80_FR_67588 80 FR 67377 - Medicaid Program; Request for Information (RFI)-Data Metrics and Alternative Processes for Access to Care in the Medicaid Program

80 FR 67377 - Medicaid Program; Request for Information (RFI)-Data Metrics and Alternative Processes for Access to Care in the Medicaid Program

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 80, Issue 211 (November 2, 2015)

Page Range67377-67381
FR Document2015-27696

In this request for information (RFI), we seek public input to inform the potential development of standards with regard to Medicaid beneficiaries' access to covered services under the Medicaid program. Specifically, we are interested in obtaining information on core access to care measures and metrics that could be used to measure access to care for beneficiaries in the Medicaid program (including in fee-for- service and managed care delivery systems) and used to develop local, state and national thresholds and goals to inform and improve access in the program. We are also interested in feedback on approaches to using the metrics, which could include setting access goals and thresholds and formal processes for beneficiaries to raise access concerns.

Federal Register, Volume 80 Issue 211 (Monday, November 2, 2015)
[Federal Register Volume 80, Number 211 (Monday, November 2, 2015)]
[Proposed Rules]
[Pages 67377-67381]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2015-27696]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 447

[CMS-2328-NC]


Medicaid Program; Request for Information (RFI)--Data Metrics and 
Alternative Processes for Access to Care in the Medicaid Program

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Request for information.

-----------------------------------------------------------------------

SUMMARY: In this request for information (RFI), we seek public input to 
inform the potential development of standards with regard to Medicaid 
beneficiaries' access to covered services under the Medicaid program. 
Specifically, we are interested in obtaining information on core access 
to care measures and metrics that could be used to measure access to 
care for beneficiaries in the Medicaid program (including in fee-for-
service and managed care delivery systems) and used to develop local, 
state and national thresholds and goals to inform and improve access in 
the program. We are also interested in feedback on approaches to using 
the metrics, which could include setting access goals and thresholds 
and formal processes for beneficiaries to raise access concerns.

DATES: Comment Date: To be assured consideration, comments must be 
received at one of the addresses provided below, no later than 5 p.m. 
on January 4, 2016.

ADDRESSES: In commenting, refer to file code CMS-2328-NC. Because of 
staff and resource limitations, we cannot accept comments by facsimile 
(FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address only: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-2328-NC, P.O. Box 8016, 
Baltimore, MD 21244-8016.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address only: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-2328-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. Alternatively, you may deliver (by hand or 
courier) your written comments ONLY to the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
call telephone number (410) 786-7195 in advance to schedule your 
arrival with one of our staff members.
    Comments erroneously mailed to the addresses indicated as 
appropriate for hand or courier delivery may be delayed and received 
after the comment period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Jeremy Silanskis, (410) 786-1592.

SUPPLEMENTARY INFORMATION: 
    Inspection of Public Comments: All comments received before the 
close of

[[Page 67378]]

the comment period are available for viewing by the public, including 
any personally identifiable or confidential business information that 
is included in a comment. We post all comments received before the 
close of the comment period on the following Web site as soon as 
possible after they have been received: http://www.regulations.gov. 
Follow the search instructions on that Web site to view public 
comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

    CMS and states have the responsibility under section 1902(a)(30)(A) 
of the Social Security Act (the Act) to assure that Medicaid 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 state plan at least to the extent that such care 
and services are available to the general population in the geographic 
area. We interpret this provision to mean rates and payments for 
Medicaid services are set at levels that ensure value, quality and 
provider participation. In the past, our oversight of this provision 
has primarily focused on ensuring that payment methodologies are 
economic and efficient, as well as consistent with upper payment limits 
for certain services. During the recent economic downturn, and in light 
of state proposals to dramatically reduce provider payments, we began 
requesting that states provide information to document that services 
are available and access remains after payment reductions go into 
effect. We found that state processes for documenting access were 
generally inconsistent and in many cases did not adequately document 
access.
    To address this, on May 6, 2011, we published the proposed rule 
entitled ``Medicaid Program; Methods for Assuring Access to Covered 
Medicaid Services'' (hereafter referred to as the ``Access to Care'' 
proposed rule) (76 FR 26342). In that rule, we proposed a specific 
process through which states would document that their payment rates 
provide access to care. The proposed rule, which applies to services 
that states cover through the Medicaid state plan, is being finalized 
with comment period concurrent with the issuance of this request for 
information (RFI). Among other new processes, the rule requires states 
describe access monitoring review plans that address: The extent to 
which enrollee needs are fully met, the availability of care and 
qualified service providers, changes in service utilization and 
comparisons between Medicaid payments and payments made by other health 
payers for equivalent services. At a minimum, the access monitoring 
review plans apply to the following service categories: Primary care 
(including pediatric care), physician specialists, behavioral health 
(including substance use disorder services), pre- and post-natal 
obstetric services, and home health. If states reduce or restructure 
payments, or receive complaints about access to care for other 
services, they must add those services to the review plans and monitor 
access to those services over the ensuing 3 years. States, with public 
input from stakeholders, would determine measures and thresholds used 
to monitor access as the final rule does not require a core set of 
measures or describe national thresholds for Medicaid access to care.
    We also recently proposed changes that promote access to care for 
beneficiaries who receive services through Medicaid managed care. On 
June 1, 2015, we issued a proposed rule entitled ``Medicaid and 
Children's Health Insurance Program (CHIP) Programs; Medicaid Managed 
Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive 
Quality Strategies, and Revisions Related to Third Party Liability (80 
FR 31098), which proposed to modernize Medicaid and Children's Health 
Insurance Program (CHIP) managed care regulations to update the 
programs' rules and strengthen the delivery of quality care for 
beneficiaries. In that rule, we proposed: Minimum requirements for 
states when setting and monitoring network adequacy standards, 
certification of managed care plan networks at least on an annual 
basis, and annual reporting on the accessibility and availability of 
services. Similar to the ``Access to Care'' final rule with comment 
period that appears elsewhere in this issue of the Federal Register, 
the managed care proposed rule proposes to allow states the discretion 
to set the standards and measures for network adequacy and does not 
propose to require specific measures or thresholds for access to care. 
The access requirements for managed care plans are not directly 
governed by section 1902(a)(30)(A) of the Act, but instead are governed 
by access requirements under sections 1903(m) and 1932 of the Act. The 
proposed managed care rule, however, would apply the same principles in 
determining access in the managed care environment as are contained in 
the fee-for-service environment.
    We believe that, to the extent there are similarities in the 
methods and measures used to review and analyze network adequacy for 
managed care networks and access to care in fee-for-service, aligning 
such methods and measures would ease the administrative burden on 
states and ensure that all Medicaid beneficiaries receive the care that 
they need regardless of whether they are in fee-for-service, are 
enrolled with a managed care organization, or receive services through 
a Medicaid waiver program. We are undertaking this effort to review 
access to care across the entire program for all individuals enrolled 
in Medicaid regardless of the delivery system mechanism.
    Importantly, earlier this year, the Supreme Court decided in 
Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (2015) 
that Medicaid providers and beneficiaries do not have a private right 
of action to challenge state-determined Medicaid payment rates in 
federal courts, placing greater importance on CMS review to ensure that 
such rates are ``consistent with efficiency, economy and quality of 
care'' and ensure sufficient beneficiary access to care under the 
program. The Court concluded that federal administrative agencies are 
better suited than federal courts to make these determinations. Options 
for Medicaid providers and beneficiaries to pursue Medicaid rate-
related issues in federal courts are now limited. As we note in the 
final rule with comment period, we are therefore working to strengthen 
the framework for CMS review to ensure that rates meet the requirements 
of section 1902(a)(30)(A) of the Act, including requiring access 
improvement strategies to improve care delivery where there are 
shortcomings. In this request for information, we are asking for public 
input on what additional data sources and approaches could be used to 
determine whether access to care is sufficient.
    We recognize that many factors affect access to Medicaid services, 
including: Level of payment, geographic location, time and distance to 
the closest provider, workforce, numbers of specialists and other types 
of providers within the state, lack of knowledge of

