By 2018, up to 18 million new participants are expected to enroll in Medicaid. With that in mind, the Centers for Medicare and Medicaid Services needs to tighten their control over the program in order to ensure that these patients have access to quality care.

In a recent study, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) found that, after examining Medicaid managed care organizations in 33 states, the standards for access to care differ drastically across the nation. These standards were also rarely specific to certain types of providers or the population density. Without these standards, states may not be able to hold plans accountable for providing adequate access to care.

The most common Medicaid access standards are those that require appointments be available in a certain time period, those that limit the distance or time that patients have to travel to see a provider, and those that require a minimum number of providers in relation to the number of patients enrolled.

In the states studied, the waiting period for an appointment was anywhere between 10 to 45 days, and 10 to 60 days for specialist. In regards to distance from a PCP, standards in the 15 states that differentiate between urban and rural areas ranged from six to 30 miles in urban areas and 15 to 60 miles in rural areas. Of the states who have standards for the number of enrollees per PCP, four states require that the ratio be one PCP for one to 599 enrollees, nine states require a ratio of one to between 600 and 1999 enrollees and seven states require that it be one to 2000 enrollees or more.

The report also found that there are only a few states that use direct tests to determine how well programs are meeting access standards. Most states rely on outside contractors to assess plan compliance. These contractors often use on-site visits, satisfaction surveys, and policy and procedure reviews to evaluate the programs.

The OIG report includes a list of recommendations for CMS to improve patient care:

  • Strengthen the oversight of state standards
  • Ensure that states develop standards for key providers
  • Strengthen the oversight of methods to assess compliance and confirm that states are conducting direct tests of access standards
  • Improve state efforts to identify and address violations of access standards
  • Provide technical support and share effective procedures

In her official response to the report, CMS Administrator Marilyn Tavenner stated that CMS agrees with all of the given recommendations and will be taking the necessary steps to implement them.

Author: Lauren Daniels

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