Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Newsletter Article


Audit Finds Flaws in Medicaid Managed Care Plans’ Network Information

By Rebecca Adams, CQ HealthBeat Associate Editor

December 9, 2014 -- Getting enrolled in Medicaid is hard enough, with many people encountering enrollment delays this year. But once consumers get their cards for the health program, they face a new challenge: finding a doctor to treat them, according to a federal audit.

More than half of the 1,800 primary care doctors or specialists that the Department of Health and Human Services inspector general contacted either were not at the location that their health plan listed for them, or refused to treat program enrollees.

The biggest problem—affecting 35 percent of the providers that auditors contacted—was that private managed care plans administering Medicaid benefits were not providing accurate information about providers. In some cases, a doctor had retired. Other times, a physician group didn’t know the doctor listed in a plan’s provider directory as a member.

Another 8 percent did not participate in the Medicaid managed care plan, and another 8 percent would not accept new patients.

The findings raise questions about whether plans’ networks are broad enough to serve the influx of patients entering the Medicaid system. About 9.1 million additional people have joined the Medicaid and Children’s Health Insurance Program since last year, according to federal officials.

Among the providers who would set up an appointment, the median wait time was two weeks. But some waits were much longer. More than one-fourth of those willing to treat new Medicaid patients required a one-month wait, and 10 percent required a wait of two months or more.

Primary care doctors were less available for appointments. But the wait time for specialists was longer on average than primary care providers, said the report.

The Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner said she would implement the report’s three suggestions. The agency agreed to work with states, which help run Medicaid, to check on the number of providers offering appointments and require insurers to offer more accurate information about providers. Federal officials also said they would do more to ensure that plans’ networks are adequate to care for patients and that the plans are complying with state standards.

Many patient advocates have complained that insurers are not doing enough to give patients accurate information about which doctors are in plans’ networks. Health plans’ inaccurate information about providers may prevent a patient from getting care they need quickly.

The complaints about providers’ networks affect not only Medicaid but other types of insurers as well, such as those participating in the new marketplaces under the health care law. The National Association of Insurance Commissioners is exploring ways to update its recommendations for states, and CMS has proposed in a recent rule that insurers that offer marketplace plans update their online provider directories regularly.

The report may increase pressure on states and the federal government to require Medicaid managed care plans to offer broader networks and ensure that information about which providers are covered is correct. Federal officials are working to create a new proposed rule that will govern Medicaid managed care plans.

The Medicaid Health Plans of America, an industry trade group, said that the report looks at one of the ways that consumers get information about providers in a plan’s network, but not all of the tools available.

“Our plans have programs in place that help connect people to care,” said Amy Ingham, director of federal policy at the managed care trade group. “Plans do have robust care coordination where we connect individuals with available providers and services, helping them navigate the system.”

Ingham also noted that the report does not assess whether patients who are in fee-for-service Medicaid, in which they can use any doctor that accepts Medicaid benefits, are able to easily find a doctor.

“In order to paint a complete picture it would need to do that,” she said.

The Office of the Inspector General report is the second one on Medicaid managed care to be released this fall. The other report found that states had widely varying standards to measure whether patients were able to get access to care. It also said that states and the federal government did not do enough to oversee the standards and monitor patients’ access.

Publication Details