OIG: States need stronger standards in Medicaid managed care
By - With the Affordable Care Act (ACA), states have the option to expand Medicaid eligibility. However, even those that have not expanded eligibility have still seen increases in enrollment. But a report from the Office of the Inspector General (OIG) found that state standards for access to care are often quite different.
Specifically, OIG found that standards can range from requiring one primary care provider for every 100 enrollees to one primary care provider for every 2,500 enrollees. The state standards are also not always specific to certain types of providers or to specific areas. Moreover, states have different strategies to assess compliance with access standards, according to OIG. However, they do not typically use “direct tests,” which can include making calls to providers.
“State standards vary widely and are often not specific to providers who are important to the Medicaid population, such as pediatricians, obstetricians and high-demand specialists,” the report read. “In addition, these standards often apply to all areas within a State and do not take into account differences between urban and rural areas.”
States may not be able to hold plans accountable for ensuring adequate access to care without standards for specific provider types or areas, according to OIG.
The report also showed that different states have varying strategies to assess compliance with access standards. However, they do not commonly use direct tests, which can accurately measure whether plans comply with access standards. Direct tests can also determine the accuracy of information maintained by plans, OIG said.
The findings show that the Centers for Medicare & Medicaid Services (CMS) and states must do more to ensure that all states have adequate access standards and strategies for assessing compliance.
“This will help to ensure that enrollees in Medicaid managed care have access to the services they need,” OIG said. “With Medicaid expanding and enrollment expected to reach as many as 87 million people by 2018, ensuring adequate access to care is increasingly important.”
OIG recommended that CMS strengthen its oversight of state standards and ensure that they develop standards for key providers. Additionally, CMS needs to strengthen its oversight of states’ methods to assess plan compliance with access standards. According to OIG, CMS needs to work with states to make sure that the developed methods accurately determine plan compliance.
Lastly, OIG explained that CMS must improve states’ efforts to identify and address violations of access standards and provide technical assistance and share effective practices.
CMS reportedly concurred with all four recommendations, and said that it is considering options to create expectations for network access standards through additional guidance. Additionally, CMS said that it would collaboratively work with states to find best practices for testing plan compliance instead of endorsing a specific method.
“We support CMS’ efforts to provide effective oversight of Medicaid managed care, and we encourage it to continue to work with States to ensure access to care for managed care enrollees,” OIG said.