[[Page 67379]]

available resources by beneficiaries, insufficient provider outreach, 
scope of practice approaches, and other economic and policy factors. 
Within state Medicaid programs, there are also considerable diversities 
in delivery system designs, populations served, and provider networks. 
We seek public input on what additional approaches we and states can 
take to understand, measure and improve Medicaid access more uniformly 
and in ways that account for these unique program features. This RFI 
solicits input from states, providers, beneficiaries and other members 
of the public on the feasibility of and methodologies related to the 
following four specific approaches:
     Developing a core set of measures of access that all 
states would monitor and publicly report on;
     Measuring access to long term care and home and community 
based services;
     Setting national access to care thresholds; and
     Establishing a process for access to care that would allow 
beneficiaries experiencing access issues to raise and seek resolution 
of their concerns.
    We also invite input on additional actions that we or states may 
take to further measure and promote access to care in the Medicaid 
program.
    In seeking this input, we recognize that we have not yet identified 
a clear, defined set of access measures that demonstrates whether 
access to care is sufficient. We are seeking input to identify a 
feasible set of measures and metrics that meaningfully demonstrate 
whether access to care is sufficient. We requested comments on 
potential core metrics and thresholds through the ``Access to Care'' 
proposed rule and received many suggestions. Generally, the responses 
suggested set levels of payment or access to providers consistent with 
Medicare or private insurance, without corresponding metrics and data 
sources to conduct a comparative analysis. Other health payers, such as 
Medicare, may be further along in measuring access through data 
collection tools. As any new data collection requirements would impose 
administrative burden on states and providers, we are particularly 
interested in how existing efforts, like the Medicare Current 
Beneficiary Survey and the Consumer Assessment of Healthcare Providers 
and Systems (and approved supplemental data sets), may be modified to 
apply to the Medicaid program.
    We note that through this RFI, we are seeking comments on areas of 
measurement and metrics that may indicate sufficient access in Medicaid 
programs regardless of delivery system. We are not attempting to 
develop areas of measurement that indicate causes of access deficiency, 
such as information on social determinants of health. While we 
appreciate the importance of understanding the reasons behind access 
problems and identifying those issues through data, our initial goal is 
to develop indicators of sufficient access that can be affected by 
Medicaid policy levers.

II. Provisions of the Request for Information

    We are inviting states, beneficiaries, advocacy organizations, 
providers, managed care organizations, research and measurement 
communities, professional associations and other members of the public 
to share analyses and opinions related to the following topics: (1) 
Access to care data collection and methodology; (2) access to care 
thresholds and goals; (3) alternative processes for access concerns; 
and (4) access to care measures.
    The terms: Measures, metrics, and thresholds, are used throughout 
this RFI. By measures, we mean concrete, quantifiable indicators that 
can be used to assess access to care in Medicaid. Measures have both a 
numerator and a denominator (for example, 500 Medicaid participating 
physicians in the state this year divided by the number of Medicaid 
enrollees this year, or the state received 50 beneficiary complaints 
this month divided by the number of beneficiaries enrolled). Metrics 
are used to examine measures relative to a baseline assessment (for 
example, there 10 percent more physicians participating in Medicaid 
this year than last year, or the state received 20 percent fewer 
complaints this month than last month). A threshold would be a minimum 
acceptable value for access to care that is based on the measures and 
metrics.

A. Access to Care Data Collection and Methodology

    To better inform us on the nature and scope of access to care 
measures and metrics, we are requesting comments on how to focus our 
efforts to determine the best indicators of access in Medicaid across 
services and delivery systems. Consideration of the following questions 
may be helpful in providing us your ideas and suggestions.
     What do you perceive to be the advantages and 
disadvantages to requiring a national core set of access to care 
measures and metrics? Who do you believe should collect and analyze the 
national core set data?
     Do you believe there are specific access to care measures 
that could be universally applied across services? If so, please 
describe such measures.
     What information and methods do you believe large health 
care programs use to measure access to care that could be used by the 
Medicaid program? What role can health information technology lay in 
measuring access to care?
     What do you believe are the primary indicators of access 
to care in the Medicaid program? Is measured variance in these 
indicators based on differences in things such as: Provider 
participation and location, appointment times, waiting room times, call 
center times, prescription fill times, other?
     Do you believe a national core set of access measures or 
metrics should apply across all services, or is it more appropriate to 
target a core set of access measures by service?
     Do you believe questions in provider and beneficiary 
surveys should be consistent for Medicaid and Medicare beneficiaries? 
If not, what differences do you believe should be accommodated for the 
Medicaid program, including differences in covered services?
     What do you believe we should consider in undertaking 
access to care data collection in areas related to: Differences between 
fee-for-service (FFS) and managed care delivery, variations in services 
such as acute and long-term care, community and institutional settings 
for long-term care delivery, behavioral health, variations in access 
for pediatric and adult populations and individuals with disabilities, 
and variations in access for rural and urban areas? Consider also 
individuals with chronic conditions who may have limited functional 
support needs related to activities of daily living but nonetheless 
require more intensive care than other Medicaid beneficiaries, such as 
persons living with HIV/AIDS.
     Specific to long-term services and supports, including 
home and community based services, what factors do you believe we 
should consider in measuring access to care? Do you believe we should 
incorporate into reviews of access to care for these services economic 
factors and significant policy factors such as: Minimum wage and 
overtime requirements, direct service worker shortages, training and 
professional development costs, or other factors?
     Do you believe measuring access to Home and Community 
Based Services (HCBS) differs from measuring access to acute medical 
care? Please describe.

