CMS and state agencies need to work to strengthen standards to ensure adequate access to care services for Medicaid managed care enrollees, according to an HHS Office of Inspector General report.
In response to a congressional request, the OIG surveyed state Medicaid agency officials (in addition to CMS officials and external quality review organizations) and collected documentation on standards for access to care from 33 states with comprehensive, "full-risk" Medicaid managed care, according to the report.
The OIG found state standards for access to care differ significantly. For instance, 20 states have standards requiring a minimum number of providers in a plan's network for a certain number of enrollees. Those numbers range from one primary care provider per every 100 enrollees to one for every 2,500 enrollees. Furthermore, standards for access to care often aren't specific to certain areas of the state (failing to account for differences between urban and rural regions) or particular types of providers, according to the OIG.
Additionally, while states employ various methods to ensure compliance with their access standards, only eight reported using "direct tests" (e.g., conducting "secret shopper" calls to providers while posing as patients), and only 11 of the states studied identified any violations of their standards from 2008 to 2013. "When states fail to identify violations of their access standards, they are unable to correct problems and improve access to care for enrollees," the report states.
Based on these findings, the OIG recommended that CMS strengthen its currently limited oversight of state Medicaid agency standards for access to care. CMS should require states to develop standards for a core set of providers that the Medicaid managed care population needs, such as pediatricians, obstetricians, primary care providers and other in-demand specialists, according to the report. Furthermore, CMS should increase its oversight of states' methods to assess compliance with these standards and ensure states identify and address violations appropriately.
The OIG also recommends that CMS share best practices for improving access and provide technical assistance to the states to ensure the adequacy of their access standards and their methods for testing compliance and addressing violations. CMS agreed with all of the OIG's recommendations, according to the report.