• AAFP Calls for Post-PHE Medicaid Access, Payment, Simplification

    New Guidance to CMS Details Path to Comprehensive Care, Including Telehealth

    May 2, 2022, 8:55 a.m. News Staff — The Academy recently offered CMS detailed new guidance on ensuring Medicaid beneficiaries’ access to timely and comprehensive care — including primary care and behavioral health care — while calling out barriers such as low Medicaid physician payment and burdensome administrative processes.  

    medicaid eligibility concept

    The AAFP praised CMS for its work to preempt coverage disruptions when state Medicaid agencies resume eligibility determinations following the end of the COVID-19 public health emergency. The Academy also urged an accelerated transition to value-based care, improved transparency for Medicaid graduate medical education funding and permanent coverage and payment policies that advance equitable telehealth access from patients’ usual sources of care.  

    The April 18 letter to CMS Administrator Chiquita Brooks-LaSure was sent in response to a request for information titled “Access to Coverage and Care in Medicaid and the Children’s Health Insurance Program,” published Feb. 17 in the Federal Register. It was signed by AAFP Board Chair Ada Stewart, M.D., of Columbia, S.C.

    “Medicaid is essential to achieving our shared goals of advancing health equity, increasing health coverage and facilitating access to comprehensive, person-centered primary care,” the Academy said. Given the uptick in Medicaid enrollment due to the pandemic, and supported by provisions in the Families First Coronavirus Response Act, the letter asked CMS to establish support and oversight mechanisms for states in order to avoid loss of coverage for Medicaid enrollees after the end of the PHE, as well as minimum federal access standards that states and managed care plans must comply with.

    Story Highlights

    To reinforce the health care safety net while moving toward better payment, mental health parity and administrative simplification for physicians, the Academy said CMS should make top priorities of

    • reinstating and strengthening federal Medicaid access standards;
    • instituting a strong national monitoring approach;
    • implementing race, ethnicity and language data-reporting requirements;
    • enhancing federal monitoring of racial, ethnic and language-based disparities;
    • addressing low Medicaid payment rates and burdensome administrative processes; and
    • continuing flexibility, support, technical assistance and oversight to state Medicaid agencies with the goal of minimizing coverage disruptions during eligibility redeterminations after the end of the PHE.

    Consistent Coverage

    To ensure ongoing, in-community comprehensive health care access, the Academy repeated recent advocacy that called on CMS to provide states and managed care plans at least 120 days of lead time before unwinding pandemic-related coverage provisions. To prevent erroneous loss of coverage for patients whose Medicaid eligibility will be subject to redetermination after the PHE, the letter reminded the agency, robust efforts must be undertaken to inform Medicaid enrollees how to keep their coverage or transition to a new qualified health plan.

    The letter suggested the use of navigators or similar assistance to state health officials and Medicaid enrollees but warned against brokerages and other organizations that have incentives to steer prospective QHP enrollees away from affordable, comprehensive plans.

    “CMS should continue to support states in preparing IT systems for eligibility redeterminations, including the implementation of electronic health record and patient portal reminder messages for clinicians and patients,” the letter added, again calling for support for state outreach. “Alerts in patient portals could include guidance and information on how to report contact information changes and changes in circumstance that might affect Medicaid eligibility as well as direct patients to resources that can connect them with alternative coverage and safety-net care in the event they lose Medicaid coverage.

    “CMS should also consider similar targeted outreach and educational resources for current Medicaid enrollees who may have become eligible for Medicare and missed their initial Medicare enrollment period. The AAFP recommends CMS also conduct direct outreach to enrollees who missed their initial enrollment period and may face penalties and coverage gaps to provide them with technical assistance. CMS could consider using navigators to facilitate these processes.”

    Access Standards

    “CMS should set minimum federal access standards for primary care, behavioral health, specialty and emergency care for both children and adults. These minimum standards should function as a floor for states, with the option to set higher standards if the state so chooses,” the letter said. “The AAFP supports the use of time and distance standards across programs, including in Medicaid and CHIP.”

    The agency should set separate standards for substance use disorder treatment, the Academy added. “We are concerned that, if SUD treatment is only monitored as part of behavioral health care access, CMS, states and other stakeholders will be unaware of beneficiaries’ unique challenges with obtaining SUD treatment. We note that many family physicians provide buprenorphine treatment in their practices, often serving as the only source of outpatient SUD treatment in their communities. Time and distance standards should recognize the availability of SUD treatment in primary care clinics and also acknowledge the limited capacity these practices have to take on new patients due to regulatory and other requirements.”

    The letter further advised CMS to “monitor the availability of integrated behavioral health services in primary care and consider implementing access standards for these services in the future.”