[[Page 67380]]

     Do you believe access to HCBS should be tracked in FFS and 
in managed care delivery systems? Do you perceive any differences 
between tracking HCBS in each system?
     Do you believe there are additional metrics that need to 
be tracked related to HCBS?

B. Access to Care Thresholds/Goals

    To better inform us on how to interpret and use access to care 
metrics, we are requesting comments on setting access thresholds and 
how we might use the thresholds to improve access in the Medicaid 
program. Consideration of the following questions may be helpful in 
providing us your ideas and suggestions.
     Do you believe we should set thresholds for Medicaid 
access to care? If so, do you believe such thresholds should be set at 
the national, state or local levels? Why?
     If we set Medicaid access thresholds, how do you believe 
they should be used? For instance: For issuing compliance actions to 
states that do not meet the thresholds, as benchmarks for state 
improvement, for use in appeals processes for beneficiaries that have 
trouble accessing services, or in other ways?

C. Alternative Processes for Access Concerns

    We are considering requiring standard access to care complaint 
driven processes to better ensure access and are interested in how data 
gathered and analyzed through a core set of measures might aid in 
resolving complaints, please consider the following questions:
     Do you believe there are existing and effective processes 
to resolve consumers' concerns regarding health care access issues that 
might be useful for all state Medicaid programs?
     What do you believe are the advantages and disadvantages 
of either a complaint resolution process or a formal appeals hearing 
for access to care concerns?
     Who do you believe should be the responsible party (for 
example, the state or federal government, an independent third party, a 
civil servant, an administrative law judge, etc.) to hear beneficiary 
access to care complaints and/or appeals?
     For an access to care appeal, what criteria do you believe 
should be used to help determine:
    ++Whether an appeal should be heard?
    ++Whether an appeal merits recommendations to the state Medicaid 
agency?
     Which access to care areas of measurement or specific 
metrics may be useful in setting thresholds that would help hearings 
officers assess appeals and determine access to care remedies?
     Lack of timeliness of an appeal could undermine the time 
sensitive efforts associated with remediating an individual's access to 
medical services. You may want to consider providing information on the 
following:
    ++How could appeals be expedited?
    ++What outcomes could an appeals officer offer if services are 
unavailable to Medicaid beneficiaries?
    ++Are there other non-appeal based processes that could be used 
instead?

D. Access to Care Measures

    In conjunction with this RFI, you may want to consider each of the 
topics listed below, and suggest what you believe we should prioritize. 
You are also welcome to provide additional metrics that are associated 
with measurement areas that are relevant indicators of access to care 
in the Medicaid program and feasible to collect and analyze.
    For each suggested metric, you may consider describing the 
following:
     Suggested relevant data metrics,
     whether the metric is currently reported for Medicaid 
services,
     the feasibility of collecting the metric,
     the associated data sources/set(s) where the metrics are 
available,
     the financial cost (if any) of collecting the proposed 
metric,
     should including the metric in a more robust (or updated) 
Medicaid access policy be given priority;
     the party responsible/steward(s) of the metric data 
source,
     the metric validation process,
     whether the metric is relevant to all Medicaid populations 
or specific to particular groups, (for example, adults or pediatric 
populations, including children with special health care needs, or to 
people with disabilities or to dually eligible beneficiaries),
     whether the metric is applicable to FFS, managed care or 
both delivery systems,
     whether the metric is relevant for various subpopulations 
such as eligibility category, institutional status, or geographic 
region,
     whether the metric should be measured at the local, state 
or national level,
     as appropriate for Medicaid, thresholds associated with 
the metric,
     the challenges and advantages of the proposed metric, and 
how the metric is indicative to Medicaid access to care.
1. Measures for Availability of Care and Providers
    We are soliciting public comment on the following availability of 
care and providers measurement areas within geographic areas. In 
addition to feedback on the proposed metrics below, we are also 
interested in your thoughts on how ``geographic areas'' should be 
defined.
     Primary care physicians (including pediatricians) and 
clinicians accepting any/new patients.
     Physician specialists accepting any/new patients.
     Specialty care (for example, addiction and psychiatric 
services,, home and community based services, specialty pharmacy) 
accepting any/new patients.
     Availability of direct support workforce for home health 
and home and community-based services.
     Dentists accepting any/new patients.
     Psychiatric and substance abuse clinicians such as 
psychiatrists, child psychiatrists, psychologists, and psychiatric 
social workers and mental health counselors accepting any/new patients.
     Physicians and clinicians experiencing difficulties 
referring patients to specialty care.
     Psychiatrists experiencing difficulties referring patients 
with serious mental illness to primary care.
     Available primary care clinics, federally qualified health 
centers or rural health clinics.
     Available retail community pharmacies.
     Available behavioral health clinics or community mental 
health centers.
     Available inpatient care.
     Other.
2. Measures for Beneficiary Reported Access
    We are soliciting public comment on the following beneficiary 
reported access measurement areas:
     Beneficiaries reporting a usual source of primary care.
     Beneficiaries reporting difficulty finding a specialist/
general clinician, not taking any new patients and/or the beneficiary's 
insurance.
     Beneficiaries able to access specialists or behavioral 
health care if they have: Chronic conditions, heart disease, behavioral 
health issues, etc.
     Beneficiaries able to access long-term services and 
supports in institutional settings.
     Beneficiaries able to access home and community based 
services.
     Women able to access: Pap smears, mammograms.

