(a) The agency's payments must be consistent with efficiency, economy, and quality of care and sufficient to enlist enough providers so that services under the plan are available to beneficiaries at least to the extent that those services are available to the general population. In reviewing payment sufficiency, states are required to consider, prior to the submission of any state plan amendment that proposes to reduce or restructure Medicaid service payment rates:
(1) The data collected, and the State analysis performed, under § 447.203(c).
(2) Input from beneficiaries, providers and other affected stakeholders on beneficiary access to the affected services and the impact that the proposed rate change will have, if any, on continued service access. The state should maintain a record of the public input and how it responded to such input.
(b) The State must submit to CMS with any such proposed State plan amendment affecting payment rates documentation of the information and analysis required under § 447.203(c) of this chapter.
(c) CMS may disapprove a proposed state plan amendment affecting payment rates if the state does not include in its submission the supporting documentation described in paragraph (b) of this section, for failure to document compliance with statutory access requirements. Any such disapproval would follow the procedures described at part 430 Subpart B of this title.
[80 FR 67612, Nov. 2, 2015, as amended at 89 FR 40874, May 10, 2024]
Notes of Decisions
King Ex Rel. King v. Sullivan, 776 F. Supp. 645 (D.R.I. 1991).
· cites it 4× “§ 1396a(a)(30) and 42 C.F.R. § 447.204 . (V) Defendants allegedly fail to give Plaintiffs freedom to choose their ICF-MR providers, 5 in violation of 42 U.”
Pennsylvania Pharm. Ass'n v. Dep't of Pub. Welfare, 542 F. Supp. 1349 (W.D. Pa. 1982).
· cites it 6× “1 The plaintiffs contend that the State’s reimbursement to pharmacists for prescription drugs purchased by Medicaid recipients fails to comply with the Federal statute establishing the Medicaid program, 42 U.”
DeGregorio v. O'BANNON, 500 F. Supp. 541 (E.D. Pa. 1980).
· cites it 5× “” See 42 C.F.R. 447.204. Defendants argue against plaintiffs’ motion, and in support of their own summary judgment motion, that the Department of Health, Education and Welfare’s (now Health and Human Services) approval of Pennsylvania’s state plan, and the plan’s provisions for…”
Clark v. Kizer, 758 F. Supp. 572 (E.D. Cal. 1990).
· cites it 3× “II EQUAL ACCESS PROVISION Plaintiffs first contend that MediCal recipients have been denied equal access to dental care in violation of 42 C.F.R. § 447.204 . Under federal law, states which participate in the Medicaid program must operate an early and periodic screening,…”
Sobky v. Smoley, 855 F. Supp. 1123 (E.D. Cal. 1994).
· cites it 2× “§ 1396a(a)(30). The corresponding regulation provides that “the agency’s payments must be sufficient to enlist enough providers so that services under the plan are available to recipients at least to the extent that those services are available to the general population.”
Astrazeneca Lp v. State, 41 So. 3d 15 (Ala. 2009).
· cites it 2× “" 42 C.F.R. § 447.204 . [2] "Providers" are typically physicians and retail pharmacies that disburse prescription drugs to persons eligible for Medicaid benefits.”
Thomas v. Johnston, 557 F. Supp. 879 (W.D. Tex. 1983).
· cites it 2× “§ 1396a(a)(23), 8 42 C.F.R. § 447.204 9 and therefore 42 U.”
California Ass'n of Bioanalysts v. Rank, 577 F. Supp. 1342 (C.D. Cal. 1983).
· cites it 2× “42 C.F.R. § 447.204 (1982). This regulation, the so-called “equal access” regulation, does not require that, in order to ensure that undersupplies do not fall disproportionately on medicaid beneficiaries, states set medicaid rates which are price competitive; but .”
Dental Soc'y v. Carey, 462 N.E.2d 362 (NY 1984).
“” (42 CFR 447.204.) Whether administrative action violates applicable statutes and regulations is a question within the traditional competence of the courts to decide.”
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