Publication
SHADAC Newsletter - January 2017
The SHADAC newsletter contains updates on SHADAC activities, news from the states, resource updates, and blog highlights. Subscribe to our newsletter here.
The SHADAC newsletter contains updates on SHADAC activities, news from the states, resource updates, and blog highlights. Subscribe to our newsletter here.
In November 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule implementing Medicaid’s “equal access” provision, nearly 25 years after the statute was enacted and more than four years after the rule was initially proposed. One piece of the final rule requires that states develop Access Review Monitoring Plans (ARMPs) to address and analyze the extent to which the health care needs of Medicaid fee-for-service (FFS) beneficiaries are met, the availability of health care and providers, changes to beneficiary utilization, as well as comparisons of payment rates.
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.
The upcoming administration has indicated that it will be looking for ways to give states greater flexibility in how they design their Medicaid programs. One way to achieve this flexibility is through the use of Section 1115 demonstration waivers, through which the Centers for Medicare and Medicaid Services (CMS) can approve state-led experimental, pilot, or demonstration projects to evaluate program modifications such as eligibility expansion, provision of additional services not typically covered, or the use of innovative delivery systems that improve care, increase efficiency, and reduce costs. [1]
Shifting from Traditional Expansion to a Section 1115 Expansion: Uncharted Territory
Six of the 32 states that have expanded—or announced plans to expand—their Medicaid programs under the Affordable Care Act have done so using Section 1115 waivers. The State of Kentucky is among the 26 states that have implemented a traditional Medicaid expansion, but it has since announced plans to shift to an alternative 1115 waiver-based expansion. To date, only New Hampshire has transitioned from a traditional to a waiver-based expansion. And unlike Kentucky, that state’s traditional expansion was planned as a temporary step until the state implemented a waiver-based expansion.
A Closer Look at the Waiver Components under Discussion
SHADAC is currently conducting a study of the impact of ACA implementation in Kentucky that evaluates the ways in which the ACA impacts health care coverage, access, quality, cost, and health outcomes in the state.
Most recently, in light of Kentucky’s waiver proposal and in order to inform the discussion around the waiver, we have examined the main components of existing Medicaid expansion waivers in five states where the waivers most closely align with the Kentucky’s waiver discussion: Arkansas, Indiana, Iowa, Michigan, and Montana. The findings from this analysis are detailed in a special issue brief, “Section 1115 Waivers and ACA Medicaid Expansions: A Review of Policies and Evidence from Five States.” The waiver components explored in the brief include premium assistance, enrollee contributions, modified cost-sharing, healthy behavior incentives, and waiver of required benefits. In each case, arguments for and against the specific component as well as the relevant evidence. Overall, the results were mixed on the potential of the specific waiver activities to impact either access to health coverage and services or costs for newly eligible Medicaid beneficiaries.
View the full brief to access the detailed findings.
Waivers Increasingly Considered
The findings from this analysis having implications for other states moving forward with or considering Section 1115 waiver proposals. So far, in addition to Kentucky, Arizona and Ohio have announced intentions to transition from traditional to waiver-based expansions.
Learn more about SHADAC’s analysis of the impact of ACA implementation in Kentucky.
[1] Centers for Medicare and Medicaid Services. “About Section 1115 Waivers.” Baltimore, MD. Available at https://www.medicaid.gov/medicaid/section-1115-demo/about-1115/index.html.
Principal Investigator: Brant Fries, PhD, University of Michigan
The goal of this study is to examine Medicaid long-term medical care eligibility criteria across states, and in particular, how the nursing facility level of care (LOC) criteria affect access to care through home and community-based services (HCBS). The researchers will compare LOC policies across four states that have adopted a standardized, comprehensive assessment instrument, the interRAI Home Care instrument. They will apply state-specific algorithms to data from a fifth state to measure each state’s relative degree of access to HBCS.
Grant Products & Publications
Using Standardized Data to Compare Access to Long-Term Services and Supports in Five U.S. States
(July 2017, Presentation at 21st IAGG World Congress of Gerontology & Geriatrics)
Principal Investigator: Alexander Cowell, PhD, RTI International
The goal of this research is to inform state policy discussions around access to and continuity of behavioral health care in Medicaid and the exchanges for those who transition between these sources of coverage. The research team will analyze documents from state Medicaid plans and health insurance exchanges to assess the extent of alignment between Medicaid and private insurance in terms of the scope, level of coverage, and formulary design for behavioral health care. They will also assess whether alignment for behavioral health is different from that for general medical coverage.