[[Page 67381]]

     Children and adults able to access appropriate 
immunizations and/or seasonal vaccines.
     Beneficiaries reporting delayed care and reason for delay.
     Unmet need for specialty, primary, follow-up, dental, 
prescriptions, and mental health and substance abuse treatment due to 
cost concerns.
     Beneficiaries getting needed care quickly.
     Wait times for appointments (for example, to primary care, 
urgent care, physician specialists, pre-natal care, behavioral health 
providers, and long-term services and supports in community settings).
     Length of delays in accessing long term services and 
supports in community setting due to direct service worker shortages 
and/or lack of adequate training.
     Call-center capability standards to support providing 
beneficiaries with information that can improve their access, and 
produce useful metrics for monitoring.
     Call-center metrics that reveal issues with beneficiary 
access and their resolution.
     Other.
3. Measures regarding Service Utilization--
    We are soliciting public comment on the following service 
utilization measurement areas:
     Trends in service utilization by geographic regions within 
the state.
     Trends in emergency room utilization relative to primary 
and mental health and substance abuse treatment care utilization.
     Rates of utilization (for example, At least one of the 
following visits in the prior six months/year: Physician (including 
nurse practitioners and physician assistants), dental, specialty, 
behavioral health, and primary care/well-child.)
     Other.
4. Comparison of Payments
    We are soliciting public comment on the following comparison of 
payment measurement areas:
     Payment rates for services set at a specific percentage of 
Medicare.
     Medicaid payment rates compared to surrounding states, 
Medicare, commercial payers.
     Acquisition costs compared to Medicaid payments for 
pharmaceuticals.
     Comparisons or measures that would inform managed care 
rate adequacy (the payment managed care plans make to providers).
     Other.
    We will evaluate the responses to this RFI, in addition to the 
findings from research that we are currently conducting, to inform 
whether it is advisable to collect and analyze core national measures 
at this time and the methods to conduct the collection. We may also use 
this information to help determine which measures could best inform 
understanding of access to care and to support the design of national 
or state and local thresholds.

III. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
if and, when we proceed with a subsequent document, we will respond to 
the comments in the preamble to that document.

    Dated: October 20, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2015-27696 Filed 10-29-15; 11:15 am]
 BILLING CODE 4120-01-P



                                                                            Federal Register / Vol. 80, No. 211 / Monday, November 2, 2015 / Proposed Rules                                          67377




                                                      *      *     *       *      *                           approaches to using the metrics, which                your written comments ONLY to the
                                                        By direction of the Commission.                       could include setting access goals and                following addresses:
                                                      Donald S. Clark,                                        thresholds and formal processes for                      a. For delivery in Washington, DC—
                                                                                                              beneficiaries to raise access concerns.               Centers for Medicare & Medicaid
                                                      Secretary.
                                                                                                              DATES: Comment Date: To be assured                    Services, Department of Health and
                                                      [FR Doc. 2015–27773 Filed 10–30–15; 8:45 am]
                                                                                                              consideration, comments must be                       Human Services, Room 445–G, Hubert
                                                      BILLING CODE 6750–01–C
                                                                                                              received at one of the addresses                      H. Humphrey Building, 200
                                                                                                              provided below, no later than 5 p.m. on               Independence Avenue SW.,
                                                                                                              January 4, 2016.                                      Washington, DC 20201.
                                                      DEPARTMENT OF HEALTH AND                                                                                         (Because access to the interior of the
                                                      HUMAN SERVICES                                          ADDRESSES: In commenting, refer to file               Hubert H. Humphrey Building is not
                                                                                                              code CMS–2328–NC. Because of staff                    readily available to persons without
                                                      Centers for Medicare & Medicaid                         and resource limitations, we cannot                   federal government identification,
                                                      Services                                                accept comments by facsimile (FAX)                    commenters are encouraged to leave
                                                                                                              transmission.                                         their comments in the CMS drop slots
                                                      42 CFR Part 447                                            You may submit comments in one of                  located in the main lobby of the
                                                      [CMS–2328–NC]                                           four ways (please choose only one of the              building. A stamp-in clock is available
                                                                                                              ways listed):                                         for persons wishing to retain a proof of
                                                      Medicaid Program; Request for                              1. Electronically. You may submit                  filing by stamping in and retaining an
                                                      Information (RFI)—Data Metrics and                      electronic comments on this regulation                extra copy of the comments being filed.)
                                                      Alternative Processes for Access to                     to http://www.regulations.gov. Follow                    b. For delivery in Baltimore, MD—
                                                      Care in the Medicaid Program                            the ‘‘Submit a comment’’ instructions.                Centers for Medicare & Medicaid
                                                                                                                 2. By regular mail. You may mail                   Services, Department of Health and
                                                      AGENCY:  Centers for Medicare &
                                                                                                              written comments to the following                     Human Services, 7500 Security
                                                      Medicaid Services (CMS), HHS.
                                                                                                              address only: Centers for Medicare &                  Boulevard, Baltimore, MD 21244–1850.
                                                      ACTION: Request for information.
                                                                                                              Medicaid Services, Department of                         If you intend to deliver your
                                                      SUMMARY: In this request for information                Health and Human Services, Attention:                 comments to the Baltimore address, call
                                                      (RFI), we seek public input to inform                   CMS–2328–NC, P.O. Box 8016,                           telephone number (410) 786–7195 in
                                                      the potential development of standards                  Baltimore, MD 21244–8016.                             advance to schedule your arrival with
                                                      with regard to Medicaid beneficiaries’                     Please allow sufficient time for mailed            one of our staff members.
                                                      access to covered services under the                    comments to be received before the                       Comments erroneously mailed to the
                                                      Medicaid program. Specifically, we are                  close of the comment period.                          addresses indicated as appropriate for
                                                      interested in obtaining information on                     3. By express or overnight mail. You               hand or courier delivery may be delayed
asabaliauskas on DSK5VPTVN1PROD with PROPOSALS




