise Medicaid physician payment levels to at least Medicare rates for services rendered by primary care physicians.

    The AAFP provided some historical background for CMS' consideration.

    Medicaid Payment Background

    The AAFP reminded CMS that in 2012, a provision in the Patient Protection and Affordable Care Act increased Medicaid payments rates to at least 100 percent of Medicare rates for two years for primary care services.

    "While Congress allowed this increase to lapse in 2014, 21 states continued the fee increase either partially or in full," said the letter.

    Since that time, multiple studies have shown the positive effect of the pay increase on patients' access to primary care services covered by Medicaid, said the AAFP.

    Conversely, authors of a research letter published in the January 2018 issue of JAMA Internal Medicine concluded that reductions in Medicaid funding led some states to lower Medicaid fees to physicians.

    Those actions have jeopardized access to care and reinforce the importance of the Medicaid pay increase to physicians in terms of patient care and positive health outcomes, said the AAFP, echoing the authors' concerns.

    The AAFP pointed out that on average, Medicaid payment across the nation is 66 percent of Medicare payment for primary care services.

    Furthermore, in addition to low payments, the AAFP told CMS that "fee-for-service Medicaid is the most challenging type of insurance to bill," and that family physicians report the Medicaid denial rate is "shockingly high."

    Worse yet, the AAFP pointed out that the denial rate for Medicaid managed care was even higher -- a full six percentage points higher -- than FFS denials.

    The Academy urged CMS to consider these facts and asked the agency to hold states with FFS Medicaid and Medicaid Managed Care Organizations (MCOs) "to a higher standard" than currently is occurring.

    "States and MCOs should not make it harder to care for the lowest resourced and most vulnerable members of family physicians' patient panels," said the AAFP.

    Story Highlights

    Proposed Exemption for States

    The AAFP adamantly opposes CMS' proposal to grant an exemption to 17 states that currently have a comprehensive, risk-based managed care enrollment rate of 85 percent or more.

    Such an exemption would "allow these states to forego an access monitoring review plan (AMRP)," said the AAFP, and "adding services to the AMRP when reducing or restructuring payment rates would also not trigger a new AMRP for states with high MCO penetration."

    This proposal "will almost certainly lower the level of access monitoring in those states," even though the Medicaid recipients in question represent 15 percent or less of the state's total Medicaid population.

    "All Medicaid beneficiaries deserve access to high quality care as guaranteed by the Medicaid statute," continued the AAFP. The letter pointed out that the proposal likely would affect patients with the most complex care, including those with severe disabilities.

    The proposed rule would excuse states from monitoring access conditions for these populations -- as well as access to long-term nursing home services -- "simply because 85 percent of the total Medicaid population might be enrolled with managed care organizations."

    The proposal also would "hamper efforts by CMS to monitor the effects of payment rates on access to laboratory services," said the AAFP.

    "We believe that there is no substantive justification for the proposed 85 percent threshold in the proposed rule and request that CMS provide data and analysis to justify this seemly arbitrary rate," continued the letter.

    Proposed Exemption for Payment Rate Changes

    The AAFP also relayed its strong objection to CMS' proposal to exempt states from analysis and monitoring procedures associated with payment rate changes for specific rate reductions over a period of years.

    The proposal states that if FFS rate reductions in a specific service category are lower than 4 percent for a state's fiscal year -- and lower than 6 percent across two consecutive fiscal years -- a safe harbor clause would kick in.

    The proposed monitoring exemption does not "guarantee access equivalent to individuals in the general population," said the AAFP. "Furthermore, it seems to ignore the thin margins at which primary care physicians operate -- especially in Medicaid."

    Such cuts "could have a devastating impact on access to primary care in a community," continued the letter.

    The AAFP urged CMS to limit its proposal to service categories other than primary care "while maintaining the current level of access analysis and monitoring for the primary care service category, regardless of the size of payment rate changes."

    Additional Resources
    New England Journal of Medicine:
     Appointment Availability after Increases in Medicaid Payments for Primary Care(www.nejm.org)


    JAMA Internal Medicine: Changes in Primary Care Access Between 2012 and 2016 for New Patients With Medicaid and Private Coverage(jamanetwork.com)
    (April 2017)