LEGAL NOTICE: COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Dept. of Medical Assistance Services Draft Provider Access Monitoring Plan
Notice is hereby given that the Department of Medical Assistance Services (DMAS) is publishing for public comment the Agency’s Draft Provider Access Monitoring Plan as required by the Final Provider Access Monitoring Rule found in 42 CFR § 447.203.
Comments or inquiries may be submitted, in writing, within 30 days of this notice publication at this site in the comment section, or to Brian McCormick at Brian.McCormick@dmas.virginia.gov and such comments are available for review at this web address. The full text of the report may be found at the top of the “What’s New” section on the right hand side of the DMAS website at: http://www.dmas.virginia.gov/
Virginia Access Monitoring Review Plan Overview
In November 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule regarding member access to Medicaid services in a Medicaid fee-for-service (FFS) environment. This rule creates new requirements for states to monitor access to care for Medicaid FFS members. Under these requirements, states must develop an access monitoring review plan, which must be published for public review and comment and submitted to CMS. In accordance with these requirements, the Virginia Department of Medical Assistance Services (DMAS) has prepared the access monitoring review plan contained herein.
The Virginia Medicaid program provides healthcare coverage for low-income individuals, including children, pregnant women, individuals with disabilities, the elderly, parents and other adults. The Virginia Department of Medical Assistance Services is the single state agency that administers the Medicaid program in the Commonwealth of Virginia. The mission of the Virginia Medicaid program is to provide access to a comprehensive system of high quality and cost effective health care services to qualifying Virginians.
DMAS provides Medicaid coverage to individuals through managed care and fee-for-service delivery models. The managed care delivery system, known as Medallion 3.0., covers Medicaid members through six commercial health plans. Virginia has been increasing its use of the managed care program, and as of December 2015, over 68% of Medicaid enrollees are in managed care. During state fiscal year (SFY) 2015, the Virginia Medicaid program provided coverage to approximately 1.35 million enrolled members, and total Medicaid spending was approximately $7.9 billion.
Virginia has a population of 8.4 million people, making it the 12th most populous state in the United States. With 98 acute care hospitals and affiliated practices and a network of 130 federally qualified health center (FQHC) and rural health clinic (RHC) sites, there are numerous options for Medicaid members to receive health care services.
Virginia is committed to ensuring its enrolled members have adequate access to health care services. A key component of DMAS’ strategic plan is ensuring adequate provider network access by monitoring and analyzing utilization, provider caseloads, reimbursement rates, and Medicaid population groups. The state has conducted other studies on member access to health care services, including a 2013 study by the Joint Legislative Audit and healthcare access to ensure that its Medicaid FFS members have access to care that is comparable to the general population. The methodology employed in this plan will consist of evaluating trends in provider availability and participation in the Medicaid program, trends in utilization of services by Medicaid members, and member and provider feedback.
Using the metrics and data sources described in this plan, DMAS will measure and monitor indicators of healthcare access to ensure that its Medicaid FFS members have access to care that is comparable to the general population. The methodology employed in this plan will consist of evaluating trends in provider availability and participation in the Medicaid program, trends in utilization of services by Medicaid members, and member and provider feedback. Through the FFS monitoring plan and subsequent updates to the plan, DMAS anticipates that the access monitoring analysis, metrics, data sources, and other factors will evolve over time. Separate access monitoring and provider network sufficiency requirements are present in a managed care environment and under home and community based services waiver programs, and these issues are not addressed in this plan.
Because members located in different areas may have different experiences accessing health care services, this plan will analyze access to care by geographic region. Specifically, the plan will analyze access to care for the regions utilized by the Virginia Medicaid program for Managed Long-term Supports and Services (MLTSS) and the managed care program, Medallion 3.0.
In accordance with 42 CFR 447.203, Virginia developed this access monitoring review plan (AMRP) for the following service categories provided under a fee-for-service (FFS) arrangement:
- Primary care services
- Physician specialist services
- Behavioral health services
- Pre- and post-natal obstetric services, including labor and delivery
- Home health services
The plan describes data that will be used to measure access to care for members in FFS. The plan considers the availability of Medicaid providers, utilization of Medicaid services and the extent to which Medicaid members’ healthcare needs are fully met. The plan was developed during the months of July and August 2016 and posted on the Virginia Regulatory Town Hall website under General Notices, found at the following address:
http://townhall.virginia.gov/L/EditNotice.cfm?GNid=new from August 28, 2016 to September 29, 2016, as well as being posted on the DMAS website, http://www.dmas.virginia.gov/ to allow for public inspection and feedback.