                                                      core access to care measures and metrics                may send written comments to the                      and received after the comment period.
                                                      that could be used to measure access to                 following address only: Centers for                      For information on viewing public
                                                      care for beneficiaries in the Medicaid                  Medicare & Medicaid Services,                         comments, see the beginning of the
                                                      program (including in fee-for-service                   Department of Health and Human                        SUPPLEMENTARY INFORMATION section.
                                                      and managed care delivery systems) and                  Services, Attention: CMS–2328–NC,                     FOR FURTHER INFORMATION CONTACT:
                                                      used to develop local, state and national               Mail Stop C4–26–05, 7500 Security                     Jeremy Silanskis, (410) 786–1592.
                                                      thresholds and goals to inform and                      Boulevard, Baltimore, MD 21244–1850.                  SUPPLEMENTARY INFORMATION:
                                                      improve access in the program. We are                      4. By hand or courier. Alternatively,                 Inspection of Public Comments: All
                                                                                                                                                                                                                EP02NO15.009</GPH>




                                                      also interested in feedback on                          you may deliver (by hand or courier)                  comments received before the close of


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                                                      67378                 Federal Register / Vol. 80, No. 211 / Monday, November 2, 2015 / Proposed Rules

                                                      the comment period are available for                    proposed rule, which applies to services              care. The access requirements for
                                                      viewing by the public, including any                    that states cover through the Medicaid                managed care plans are not directly
                                                      personally identifiable or confidential                 state plan, is being finalized with                   governed by section 1902(a)(30)(A) of
                                                      business information that is included in                comment period concurrent with the                    the Act, but instead are governed by
                                                      a comment. We post all comments                         issuance of this request for information              access requirements under sections
                                                      received before the close of the                        (RFI). Among other new processes, the                 1903(m) and 1932 of the Act. The
                                                      comment period on the following Web                     rule requires states describe access                  proposed managed care rule, however,
                                                      site as soon as possible after they have                monitoring review plans that address:                 would apply the same principles in
                                                      been received: http://                                  The extent to which enrollee needs are                determining access in the managed care
                                                      www.regulations.gov. Follow the search                  fully met, the availability of care and               environment as are contained in the fee-
                                                      instructions on that Web site to view                   qualified service providers, changes in               for-service environment.
                                                      public comments.                                        service utilization and comparisons                      We believe that, to the extent there are
                                                         Comments received timely will also                   between Medicaid payments and                         similarities in the methods and
                                                      be available for public inspection as                   payments made by other health payers                  measures used to review and analyze
                                                      they are received, generally beginning                  for equivalent services. At a minimum,                network adequacy for managed care
                                                      approximately 3 weeks after publication                 the access monitoring review plans                    networks and access to care in fee-for-
                                                      of a document, at the headquarters of                   apply to the following service                        service, aligning such methods and
                                                      the Centers for Medicare & Medicaid                     categories: Primary care (including                   measures would ease the administrative
                                                      Services, 7500 Security Boulevard,                      pediatric care), physician specialists,               burden on states and ensure that all
                                                      Baltimore, Maryland 21244, Monday                       behavioral health (including substance                Medicaid beneficiaries receive the care
                                                      through Friday of each week from 8:30                   use disorder services), pre- and post-                that they need regardless of whether
                                                      a.m. to 4 p.m. To schedule an                           natal obstetric services, and home                    they are in fee-for-service, are enrolled
                                                      appointment to view public comments,                    health. If states reduce or restructure               with a managed care organization, or
                                                      phone 1–800–743–3951.                                   payments, or receive complaints about                 receive services through a Medicaid
                                                                                                              access to care for other services, they               waiver program. We are undertaking
                                                      I. Background
                                                                                                              must add those services to the review                 this effort to review access to care across
                                                         CMS and states have the                                                                                    the entire program for all individuals
                                                                                                              plans and monitor access to those
                                                      responsibility under section                                                                                  enrolled in Medicaid regardless of the
                                                                                                              services over the ensuing 3 years. States,
                                                      1902(a)(30)(A) of the Social Security Act                                                                     delivery system mechanism.
                                                                                                              with public input from stakeholders,
                                                      (the Act) to assure that Medicaid                                                                                Importantly, earlier this year, the
                                                                                                              would determine measures and
                                                      payments are consistent with efficiency,                                                                      Supreme Court decided in Armstrong v.
                                                                                                              thresholds used to monitor access as the
                                                      economy, and quality of care and are                                                                          Exceptional Child Center, Inc., 135 S.
                                                      sufficient to enlist enough providers so                final rule does not require a core set of
                                                                                                                                                                    Ct. 1378 (2015) that Medicaid providers
                                                      that care and services are available                    measures or describe national
                                                                                                                                                                    and beneficiaries do not have a private
                                                      under the state plan at least to the extent             thresholds for Medicaid access to care.
                                                                                                                                                                    right of action to challenge state-
                                                      that such care and services are available                  We also recently proposed changes                  determined Medicaid payment rates in
                                                      to the general population in the                        that promote access to care for                       federal courts, placing greater
                                                      geographic area. We interpret this                      beneficiaries who receive services                    importance on CMS review to ensure
                                                      provision to mean rates and payments                    through Medicaid managed care. On                     that such rates are ‘‘consistent with
                                                      for Medicaid services are set at levels                 June 1, 2015, we issued a proposed rule               efficiency, economy and quality of care’’
                                                      that ensure value, quality and provider                 entitled ‘‘Medicaid and Children’s                    and ensure sufficient beneficiary access
                                                      participation. In the past, our oversight               Health Insurance Program (CHIP)                       to care under the program. The Court
                                                      of this provision has primarily focused                 Programs; Medicaid Managed Care,                      concluded that federal administrative
                                                      on ensuring that payment                                CHIP Delivered in Managed Care,                       agencies are better suited than federal
                                                      methodologies are economic and                          Medicaid and CHIP Comprehensive                       courts to make these determinations.
                                                      efficient, as well as consistent with                   Quality Strategies, and Revisions                     Options for Medicaid providers and
                                                      upper payment limits for certain                        Related to Third Party Liability (80 FR               beneficiaries to pursue Medicaid rate-
                                                      services. During the recent economic                    31098), which proposed to modernize                   related issues in federal courts are now
                                                      downturn, and in light of state                         Medicaid and Children’s Health                        limited. As we note in the final rule
                                                      proposals to dramatically reduce                        Insurance Program (CHIP) managed care                 with comment period, we are therefore
                                                      provider payments, we began requesting                  regulations to update the programs’                   working to strengthen the framework for
                                                      that states provide information to                      rules and strengthen the delivery of                  CMS review to ensure that rates meet
                                                      document that services are available and                quality care for beneficiaries. In that               the requirements of section
                                                      access remains after payment reductions                 rule, we proposed: Minimum                            1902(a)(30)(A) of the Act, including
                                                      go into effect. We found that state                     requirements for states when setting and              requiring access improvement strategies
                                                      processes for documenting access were                   monitoring network adequacy                           to improve care delivery where there are
                                                      generally inconsistent and in many                      standards, certification of managed care              shortcomings. In this request for
                                                      cases did not adequately document                       plan networks at least on an annual                   information, we are asking for public
                                                      access.                                                 basis, and annual reporting on the                    input on what additional data sources
                                                         To address this, on May 6, 2011, we                  accessibility and availability of services.           and approaches could be used to
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                                                      published the proposed rule entitled                    Similar to the ‘‘Access to Care’’ final               determine whether access to care is
                                                      ‘‘Medicaid Program; Methods for                         rule with comment period that appears                 sufficient.
                                                      Assuring Access to Covered Medicaid                     elsewhere in this issue of the Federal                   We recognize that many factors affect
                                                      Services’’ (hereafter referred to as the                Register, the managed care proposed                   access to Medicaid services, including:
                                                      ‘‘Access to Care’’ proposed rule) (76 FR                rule proposes to allow states the                     Level of payment, geographic location,
                                                      26342). In that rule, we proposed a                     discretion to set the standards and                   time and distance to the closest
                                                      specific process through which states                   measures for network adequacy and                     provider, workforce, numbers of
                                                      would document that their payment                       does not propose to require specific                  specialists and other types of providers
                                                      rates provide access to care. The                       measures or thresholds for access to                  within the state, lack of knowledge of


