State Standards for Access to Care in Medicaid Managed Care

WHY WE DID THIS STUDY

Examining access to care takes on heightened importance as enrollment grows in Medicaid managed care programs. Under the Patient Protection and Affordable Care Act, States can opt to expand Medicaid eligibility, and even States that have not expanded eligibility have seen increases in enrollment. Most States provide some of their Medicaid services-if not all of them-through managed care. OIG received a congressional request to evaluate the adequacy of access to care for enrollees in Medicaid managed care. This report describes the standards that States establish for access to care in their Medicaid managed care programs and how States determine compliance with these standards. A companion report determines the extent to which providers offer appointments to enrollees and the timeliness of these appointments.

HOW WE DID THIS STUDY

We surveyed State Medicaid agency officials in the 33 States with comprehensive, "full risk" Medicaid managed care and collected documentation from each State on its standards for access to care. We also conducted structured interviews with external quality review organizations and CMS.

WHAT WE FOUND

State standards for access to care vary widely. For example, standards range from requiring 1 primary care provider for every 100 enrollees to 1 primary care provider for every 2,500 enrollees. Additionally, standards are often not specific to certain types of providers or to areas of the State. States have different strategies to assess compliance with access standards, but they do not commonly use what are called "direct tests," such as making calls to providers. Further, most States did not identify any violations of their access standards over a 5 year period. The States that found the most violations were those that conducted direct tests of compliance. Among the States that identified violations, most relied on corrective action plans to address the violations; six imposed sanctions. Finally, our review found that CMS provides limited oversight of State access standards.

WHAT WE RECOMMEND

We recommend that CMS (1) strengthen its oversight of State standards and ensure that States develop standards for key providers, (2) strengthen its oversight of States' methods to assess plan compliance and ensure that States conduct direct tests of access standards, (3) improve States' efforts to identify and address violations of access standards, and (4) provide technical assistance and share effective practices. CMS concurred with all four of our recommendations.