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From Health Law Daily, September 29, 2014

Increased oversight needed for state Medicaid managed care access standards

By Bryant Storm, JD

The Office of Inspector General (OIG) has issued a report analyzing the adequacy of access to care standards for state Medicaid managed care programs. The OIG review identified significant variation in the standards employed by states and discovered that the present standards and compliance evaluations are inadequate to ensure quality and timely access to care. As a result of the findings, the OIG recommends that states and CMS work together to improve access standards for Medicaid managed care so that they better address the needs of beneficiaries (OIG Report, No. OEI-02-11-00320, September 29, 2014).

Medicaid growth. The federal and state funded health care program known as Medicaid currently serves over 69 million people. The OIG report indicates that as a result of the optional Medicaid expansion that many states have taken on as a result of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), Medicaid is expected to cover as many as 18 million additional people by 2018. In response to a Congressional request and the growing size of the Medicaid program, the OIG was asked to evaluate the access standards for state Medicaid managed care programs.

Managed care. States are given the option to provide some or all of their Medicaid services through managed care. The most common variety of managed care utilizes managed care organizations (MCOs), which, under the type of managed care known as full-risk, take on all of the financial risk for the delivery of beneficiaries’ health care services in return for a monthly per enrollee fee from the state. Under full-risk managed care, MCOs deliver services through a provider network.

Standards. Under 42 CFR sec. 438.206(b)(1), states are obligated to establish standards for access to MCOs. The standards are meant to ensure that beneficiaries have meaningful access to a network of providers. The regulations require that states provide timely access to care and establish a procedure for allowing out-of-network care when a beneficiary cannot meaningfully access in-network care. As part of the standards, states are obligated to conduct external quality reviews to evaluate the quality and timeliness of care access. Either states themselves or independent entities called external quality review organizations (EQROs) must perform the reviews every three years.

Method. To evaluate the quality of state access standards, the OIG review looked at (1) a survey of Medicaid officials; (2) state and MCO data; (3) interviews with EQRO officials; and (4) interviews with CMS officials. The review looked at 33 states with MCOs who use full-risk managed care. The OIG’s analysis was focused on access standards for primary care providers and specialists.

Findings. The findings of the OIG review included the discovery that managed care standards vary widely as a result of the latitude that states are given in establishing access to care standards for Medicaid. The review revealed the three most common access standards are: “(1) standards that limit the distance or amount of time enrollees should have to travel to see a provider; (2) standards that require appointments to be provided within a certain timeframe; and (3) standards that require a minimum number of providers in relation to the number of enrollees.” The review identified that the standards are not necessarily effective in holding plans accountable for quality access to care because they do not take into account things like differences in rural and urban areas or the specific needs of certain geographic groups of beneficiaries.

Types of standards. States that used distance standards had wide variation with primary care provider ranges as low as five and as high as 60 miles. In some states specialist travel standards ranged from 15 to 100 miles. Several states require that appointments be provided within a certain timeframe, for those states, the OIG discovered that the time difference for primary care provider standards ranged from as low as 10 to as high as 45 days. In those states, specialist ranges stretched from 10 to 60 days. In states that used the number of enrollees per provider as an access standard, there was considerable variation. The OIG discovered the lowest ratio of enrollees to primary care providers was one provider to 100 enrollees and the highest differential was one provider for every 2,500 enrollees. The OIG review identified several other standards used by states, which include: (1) in office wait time; (2) access to multilingual care; (3) twenty four hour telephone access for providers; and (4) access related performance measures.

Compliance. The review also analyzed the manner in which states evaluate compliance with access standards. The OIG’s primary finding was that although states used differing approaches for testing compliance, few states used direct testing that would include a phone call to evaluate wait times and the accuracy of provider information. Similarly, even in states that use EQROs, the OIG identified that direct tests are not often used. States also rely on reports that MCOs are required to submit, however, due to variation in what the reports require, the OIG identified that the reports are generally inadequate in helping states ensure compliance with access standards.

Recommendations. The OIG recommended that CMS and states take additional steps to ensure that access standards are adequate and being appropriately reviewed. To assist the process, the OIG recommended that CMS issue guidance to help strengthen state standards. Additionally, the report suggests that standards should be revised to address the differences between the needs of urban and rural beneficiaries. Regarding testing and compliance, the OIG recommends that states and ERQOs use direct tests to evaluate the adequacy of access standards.

MainStory: TopStory OIGReports ManagedCareNews QualityNews CMSNews MedicareContractorNews

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