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                                                                            Federal Register / Vol. 80, No. 211 / Monday, November 2, 2015 / Proposed Rules                                           67379

                                                      available resources by beneficiaries,                   programs regardless of delivery system.                 • Do you believe there are specific
                                                      insufficient provider outreach, scope of                We are not attempting to develop areas                access to care measures that could be
                                                      practice approaches, and other                          of measurement that indicate causes of                universally applied across services? If
                                                      economic and policy factors. Within                     access deficiency, such as information                so, please describe such measures.
                                                      state Medicaid programs, there are also                 on social determinants of health. While                 • What information and methods do
                                                      considerable diversities in delivery                    we appreciate the importance of                       you believe large health care programs
                                                      system designs, populations served, and                 understanding the reasons behind                      use to measure access to care that could
                                                      provider networks. We seek public                       access problems and identifying those                 be used by the Medicaid program? What
                                                      input on what additional approaches we                  issues through data, our initial goal is to           role can health information technology
                                                      and states can take to understand,                      develop indicators of sufficient access               lay in measuring access to care?
                                                      measure and improve Medicaid access                     that can be affected by Medicaid policy                 • What do you believe are the
                                                      more uniformly and in ways that                         levers.                                               primary indicators of access to care in
                                                      account for these unique program                                                                              the Medicaid program? Is measured
                                                      features. This RFI solicits input from                  II. Provisions of the Request for
                                                                                                              Information                                           variance in these indicators based on
                                                      states, providers, beneficiaries and other                                                                    differences in things such as: Provider
                                                      members of the public on the feasibility                  We are inviting states, beneficiaries,              participation and location, appointment
                                                      of and methodologies related to the                     advocacy organizations, providers,                    times, waiting room times, call center
                                                      following four specific approaches:                     managed care organizations, research                  times, prescription fill times, other?
                                                         • Developing a core set of measures of               and measurement communities,                            • Do you believe a national core set
                                                      access that all states would monitor and                professional associations and other                   of access measures or metrics should
                                                      publicly report on;                                     members of the public to share analyses               apply across all services, or is it more
                                                         • Measuring access to long term care                 and opinions related to the following                 appropriate to target a core set of access
                                                      and home and community based                            topics: (1) Access to care data collection            measures by service?
                                                      services;
                                                         • Setting national access to care
                                                                                                              and methodology; (2) access to care                     • Do you believe questions in
                                                                                                              thresholds and goals; (3) alternative                 provider and beneficiary surveys should
                                                      thresholds; and
                                                                                                              processes for access concerns; and (4)                be consistent for Medicaid and
                                                         • Establishing a process for access to
                                                                                                              access to care measures.                              Medicare beneficiaries? If not, what
                                                      care that would allow beneficiaries
                                                      experiencing access issues to raise and                   The terms: Measures, metrics, and                   differences do you believe should be
                                                      seek resolution of their concerns.                      thresholds, are used throughout this                  accommodated for the Medicaid
                                                         We also invite input on additional                   RFI. By measures, we mean concrete,                   program, including differences in
                                                      actions that we or states may take to                   quantifiable indicators that can be used              covered services?
                                                      further measure and promote access to                   to assess access to care in Medicaid.                   • What do you believe we should
                                                      care in the Medicaid program.                           Measures have both a numerator and a                  consider in undertaking access to care
                                                         In seeking this input, we recognize                  denominator (for example, 500                         data collection in areas related to:
                                                      that we have not yet identified a clear,                Medicaid participating physicians in the              Differences between fee-for-service
                                                      defined set of access measures that                     state this year divided by the number of              (FFS) and managed care delivery,
                                                      demonstrates whether access to care is                  Medicaid enrollees this year, or the state            variations in services such as acute and
                                                      sufficient. We are seeking input to                     received 50 beneficiary complaints this               long-term care, community and
                                                      identify a feasible set of measures and                 month divided by the number of                        institutional settings for long-term care
                                                      metrics that meaningfully demonstrate                   beneficiaries enrolled). Metrics are used             delivery, behavioral health, variations in
                                                      whether access to care is sufficient. We                to examine measures relative to a                     access for pediatric and adult
                                                      requested comments on potential core                    baseline assessment (for example, there               populations and individuals with
                                                      metrics and thresholds through the                      10 percent more physicians                            disabilities, and variations in access for
                                                      ‘‘Access to Care’’ proposed rule and                    participating in Medicaid this year than              rural and urban areas? Consider also
                                                      received many suggestions. Generally,                   last year, or the state received 20                   individuals with chronic conditions
                                                      the responses suggested set levels of                   percent fewer complaints this month                   who may have limited functional
                                                      payment or access to providers                          than last month). A threshold would be                support needs related to activities of
                                                      consistent with Medicare or private                     a minimum acceptable value for access                 daily living but nonetheless require
                                                      insurance, without corresponding                        to care that is based on the measures                 more intensive care than other Medicaid
                                                      metrics and data sources to conduct a                   and metrics.                                          beneficiaries, such as persons living
                                                      comparative analysis. Other health                                                                            with HIV/AIDS.
                                                                                                              A. Access to Care Data Collection and
                                                      payers, such as Medicare, may be                        Methodology                                             • Specific to long-term services and
                                                      further along in measuring access                                                                             supports, including home and
                                                      through data collection tools. As any                     To better inform us on the nature and               community based services, what factors
                                                      new data collection requirements would                  scope of access to care measures and                  do you believe we should consider in
                                                      impose administrative burden on states                  metrics, we are requesting comments on                measuring access to care? Do you
                                                      and providers, we are particularly                      how to focus our efforts to determine                 believe we should incorporate into
                                                      interested in how existing efforts, like                the best indicators of access in Medicaid             reviews of access to care for these
                                                      the Medicare Current Beneficiary                        across services and delivery systems.                 services economic factors and
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                                                      Survey and the Consumer Assessment                      Consideration of the following questions              significant policy factors such as:
                                                      of Healthcare Providers and Systems                     may be helpful in providing us your                   Minimum wage and overtime
                                                      (and approved supplemental data sets),                  ideas and suggestions.                                requirements, direct service worker
                                                      may be modified to apply to the                           • What do you perceive to be the                    shortages, training and professional
                                                      Medicaid program.                                       advantages and disadvantages to                       development costs, or other factors?
                                                         We note that through this RFI, we are                requiring a national core set of access to              • Do you believe measuring access to
                                                      seeking comments on areas of                            care measures and metrics? Who do you                 Home and Community Based Services
                                                      measurement and metrics that may                        believe should collect and analyze the                (HCBS) differs from measuring access to
                                                      indicate sufficient access in Medicaid                  national core set data?                               acute medical care? Please describe.


