Medicaid rate setting

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As previously reported, the 21st Century Cures Act prohibits federal financial participation (FFP) payments to the states for certain Medicaid durable medical equipment (DME) expenditures that exceed what Medicare would have paid for such items, either on a fee schedule basis or under competitive bidding.  The provision is effective January 1, 2018.

CMS…

CMS has published a notice giving states more time to submit state access monitoring review plans under a November 2015 rule intended to assure access to covered Medicaid services.  By way of background, the final rule required states to develop and submit to CMS an access monitoring review plan for the following service categories:…

On November 2, 2015, CMS published a final rule with comment period that is intended to provide a transparent, data-driven process for states to follow when they set Medicaid provider payment rates, effective January 4, 2016. Under the Social Security Act, state plans must ensure that payment rates for Medicaid services “are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that services are available to Medicaid eligible individuals to the extent that they are available to the general population in the geographic area.” The final rule requires states to review data and trends to evaluate access to care for covered services and conduct public processes to obtain public input on the adequacy of access to covered services in the Medicaid program. Should access deficiencies be identified, the state must submit to CMS within 90 days after discovery a corrective action plan on how it will achieve measurable and sustainable improvements. Notably, the final rule only focuses on the “access” portion of the statute; there is no more than lip services to the “quality of care” aspect of the law. Further, the final rule only applies to Medicaid fee-for-service rates. The final rule is especially important for providers in light of the Supreme Court’s decision in Armstrong v. Exceptional Child Center, Inc. holding that Medicaid providers do not have a cause of action to challenge a state’s Medicaid reimbursement rates. This means that challenges to the adequacy of rates will now likely gravitate to the state level.
Continue Reading CMS Publishes Final Rule on Medicaid Fee-For-Service Ratesetting for Assuring Access to Covered Medicaid Services

On May 6, 2011, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule to create a standardized, transparent process for states to follow when they set Medicaid payment rates. Under the Social Security Act, state plans must ensure that payment rates for Medicaid services “are consistent with efficiency, economy, and quality…