DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard,  
Mail Stop S2-26-12  
Baltimore, MD 21244-1850 
 CMCS Informational Bulletin 
DATE:  July 11, 2019 
FROM:  Calder Lynch 
Acting Deputy Administrator and Director 
SUBJECT:  Comprehensive Strategy for Monitoring Access in Medicaid 
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that we are 
initiating a strategy to measure and monitor beneficiary access to care across Medicaid.  We 
are committed to develop a new data-driven strategy to understand access to care in the 
Medicaid program across fee-for-service and managed care delivery systems, as well as in 
home and community-based services (HCBS) waiver programs.  This new strategy will focus 
on a more uniform and comprehensive methodology for analyzing Medicaid access data for all 
states and will be led by CMS working in partnership with states.  
Background: 
Section 1902(a)(30)(A) of the Act requires states to 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) we 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 their compliance with section 1902(a)(30)(A) of the Act. Among other 
requirements, the 2015 final rule with comment period required states to develop and submit to 
CMS an access monitoring review plan (AMRP) for certain Medicaid services that is updated 
at least every three years. Additionally, the rule required that when states submit a State plan 
amendment (SPA) to reduce or restructure provider payment rates, they must consider the data 
collected through the AMRP and undertake a public process that solicits input on the potential 
impact of the proposed reduction or restructuring of Medicaid payment rates on beneficiary 
access to care.  
Numerous states expressed concern regarding the administrative burden associated with the 
November 2015 regulatory requirements, especially those states with high rates of beneficiary 
enrollment in managed care.  States have also questioned whether the AMRP process is the 
most effective or accurate reflection of access to care in a states Medicaid program.  In  Page 2  
 
attempt to address some of the states concerns regarding unnecessary administrative burden, 
in the March 23, 2018 Federal Register (83 FR 12696), we published a proposed rule that 
would have exempted states from requirements to analyze certain data or monitor access when 
the vast majority of their covered beneficiaries receive services through managed care plans 
and would have provided similar flexibility to all states when they make nominal rate 
reductions to fee-for-service payment rates. Based on the responses we received during the 
public comment period, we have decided not to finalize the proposed exemptions and instead 
are setting out a new approach to understanding access and ensuring statutory compliance 
while eliminating unnecessary burden on states. 
Please note that CMS intent is to improve access to care and will continue to ask states how 
they are meeting the statutory requirements, and address access to care concerns expressed by 
beneficiaries and other stakeholders. 
While CMS believes the AMRPs can be useful to guide states overall process to monitor 
beneficiary access, because they are generally limited to access in fee-for-service delivery 
systems and focused on targeted payment rate changes rather than the availability of care or 
population health outcomes, we have decided a more comprehensive approach is warranted.  
Concurrently with this Informational Bulletin, we are publishing a Notice of Proposed 
Rulemaking (NPRM) in the Federal Register that proposes to rescind the requirements of the 
2015 final rule with comment period while we develop a more comprehensive approach to 
monitoring access across delivery systems. Through the NPRM, we are seeking comments and 
feedback from our stakeholders regarding both the rescission of the current regulatory 
requirements and our approach moving forward. 
It is important to note, that until such point that the NPRM is finalized, the current regulatory 
requirements are still applicable. And, although the NPRM would remove the regulatory 
process requirements for states to develop and update an AMRP and to submit certain access 
analysis when proposing to reduce or restructure provider payment rates, states still are 
obligated by the statute to ensure Medicaid payment rates are sufficient to enlist enough 
providers to assure that beneficiary access to covered care and services is at least 
consistent with that of the general population in the same geographic area, particularly 
when reducing or restructuring Medicaid payment rates through SPAs.  If the regulatory 
amendments in this proposed rule are finalized, we would utilize existing CMS authority 
concurrently with the publication of the final rule through a letter to State Medicaid Directors 
to provide information on data and analysis that states may submit with SPAs to support 
compliance with section 1902(a)(30)(A) of the Act.  Such data might include:  rate 
comparisons; ratios of participating providers to total providers in the geographic area; ratios of 
participating providers to beneficiaries in the geographic area; available transportation in the 
geographic area; direct comparisons of access for Medicaid beneficiaries to that of the general 
population in the geographic area; and provider, beneficiary, and other stakeholder complaints 
and recommendations for resolution of such complaints.   
Developing a New Access Strategy: 
We want to work collaboratively with states and other stakeholders to develop a streamlined, 
comprehensive approach to monitoring access across Medicaid delivery systems by identifying 
uniform access indicators that may be measured through available data. To accomplish this, we  Page 3  
 
will convene workgroups and technical expert panels that include key state and federal 
stakeholders in the upcoming months.  The workgroup will focus on identifying:  1) how the 
current requirements could be improved; 2) the most effective approach to ensuring beneficiary 
access to care; 3) how can CMS best ensure states comply with the statutory access 
requirements; and 4) the best way to align access monitoring across fee-for-service and 
managed care delivery systems.  The workgroups will also identify data that could be available 
to conduct access reviews at the federal level and the types of analyses that would be 
beneficial.   
Next Steps: 
In the coming weeks, CMS will be working with the National Association of Medicaid 
Directors (NAMD) to identify states that would be interested in partnering with us on this 
important initiative by participating in technical expert panels and ongoing working groups.  
Our focus will be to identify measures and benchmarks and data that may be used as common 
access indicators across fee-for-service, managed care and home and community based 
waivers.  Throughout the process, we will be soliciting feedback and input on the strategy and 
will work collaboratively with our state partners and other stakeholders to determine a 
comprehensive access measurement approach.  
    /s/