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                                                      67380                 Federal Register / Vol. 80, No. 211 / Monday, November 2, 2015 / Proposed Rules

                                                         • Do you believe access to HCBS                         • Which access to care areas of                    1. Measures for Availability of Care and
                                                      should be tracked in FFS and in                         measurement or specific metrics may be                Providers
                                                      managed care delivery systems? Do you                   useful in setting thresholds that would                  We are soliciting public comment on
                                                      perceive any differences between                        help hearings officers assess appeals                 the following availability of care and
                                                      tracking HCBS in each system?                           and determine access to care remedies?                providers measurement areas within
                                                         • Do you believe there are additional                   • Lack of timeliness of an appeal                  geographic areas. In addition to
                                                      metrics that need to be tracked related                 could undermine the time sensitive                    feedback on the proposed metrics
                                                      to HCBS?                                                efforts associated with remediating an                below, we are also interested in your
                                                                                                              individual’s access to medical services.              thoughts on how ‘‘geographic areas’’
                                                      B. Access to Care Thresholds/Goals                      You may want to consider providing                    should be defined.
                                                         To better inform us on how to                        information on the following:                            • Primary care physicians (including
                                                      interpret and use access to care metrics,                  ++How could appeals be expedited?                  pediatricians) and clinicians accepting
                                                      we are requesting comments on setting                      ++What outcomes could an appeals                   any/new patients.
                                                      access thresholds and how we might use                  officer offer if services are unavailable to             • Physician specialists accepting any/
                                                      the thresholds to improve access in the                 Medicaid beneficiaries?                               new patients.
                                                      Medicaid program. Consideration of the                     ++Are there other non-appeal based                    • Specialty care (for example,
                                                      following questions may be helpful in                   processes that could be used instead?                 addiction and psychiatric services,,
                                                      providing us your ideas and                             D. Access to Care Measures                            home and community based services,
                                                      suggestions.                                                                                                  specialty pharmacy) accepting any/new
                                                         • Do you believe we should set                          In conjunction with this RFI, you may
                                                                                                                                                                    patients.
                                                      thresholds for Medicaid access to care?                 want to consider each of the topics                      • Availability of direct support
                                                      If so, do you believe such thresholds                   listed below, and suggest what you                    workforce for home health and home
                                                      should be set at the national, state or                 believe we should prioritize. You are                 and community-based services.
                                                      local levels? Why?                                      also welcome to provide additional                       • Dentists accepting any/new
                                                         • If we set Medicaid access                          metrics that are associated with                      patients.
                                                      thresholds, how do you believe they                     measurement areas that are relevant                      • Psychiatric and substance abuse
                                                      should be used? For instance: For                       indicators of access to care in the                   clinicians such as psychiatrists, child
                                                      issuing compliance actions to states that               Medicaid program and feasible to                      psychiatrists, psychologists, and
                                                      do not meet the thresholds, as                          collect and analyze.                                  psychiatric social workers and mental
                                                      benchmarks for state improvement, for                      For each suggested metric, you may                 health counselors accepting any/new
                                                      use in appeals processes for                            consider describing the following:                    patients.
                                                      beneficiaries that have trouble accessing                  • Suggested relevant data metrics,                    • Physicians and clinicians
                                                                                                                 • whether the metric is currently                  experiencing difficulties referring
                                                      services, or in other ways?
                                                                                                              reported for Medicaid services,                       patients to specialty care.
                                                      C. Alternative Processes for Access                        • the feasibility of collecting the                   • Psychiatrists experiencing
                                                      Concerns                                                metric,                                               difficulties referring patients with
                                                                                                                 • the associated data sources/set(s)               serious mental illness to primary care.
                                                        We are considering requiring standard
                                                                                                              where the metrics are available,                         • Available primary care clinics,
                                                      access to care complaint driven
                                                                                                                 • the financial cost (if any) of                   federally qualified health centers or
                                                      processes to better ensure access and are
                                                                                                              collecting the proposed metric,                       rural health clinics.
                                                      interested in how data gathered and                        • should including the metric in a
                                                      analyzed through a core set of measures                                                                          • Available retail community
                                                                                                              more robust (or updated) Medicaid                     pharmacies.
                                                      might aid in resolving complaints,                      access policy be given priority;
                                                      please consider the following questions:                                                                         • Available behavioral health clinics
                                                                                                                 • the party responsible/steward(s) of              or community mental health centers.
                                                        • Do you believe there are existing                   the metric data source,
                                                      and effective processes to resolve                                                                               • Available inpatient care.
                                                                                                                 • the metric validation process,                      • Other.
                                                      consumers’ concerns regarding health                       • whether the metric is relevant to all
                                                      care access issues that might be useful                 Medicaid populations or specific to                   2. Measures for Beneficiary Reported
                                                      for all state Medicaid programs?                        particular groups, (for example, adults               Access
                                                        • What do you believe are the                         or pediatric populations, including                      We are soliciting public comment on
                                                      advantages and disadvantages of either                  children with special health care needs,              the following beneficiary reported
                                                      a complaint resolution process or a                     or to people with disabilities or to                  access measurement areas:
                                                      formal appeals hearing for access to care               dually eligible beneficiaries),                          • Beneficiaries reporting a usual
                                                      concerns?                                                  • whether the metric is applicable to              source of primary care.
                                                        • Who do you believe should be the                    FFS, managed care or both delivery                       • Beneficiaries reporting difficulty
                                                      responsible party (for example, the state               systems,                                              finding a specialist/general clinician,
                                                      or federal government, an independent                      • whether the metric is relevant for               not taking any new patients and/or the
                                                      third party, a civil servant, an                        various subpopulations such as                        beneficiary’s insurance.
                                                      administrative law judge, etc.) to hear                 eligibility category, institutional status,              • Beneficiaries able to access
                                                      beneficiary access to care complaints                   or geographic region,                                 specialists or behavioral health care if
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                                                      and/or appeals?                                            • whether the metric should be                     they have: Chronic conditions, heart
                                                        • For an access to care appeal, what                  measured at the local, state or national              disease, behavioral health issues, etc.
                                                      criteria do you believe should be used                  level,                                                   • Beneficiaries able to access long-
                                                      to help determine:                                         • as appropriate for Medicaid,                     term services and supports in
                                                        ++Whether an appeal should be                         thresholds associated with the metric,                institutional settings.
                                                      heard?                                                     • the challenges and advantages of                    • Beneficiaries able to access home
                                                        ++Whether an appeal merits                            the proposed metric, and how the                      and community based services.
                                                      recommendations to the state Medicaid                   metric is indicative to Medicaid access                  • Women able to access: Pap smears,
                                                      agency?                                                 to care.                                              mammograms.