    “The AAFP is strongly supportive of states expanding coverage and payment of telehealth services and believes that, when implemented thoughtfully, telehealth can improve both access to care and patient experience,” the Academy wrote. “To achieve the promise of telehealth and ensure that Medicaid beneficiaries have equitable access to virtual care, the AAFP recommends that CMS separately monitor telehealth services.”

    However, the letter said, states and managed care plans should not be able to count the availability of telehealth services provided by virtual, direct-to-consumer companies toward meeting minimum federal access standards for primary and emergency care.

    “These types of telehealth providers cannot serve as a substitute for comprehensive, longitudinal, person-centered primary care. Similarly, while telehealth can be used effectively to triage and treat some urgent, acute illnesses and injuries, it is inappropriate and dangerous to rely on virtual-only clinicians as a substitute for emergency care. Primary care and emergency clinicians providing telehealth services should only be included in access standard calculations if the clinician is also providing in-person care for Medicaid beneficiaries within the established time and distance standard.”

    Performance Monitoring

    CMS should require states to regularly and publicly report data demonstrating their performance on all minimum access standards, with a focus on “addressing racial and other well-documented disparities in access and beneficiary experience,” the Academy said.

    “Comprehensive race and ethnicity data collection is an essential step to identifying and ultimately addressing racial access disparities,” the letter added. “The AAFP further recommends that CMS require states to report certain data stratified by race, ethnicity and other demographic factors, such as dual-eligibility status or primary language. This requirement will facilitate the identification of access disparities. CMS should then require states to submit plans for how the state will address access disparities and regularly report on their progress to close access gaps for beneficiaries of color, those with limited English proficiency, LGBTQ+ beneficiaries and other populations experiencing systemic barriers to care.”

    Clinician Diversity and Physician Payment

    CMS asked stakeholders how to support states seeking to increase and diversify Medicaid and CHIP’s clinician pool. The Academy responded by recommending initiatives to address low Medicaid payment rates and accelerate the transition to value-based care, among other suggestions.

    “CMS should support states in raising Medicaid payment for primary care services to at least Medicare rates,” the letter said, repeating advocacy the Academy has long stressed. “Low Medicaid physician payment rates have historically been a barrier to care for beneficiaries. Physicians cite inadequate payments as a primary reason for not accepting new Medicaid patients. These low rates negatively impact primary care physicians’ overall compensation and deter medical students and residents from choosing to practice primary care.

    “To ensure all Medicaid beneficiaries can access high-quality primary care when they need it, CMS should support states in raising Medicaid payment for primary care services to at least Medicare rates.”

    Value-based care, meanwhile, is proving to be one avenue by which primary care practices can achieve reliable revenue, the letter said. “Increasing the availability of models with stable, robust prospective payments would help address longstanding challenges with low Medicaid payment rates, provided that the prospective payments adequately support the high-value care practices deliver. For example, practices participating in alternative payment models often choose to hire social workers, mental health professionals, pharmacists or other additional staff that are equipped to provide behavioral health care, connect patients to community services, and expand care coordination and medication management services.

    “CMS should make technical improvements to existing models, broaden model opportunities across payers and harmonize model requirements among payers, including Medicaid. This, along with developing transparent, stable APMs with ongoing input from physician stakeholders, will encourage physician participation in APMs and enable them to move into more advanced models over time. Incorporating Medicaid and CHIP beneficiaries in APMs will facilitate equitable access to high-quality primary care and is an important step to advancing health equity.”

    Administrative Simplification

    To promote program integrity in Medicaid while combating discrimination, health disparities and other barriers to care stemming from prior authorization, the Academy urged CMS to “include prior authorization and other utilization management practices, including step therapy, in its monitoring and oversight activities.”

    Echoing the Academy’s recent objection to solving such administrative burdens by concentrating on automation, the letter added that these efforts should come as part of a full-scale process overhaul.

    “Electronic prior authorization is just one step in addressing the flaws of utilization management, and comprehensive reform is needed,” the letter said. “We support CMS requiring state Medicaid agencies and managed care plans to adopt electronic prior authorization standards only after they are proven effective and adoptable in real-world testing. However, additional federal action is needed to address the negative impacts of prior authorization on Medicaid beneficiaries’ access to care.”

    The Academy also advised CMS to survey physicians in managed care networks as an initial step toward reducing billing denials and utilization requirements, two administrative hurdles that discourage physician participation in Medicaid and CHIP. “These surveys could help identify barriers that are specific to certain states or managed care plans and enable states to make operational and policy changes to mitigate them,” the letter said.

    Citing a recent study estimating that physicians lose 16% of Medicaid payments to billing problems, the AAFP urged CMS to “include billing processes and denials in monitoring and oversight activities to understand where issues frequently arise” and to develop guidance for states and managed care plans “with strategies for minimizing and resolving billing disruptions to streamline and optimize billing processes.”