ARMP Requirements

CMS grants states significant flexibility in selecting measures and defining their approach to the plans. However, states are required to analyze certain services (described below) and incorporate beneficiary and provider input on ARMPs. Final baseline reports were due to CMS on October 1, 2016; states are required to submit a revised plan every three years or in the event of a FFS rate reduction or a high volume of complaints about access to a service in a particular geographic area.

Limitations of ARMPs

ARMPs are meant to support CMS’s goal of assuring access to covered services in FFS Medicaid, but they are not without limitations. Notably, the plans only cover access and payment rates for FFS beneficiaries, and states have increasingly turned to managed care for delivery of care to Medicaid beneficiaries. States may also struggle with the availability of timely data and the challenge of conducting data analysis and producing triennial plans without federal funding. Despite these limitations, baseline ARMPs may shed light on states’ access priorities and approaches to analysis.

Examining ARMP Data Sources: Our Approach

In an effort to identify the range of data states leveraged in ARMPs, SHADAC researchers performed a key word search online and on State Medicaid and Dept. of Health websites during the month of November 2016 (one month after final reports were due) to identify draft or, if available, final ARMPs. We then abstracted key information about data sources and service categories to a table. We identified a total of 43 ARMPs, of which 19 were final. The summary below is based on all plans, including draft plans but relying on final plans when available.

Service Categories

All states are required to cover access to primary care, including dental services, specialty, behavioral health, obstetrics and gynecology (including labor and delivery), and home health services. These services were included for analysis in all plans identified. However, although the final rule included dental services in its definition of primary care, only 29 of the 43 states included these services in ARMPs. One state explicitly excluded dental services from analysis based on their interpretation of the final rule’s requirements for analysis of primary care. Some ARMPs examined services beyond those required in the final rule such as durable medical equipment (AZ), transportation (IN), and nursing facility services (PA).

Results: Data Sources Used

Nearly every state analyzed access using Medicaid Management Information Systems (MMIS) data (i.e., provider, individual enrollment and/or claims data), which states are required to use for mechanized claims processing and information retrieval. Approximately fifteen also included FFS Consumer Assessment of Healthcare Providers and Systems (CAHPS) data in their analyses, and many states said they would try to leverage data from the national CAHPS survey in future analyses where state level FFS CAHPS data wasn’t currently available. Eight states included (or would include in future plans) beneficiary reported access issues from call center data. Some states explored additional data sources including Census data (CA, CT, NV, ME), state-specific surveys (e.g., CO Health Access Surveys and MN Health Care Access Survey), and Healthcare Effectiveness Data and Information Set (HEDIS) measures (OH, MA, MN, SC, CT).

Potential Limitations to Reliance on MMIS Data

As mentioned above, states rely heavily on MMIS data for access analyses. Though this may reduce the administrative burden of data collection, MMIS data may not provide a complete picture of access. There are well-documented limitations to using MMIS data for patient identification as well as uncertain validity of encounter data and completeness of diagnosis information. Moreover these data were not intended for use in research. States will likely need to supplement MMIS data with other data sources to ensure an accurate reflection of access in their ARMPs.

Looking Ahead: How CMS Can Support State Efforts to Measures Access

Initial state plans are currently under CMS review. Plans are expected to change over time resulting from this review and as priorities, delivery systems, and data availability shift over time. Going forward, CMS can support states by identifying and disseminating promising data sources and approaches to measuring access, especially those not commonly used by states, and sharing solutions to common barriers to access data collection and analysis.