AAFP Sees Potential Payment, Equity Wins in Medicaid Proposals
Academy’s Recommendations to CMS Back Most Provisions, Urge Pay Parity
July 11, 2023, News Staff —The Academy is voicing strong support for a pair of proposed rules that could yield advocacy wins for family physicians by improving Medicaid beneficiaries’ access to primary care and boosting physician payment for primary care services.
“Given consistently low Medicaid payment rates as well as evidence indicating inequitable access to care for beneficiaries, the AAFP strongly agrees that additional rate transparency is urgently needed,” the Academy told CMS in response to a proposed rule aimed at increasing fee-for-service rate transparency.
That July 3 letter also called on the agency to require states and managed care plans paying less than 100% of the Medicare rate for adult and pediatric primary care, as well as behavioral health services, to annually demonstrate that they are fully meeting the equal access provision for Medicaid beneficiaries.
“While Medicare is not a perfect comparator,” the Academy added, “it is a useful starting place because states continue to pay even lower Medicaid rates, and Medicare rates are publicly available on a national basis.” The letter noted that the AAFP continues to advocate for federal legislation ensuring annual inflationary updates to the Medicare physician fee schedule and repeated a longstanding call to increase Medicaid payment rates for primary care services to at least those of Medicare.
In a separate letter sent to CMS the same day, the AAFP advocated for finalization of provisions in a different proposed rule that would codify federal care-access standards for health care plans, require managed care plans to analyze payments to compare their Medicaid physician payment rates for primary care to those of Medicare and modify Medicaid quality measurement requirements.
The Academy also urged CMS “to take action to reduce the overall volume of prior authorization requirements across federal programs” and “pursue additional regulations, guidance and other mechanisms to increase the availability of value-based payment models designed specifically for primary care that are inclusive of and appropriate for Medicaid patients and their primary care physicians.”
The AAFP was responding to the proposed rules “Ensuring Access to Medicaid Services” and “Medicaid and Children's Health Insurance Program Managed Care Access, Finance, and Quality,” both published May 3 in the Federal Register. The detailed recommendations echo and expand on Medicaid-access guidance the AAFP sent CMS last year, in line with the Academy’s steady advocacy favoring federal access standards for Medicaid managed care patients and higher Medicaid physician payment rates.
Story Highlights
The letter addressing “Ensuring Access to Medicaid Services” asked CMS to finalize a proposal that would require states to publish fee-for-service Medicaid payment rates on a publicly accessible website and compare those rates to the applicable Medicare payment rates.
“Medicaid pays, on average, 66% of the Medicare rate for primary care services,” the Academy reminded CMS, adding that in some states, that figure is just 33%. “Low payment rates in Medicaid reduce health care access for Medicaid beneficiaries and prevent primary care physicians from accepting more Medicaid patients. Medicaid beneficiaries who have a primary care physician often face longer wait times and shorter, inadequate visits because of payment challenges. However, when Congress raised Medicaid primary care payment rates to Medicare levels in 2013 and 2014, patient access improved.”
The Academy objected, however, to an element of the rule that would change the way CMS monitors the effects on beneficiaries when states reduce their Medicaid rates or restructure Medicaid payment, with the goal of avoiding significant reductions. The proposed new structure could let states reduce payment rates by up to 3% percent a year without additional reporting — which could result in significant payment reductions over time without scrutiny, force practices to stop participating in Medicaid and negatively affect access to essential primary care services, the letter warned.
“The AAFP firmly believes that increasing the threshold to 100% of the Medicare rate will more effectively encourage states to increase rates to those that are comparable to other federal payers and advance equitable access to care across programs. If the agency declines to immediately increase the threshold, we strongly recommend that CMS instead institute a graduated standard beginning with 80 percent and increasing to 100 percent of Medicare over a set period of time.”
In addressing the second proposed Medicaid rule (“Access, Finance, and Quality”), the Academy urged CMS to
- finalize a proposal to implement appointment wait-time standards for routine primary care, behavioral health, and obstetric and gynecologic services, as long as the final rule also includes robust protections for in-network clinicians and practices;
- finalize a proposal to require managed care plans to conduct payment analyses comparing Medicaid payment rates for primary care and other services to Medicare payment rates;
- incorporate prior authorization requirements, claim denials and other major sources of administrative burden in the provider payment analysis; and
- advance alignment of quality measurement requirements with measures used across other payers and federal programs.
On the first point, the letter called on CMS to add safeguards that ensure managed care plans do not pass on wait-time requirements to their in-network clinicians and practices. Rather, the AAFP said, CMS should ensure that plans failing to meet such standards broaden their networks and improve payment to come into compliance.
“The onus for meeting wait-time standards must be on the managed care plan,” the Academy wrote. “Requiring physicians to meet the needs of multiple plans’ wait-time standards without requiring a plan to expand its network would further burden physicians and could force them to reduce the amount of time they spend with each patient, hindering their ability to provide whole-person care and ultimately exacerbating already concerning access issues. Pushing these requirements onto clinicians could also cause them to stop accepting Medicaid beneficiaries, worsening timely access to care.
“The AAFP strongly supports CMS’ proposal to count appointments offered only via telehealth toward compliance with appointment wait-time standards if the clinician also offers in-person appointments,” the letter added.