DEPARTMENT  OF  HEALTH  &  HUMAN SERVICES  
CMS 
Centers  for  Medicare & Medicaid  
Services  7500  Security  Boulevard,  
Mail  Stop  S2-26-12  
CENTERS FOR MEDICARE & MEDICAID SERVICES 
Baltimore, Maryland   21244-1850   CENTER FOR MEDICAID & CHIP SERVICES 
 
CMCS Informational  Bulletin  
 
DATE:    March  31, 2022  
 
FROM:     Daniel Tsai, Deputy Administrator   and Director   
Center for Medicaid  and  CHIP  Services  
 
SUBJECT:  CMS Enforcement Discretion   Medicaid Access Monitoring Review Plans  
 
The  purpose of this informational  bulletin  is to inform  states  that  the Centers for Medicare &  
Medicaid  Services (CMS) is  exercising enforcement  discretion during the  COVID-19 public  
health emergency (PHE)  with regard to state  submissions   of  updated Medicaid access  monitoring 
review  plans  (AMRPs)  described in 42 CFR  447.203,  and will  delay enforcement of the  
requirement under 42 CFR  447.203(b)(5)(i)   that  states  submit  updated AMRPs  by October  1,  
2022.  As  provided in 42 CFR  447.203(b)(5),   states were required to submit  their  initial   AMRPs  
to CMS  by October 1,  2016,  and must update  them  at least once every three years.  Absent this  
exercise of enforcement  discretion,  updated AMRPs  would be due to CMS by October 1,  2022.   
Given the demands  on state Medicaid agencies during PHE  and the associated resource strain,  
CMS is  delaying  enforcement of  the  requirement  for  states to submit  updated AMRPs that  
otherwise would be  due  by October 1,  2022,  until  October 1,  2024.  In the interim,  as discussed  
in more detail  below,  CMS will  continue  to require  states  to demonstrate  that  they are  meeting  
the statutory obligation  to ensure  Medicaid rates are consistent  with section 1902(a)(30)(A)  of  
the Social Security Act  (the Act).  Strengthening  and expanding access  to care  is a CMS priority.  
This includes  a  broad view of access  that ensures enrollment  in and maintenance  of coverage and 
that, once  people are  enrolled, covered services  are  provided in a  timely,   equitable, high-quality 
manner, regardless of  delivery system.  
 
Background  
 
Under  section 1902(a)(30)(A)  of the Act, states  must  assure that payments  are consistent  with  
efficiency,  economy,  and quality  of care  and are  sufficient  to enlist  enough providers  so that care  
and services are available under  the plan  at least to the extent  that such care and services are 
available  to the general  population  in the geographic  area.   
 
In the November  2,  2015 Federal Register  (80 FR  67576),  CMS  published  the Methods for  
Assuring Access  to Covered Medicaid Services final  rule  with comment  period that outlined  a  
data-driven process for states  to  document  whether Medicaid  fee-for-service  payments are 
sufficient  to enlist  enough providers to ensure beneficiary  access to covered  care and  services  
consistent  with section 1902(a)(30)(A)  of the Act.  The regulations  provide  that states  must  
develop and submit  to CMS  an  AMRP  that  is updated  at least every three years  for  certain  
specified  services  and  must  identify  a  process to review  and monitor  access  to care.  When states  
reduce  Medicaid payment rates  or restructure them in  circumstances  when the changes could 
result in diminished   access, they must  implement   special  monitoring  procedures to  monitor the   CMCS Informational   Bulletin    Page 2  
effects of  the rate reduction  or restructuring  for  at least  3 years  after the effective date of  the 
change.  Any time  an  access  deficiency is identified,  the  state must submit  a corrective action  
plan to CMS within  90 days  after discovery and work to address the issues  within 12 months.  
 
Basis for Exercising Enforcement  Discretion  
 
During the  PHE,  states and providers  are experiencing unprecedented resource  strain, and CMS  
has looked to alleviate  burden to the national  health care  system when opportunities   are  
available.   This  has  included temporarily  suspending or  changing certain reporting requirements  
and administrative   processes  otherwise required under the  Medicaid statute  and regulations,  
when  necessary to  ensure that  sufficient  administrative  resources are available to  respond  
adequately to the PHE.  The volatility  of the health care  delivery system  during the  PHE  may 
present  significant   barriers  for states  and providers  to evaluate  and submit  timely health quality 
and  access to  care data.   During  this  unprecedented  time,  many states have had to divert  staff 
resources to  making  program  and operational  changes  necessary  to respond to the  PHE and 
repeated  surges in  COVID-19 infections. Additionally,   the  AMRP  process may require  states to 
obtain certain information  about  health care access from  providers,  and  many providers  have  
been  overwhelmed by an influx  of patients  (whether seeking treatment for  COVID-19, routine  or  
non-COVID-19-related  emergent care, or care that had been delayed  due to the circumstances of  
the PHE),  as well  as staff shortages.    
 
Specific  to the Medicaid AMRP  process under  42 CFR  447.203,  CMS is  concerned that states  
may be  unduly  burdened if required to adhere  to the  October  1, 2022,  timeline   for  submitting 
updated AMRPs, and that  state  resources  that  would be used for preparing these updates  would 
be more appropriately  devoted to ensuring that care  and services are available to Medicaid  
beneficiaries  and that providers  are  appropriately  paid during the PHE.  In part, our  concern that  
the  otherwise required timeline   for  AMRP  updates is outweighed by the  need to ensure  adequate 
administrative  resources are available  to respond to the PHE  is  informed by our  recognition  that  
the AMRP  process only applies  to Medicaid fee-for-service payments,  while  the vast majority of  
Medicaid  beneficiaries  receive their  care through  managed  care delivery  systems.  Additionally,  
we are concerned that  data  about  access to and quality of  care since  the  beginning  of  the  PHE  
may  reflect the extraordinary  circumstances  of the PHE  and,  therefore, may  be of limited  
usefulness  in understanding likely  access  to and quality  of care  available  to Medicaid 
beneficiaries going forward.   
 
