Provider Networks and Access in Medicaid Managed Care: A Look at Federal and State Standards
Medicaid depends on managed care. In 2016, more than 65 million Medicaid beneficiaries — about 80 percent — were enrolled in managed care. In an effort to ensure Medicaid managed care beneficiaries have appropriate access to health services, the Centers for Medicare and Medicaid Services issued updated federal regulations for Medicaid managed care in 2016, key elements of which took effect in plan years beginning in July 2018.
The rules govern states’ Medicaid provider network and access standards, which are typically established in their purchasing agreements with insurers. The rules require states to consider multiple factors as they develop their own standards, such as special cultural considerations, and require states to prevent discrimination by, for example, requiring their network providers to maintain office hours no less generous than those offered to enrollees with private insurance or fee-for-service beneficiaries.1
To assess whether the 2016 rules represent a major departure from current state practice or simply reflected current approaches to networks and access standards, we examined 19 state managed care organization (MCO) contracts available online as of February 2018 (and in effect prior to the effective date for the 2016 rules governing access and networks).2 Managed long-term services and support contracts were excluded.
Rules Reflect Existing State Standards
While some may have perceived the 2016 rules as a radical departure from prior practice, we found the rules make official requirements that are already a staple of states’ contract practices. The rules updated the federal policies underlying Medicaid managed care without increasing the level of regulatory burden. In this way the rules avoided making managed care contracting more challenging, particularly in low-income communities that already lack resources on which to build accessible provider networks. Below we detail several of the core provisions in the new policy.
Travel time and distance and provider ratios. Time and distance requirements for primary and specialty care are already a common feature of state contracts, with some states more expansive than others in the range of providers subject to such specifications. States’ measures focus on maximum travel times or distances from a beneficiaries’ home to various types of health care providers, such as adult and pediatric primary, specialty, and behavioral health care; OB/GYN services; pharmacy services; hospital care; and pediatric dental care.
All states already specify some level of travel standards for primary care. Thirteen states specify primary care drive times ranging from 10 to 45 minutes. Eight states with time and distance standards also include mileage limitations ranging from 10 to 30 miles from home, and three also include a drive-time limitation that specifies an upper limit for how long someone can spend in the car getting to a doctor. Eight states allow plans to adjust time and distance for rural, frontier, or nonurban areas based on the number and location of available providers in an area.
Fewer states set specialty or behavioral health travel-time and distance standards; as of February 2018, just 13 states did so. Three states (Florida, Pennsylvania, and Tennessee) have time and distance for specific specialties, while three states (Florida, Kentucky, and New Jersey) also include pediatric specialty travel time and distance expectations (Florida also encourages the use of pediatric telemedicine consultation). Generalized standards tend to be more common, with eight states using terms such as “sufficient providers in a range of types and specialties,” a “complete” or “comprehensive” network, and providers that serve “specialty populations.”
The 2016 rules do not require states to establish the maximum number of patients a provider can have. However, a number of states do set provider/patient ratios. Eight states set primary care/enrollee ratios varying from 1 to 1,200 to 1 to 2,500. Two states set ratio rules expressly for pediatric primary care (1 to 1,500 in Florida; more generally Ohio requires that plans include a “specified number” of pediatric primary care providers appropriate to county needs). More commonly, states express their expectations in more generalized terms; 12 states follow this model, utilizing terms such as an “adequate amount” or a “complete network” of primary care providers.
Appointment waiting times and after-hours coverage. The 2016 rules require standards for “timely access to care” and for 24/7 access when medically necessary. States’ contracts already capture this type of requirement by specifying expectations for both appointment wait time and after-hours coverage. Sixteen states include wait times for primary care and nonemergent urgent care, while 10 specify adult specialty care wait times, most commonly, 30 days. Primary care wait times range between five and 45 days, depending on whether someone is symptomatic or sick (but not urgent). No state allows more than 48 hours for nonemergent urgent care. Every state other than Connecticut and Kentucky specifies access to after-hours primary care, including extended hours on nights and weekends and 24-hour availability of information, referral, and treatment for emergency medical conditions.
Cultural competency, language, and disability services. Clarifying expectations for cultural competency is a major theme of the 2016 rules; cultural competency already is an explicit expectation in state contracts. All states include cultural competency as a formal network expectation. Some do so in general terms; that is, they specify a general cultural competency expectation. Others require network training, while Arizona, Illinois, and New Jersey require MCOs to develop cultural competency plans and Florida, Massachusetts, and Minnesota expect plans to assign enrollees to culturally competent providers. Eight states specifically address language access ranging from an “an interest and expertise in serving non-English-speakers” to a requirement of bilingual or multilingual providers (Pennsylvania) or provision of no-cost interpreters. Five states (Colorado, Massachusetts, Minnesota, New Jersey, and Pennsylvania) address disability accommodation using general terms such as “disability competency,” or inclusion of providers “with an interest or expertise in serving individuals with physical or mental disabilities.”
Identifying Best Practices
Creating network and access standards represents an important challenge. This task assumes major importance in Medicaid, because of the unique role that Medicaid managed care is designed to play, not simply in setting the terms of coverage but also in ensuring that appropriate health care is accessible.
Pre-2016 federal regulations necessarily permitted state-to-state variation and the 2016 rules will continue to do so, not only because of variable local conditions but also because of the absence of best-practice research that can inform policymakers and program administrators about which approaches yield the best results. Therefore, ongoing evaluation of the impact of Medicaid managed care by state on beneficiaries’ access to care will be critical.
Like other large-scale health care buyers, states use what can be thought of as “hard” and “soft” purchasing strategies. At times their contracts set clear and detailed specifications focusing on provider networks and access measures. At others states may keep specifications to a minimum and instead use rewards and incentives (bonuses or greater quality recognition at consumer websites). Determining which approach — or a combination of the two — is associated with better access and health outcomes represents a key area for further research to help guide state purchasing practices.
An additional question is when can states rely on industry norms as opposed to having to establish their own independent, detailed expectations. For example, can a state refrain from establishing its own provider network specifications because, through industry practice, as evidenced by accreditation standards, managed care companies already hold themselves to evidence-based performance levels?
It’s clear that given the dominance of managed care for health care for Medicaid beneficiaries, building the evidence base for best-practice contracting has become a policy priority.
1 42 C.F.R. § 438.206(c).
2 Our review included Connecticut’s third-party administrator system, which unlike other states, does not depend on competing MCOs but instead utilizes single statewide plan administrators for physical and behavioral health, much like a self-insuring employer might. Despite this organizational distinction, Connecticut, like other managed care states, uses its third-party administrative contracts to set out its operational expectations.