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                                                                            Federal Register / Vol. 80, No. 211 / Monday, November 2, 2015 / Proposed Rules                                                67381

                                                         • Children and adults able to access                 3. Measures regarding Service                         adequacy (the payment managed care
                                                      appropriate immunizations and/or                        Utilization—                                          plans make to providers).
                                                      seasonal vaccines.                                         We are soliciting public comment on                  • Other.
                                                         • Beneficiaries reporting delayed care               the following service utilization                       We will evaluate the responses to this
                                                      and reason for delay.                                   measurement areas:                                    RFI, in addition to the findings from
                                                                                                                 • Trends in service utilization by                 research that we are currently
                                                         • Unmet need for specialty, primary,                                                                       conducting, to inform whether it is
                                                      follow-up, dental, prescriptions, and                   geographic regions within the state.
                                                                                                                                                                    advisable to collect and analyze core
                                                      mental health and substance abuse                          • Trends in emergency room
                                                                                                                                                                    national measures at this time and the
                                                      treatment due to cost concerns.                         utilization relative to primary and
                                                                                                                                                                    methods to conduct the collection. We
                                                                                                              mental health and substance abuse
                                                         • Beneficiaries getting needed care                  treatment care utilization.
                                                                                                                                                                    may also use this information to help
                                                      quickly.                                                                                                      determine which measures could best
                                                                                                                 • Rates of utilization (for example, At
                                                                                                                                                                    inform understanding of access to care
                                                         • Wait times for appointments (for                   least one of the following visits in the
                                                                                                                                                                    and to support the design of national or
                                                      example, to primary care, urgent care,                  prior six months/year: Physician
                                                                                                                                                                    state and local thresholds.
                                                      physician specialists, pre-natal care,                  (including nurse practitioners and
                                                      behavioral health providers, and long-                  physician assistants), dental, specialty,             III. Response to Comments
                                                      term services and supports in                           behavioral health, and primary care/                    Because of the large number of public
                                                      community settings).                                    well-child.)                                          comments we normally receive on
                                                                                                                 • Other.
                                                         • Length of delays in accessing long                                                                       Federal Register documents, we are not
                                                      term services and supports in                           4. Comparison of Payments                             able to acknowledge or respond to them
                                                      community setting due to direct service                                                                       individually. We will consider all
                                                                                                                We are soliciting public comment on
                                                      worker shortages and/or lack of                                                                               comments we receive by the date and
                                                                                                              the following comparison of payment
                                                      adequate training.                                                                                            time specified in the DATES section of
                                                                                                              measurement areas:
                                                                                                                                                                    this preamble, if and, when we proceed
                                                         • Call-center capability standards to                  • Payment rates for services set at a
                                                                                                                                                                    with a subsequent document, we will
                                                      support providing beneficiaries with                    specific percentage of Medicare.
                                                                                                                                                                    respond to the comments in the
                                                      information that can improve their                        • Medicaid payment rates compared                   preamble to that document.
                                                      access, and produce useful metrics for                  to surrounding states, Medicare,
                                                                                                              commercial payers.                                      Dated: October 20, 2015.
                                                      monitoring.
                                                                                                                • Acquisition costs compared to                     Andrew M. Slavitt,
                                                         • Call-center metrics that reveal                                                                          Acting Administrator, Centers for Medicare
                                                                                                              Medicaid payments for
                                                      issues with beneficiary access and their                                                                      & Medicaid Services.
                                                                                                              pharmaceuticals.
                                                      resolution.                                               • Comparisons or measures that                      [FR Doc. 2015–27696 Filed 10–29–15; 11:15 am]
                                                         • Other.                                             would inform managed care rate                        BILLING CODE 4120–01–P
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Document Created: 2018-03-01 11:30:49
Document Modified: 2018-03-01 11:30:49
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionProposed Rules
ActionRequest for information.
DatesComment Date: To be assured consideration, comments must be
ContactJeremy Silanskis, (410) 786-1592.
FR Citation80 FR 67377 

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