HHS OIG Reports on Access to Medicaid Managed Care
October 7, 2014 12:10 PM
In September, the Department of Health and Human Services Office of Inspector General (HHS OIG) released a report titled State Standards for Access to Care in Medicaid Managed Care. This article discusses some of its major findings, and implications for home care agencies below.
The Report is the result of a congressional request for HHS OIG to look into access of care for Medicaid managed care enrollees. HHS OIG surveyed state Medicaid agency officials in the states that had “full risk” Medicaid managed care, in a total of 33 states. The Report defines “full risk” as an arrangement where “managed care organizations (MCOs) assume the full financial risk for delivering a comprehensive set of services.” HHS OIG also interviewed the Centers for Medicare & Medicaid Services (CMS), as well as external quality review organizations (EQROs).
The Report does not focus on home care providers, and instead focuses on primary care providers and specialists.
The Report finds that state standards for access for Medicaid managed care enrollees vary significantly. In 2013, for example, while Wisconsin had a primary care provider to enrollee ratio of 1:100, Delaware and Tennessee’s ratio was 1:2,500.
The most common access standards are: 1) those limiting the amount of time or distance enrollees need to travel to get care (32 states, with 15 of those states distinguishing between urban and rural areas); 2) required availability of appointments (31 states); and 3) a certain provider to enrollee ratio (20 states).
The Report criticizes state standards for not only being widely varied, but not specific to either areas of the states or certain types of providers. HHS OIG asserts that this lack of specificity restricts the states’ ability to ensure sufficient access of care. The Report suggests that CMS should issue guidance on improving state standards, and also develop specific standards for “a core set of providers that are important to the Medicaid managed care population.” Interestingly, the Report did not mention home care agencies as part of this core set, instead focusing on “primary care providers, pediatricians, obstetricians, and other high-demand specialists.”
While the Report did not implicate home care directly, it shows that HHS OIG is beginning to evaluate access to Medicaid managed care. Further, the Report shows potential for a greater regulatory role for the federal government in Medicaid managed care, a domain typically more regulated by the states. The federal government has already began investing in greater oversight into Medicaid managed care in home care specifically, as CMS provided guidance for managed long-term services and supports (MLTSS) and MLTSS EQRO protocols in 2013.
Home care agencies should note that some of the Report’s metrics, such as primary care provider to enrollee ratios and distance needed to travel to get care model some of the network adequacy provisions already seen in Medicaid managed care in home care, such as in the dual eligible demonstrations.