Based on these concerns,  CMS is  providing  states  until  October 1,  2024 to develop the AMRPs  
that  would otherwise  be  due on October  1, 2022.   We  believe  that  providing  states  with an 
additional   two years  to develop the AMRPs  is  appropriate  considering  the potential  for new  
surges in  COVID-19 and uncertainty around the end date of the PHE.  The two-year extension 
intends  to allow  states  to continue  to focus resources on addressing the health needs of Medicaid 
beneficiaries  during the  PHE and,  as well,  to conduct  work necessary to  resume routine  
operations  once the PHE  ends.  The  two-year extension should also  provide  time for  care 
delivery within Medicaid fee-for-service systems  to stabilize   and for states to gather and present  
data within  their  access-to-care  analysis that  does not  represent  the unique  conditions   of the PHE  
as  the baseline  period to assess  whether  future  proposed rate changes meet the statutory 
requirements.   CMCS Informational   Bulletin    Page 3  
 
Continued State  Obligation  to Ensure  Access to Care  
 
As a result  of  this  exercise of  enforcement discretion,   CMS will  not actively pursue enforcement  
of the regulatory requirement  that states  submit  an updated AMRP  by October 1,  2022,  as  
required under  42 CFR 447.203(b)(5)(i),   and will  delay enforcement  of  the requirement  to 
submit  an updated AMRP  until  October  1, 2024.   We  believe  this  delayed enforcement will  
provide states with  a reasonable timeframe for  compliance with the  regulatory AMRP update  
requirements,  in consideration  of the PHE  and the  stress  it has  placed on states  and providers.  
However, states remain responsible  for ensuring that Medicaid rates  are  consistent  with section 
1902(a)(30)(A)  of the  Act  and will  need to provide  CMS  with data and information  generally 
consistent  with the  provisions   of 42 CFR 447.203(b)(6)  and 42 CFR 447.204(b)  when proposing 
to reduce or restructure Medicaid payments  rates  through state plan amendments  (SPAs).  In the  
event that states propose  SPAs  that would reduce or restructure Medicaid payment  rates  during 
the PHE, CMS will work  closely  with  states  to ensure compliance with  the statute.   Specifically,  
through SPA reviews,  CMS will  continue  to expect states  present data demonstrating that  access  
to care  is consistent  with section 1902(a)(30)(A), to monitor  access to care data  and information 
after implementing  changes to Medicaid fee-for-service rates and  remediate access to care 
concerns.  Further,  we  will  expect  state to have conducted public  processes  to understand 
concerns from  providers  and stakeholders  related to Medicaid rate  changes  in advance of  
submitting  rate reduction or restructuring SPAs  to CMS for approval.  CMS  will  expect states  to  
present this  information  upon submission  of SPAs  and,  in the event a state  does not  provide  this  
information  upon SPA submission,   we  will  formally request the information  from  states which 
may delay SPA  approval.   Additionally,   on an ongoing  basis,  CMS will  continue  to monitor  
access-to-care concerns that  are raised  by  stakeholders  in  particular,  should such concerns  arise  
in relation to state rate  reductions.  
 
Ensuring equitable  access to health care for Medicaid and Childrens  Health Insurance Program  
(CHIP)  beneficiaries  is a  high priority  for  CMS.  Building  upon lessons learned from  
implementation  of the AMRP  process, along with other access-related work, CMS is  developing  
a comprehensive access strategy for  Medicaid  and  CHIP.  The goal  of the comprehensive access  
strategy is  to identify  and implement   ways to ensure that Medicaid and CHIP  beneficiaries  have  
access to timely,  high-quality,   and appropriate  care in both programs  and in all payment  and 
delivery systems,  regardless  of whether  care is  delivered through fee-for-service or managed  
care.  
 
Medicaid  and  CHIP beneficiaries  face a wide  range  of  potential  barriers to  accessing covered  
services, including  behavioral  health and long-term  services and supports  (including   institutional  
care  and home and community-based  services).  Such  barriers  can  vary from  people  being 
unaware they may be  eligible   for  a program  or  service,  to issues with enrollment,   provider  
participation,   and  service utilization.    A comprehensive access strategy will  enable CMS to better  
monitor  and take  action to promote  more  equitable  access  for all  Medicaid and CHIP  
beneficiaries,  consistent  with applicable   statutory requirements.   As  a first step in developing  this  
comprehensive  strategy, CMS  has  issued  a Request  for Information  (RFI)  on February 17, 2022,  
to solicit   public  feedback on potential  approaches that support  more  equitable  access  to health 
care as well  as address  barriers  faced by  Medicaid  and  CHIP beneficiaries  in  getting  and   CMCS Informational   Bulletin    Page 4  
maintaining  health  care coverage.  We strongly  encourage all  states  and stakeholders  to review  
the RFI and provide  feedback  on the matters discussed in the RFI  that are  relevant  to them.   
 
The RFI is  available 
at:https://cmsmedicaidaccessrfi.gov1.qualtrics.com/jfe/form/SV_6EYj9eLS9b74Npk.  
Stakeholders  interested in responding to the RFI should follow  the instructions   in that document  
for submitting  their  response.  
 
Should states  have any questions  about  the AMRP process  and the information  presented within 
this  bulletin,   please email  the Medicaid  access to care mailbox:  
MedicaidAccesstoCare@cms.hhs.gov.