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Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans

Executive Summary
  1. Medicaid and CHIP Payment and Access Commission, MACStats: Medicaid and CHIP Data Book (Washington, DC: Medicaid and CHIP Payment and Access Commission, December 2017), https://www.macpac.gov/wp-content/uploads/2015/11/EXHIBIT-29.-Percentage-of-Medicaid-Enrollees-in-Managed-Care-by-State-July-1-2015.pdf, p. 83.

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  2. Share of plans operating statewide may be underrepresented due to the over representation of non-profit plans among survey respondents. Only 54% of responding for-profit plans do not operate statewide.

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  3. Dental care is covered for all children in Medicaid under EPSDT, but adult dental benefits are offered at state option. However, MCOs have flexibility to use administrative savings within their capitation rates to provide services beyond Medicaid benefits required under their contracts. Other surveys indicate that many plans provide dental services as an additional service outside their state Medicaid contract. See: Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

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Introduction
  1. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/, p.2.

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  2. Medicaid and CHIP Payment and Access Commission, MACStats: Medicaid and CHIP Data Book (Washington, DC: Medicaid and CHIP Payment and Access Commission, December 2017), https://www.macpac.gov/wp-content/uploads/2015/11/EXHIBIT-29.-Percentage-of-Medicaid-Enrollees-in-Managed-Care-by-State-July-1-2015.pdf, p.83.

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  3. Eligible plans included any plan that had a 2016 Medicaid MCO contract (as several survey questions referred to plan operations in 2016) and was active during the data collection period in 2017 (as some survey questions referred to future/current plan operations). For more information about eligible plans, see “Methods” section.

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Plan Characteristics, Enrollees, and Services
  1. Some plans in MCHIP states responded that they offer Children’s Medicaid Insurance Program (CHIP) as a line of business. Of plans that serve children in SCHIP states, 71% responded that they offer Children’s Medicaid Insurance Program (CHIP) as a line of business.

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  2. Share of plans operating statewide may be underrepresented due to the over representation of non-profit plans among survey respondents. Only 54% of responding for-profit plans do not operate statewide.

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  3. “Other” organization types identified by plans include: public agency; quasi-government; joint powers agency not-for-profit public entity; government/local health initiative; non-profit, public agency; independent public agency; public for-profit; private LLC; publicly traded; and private mutual.

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  4. Dental care is covered for all children in Medicaid under EPSDT, but adult dental benefits are offered at state option. However, MCOs have flexibility to use administrative savings within their capitation rates to provide services beyond Medicaid benefits required under their contracts. Other surveys indicate that many plans provide dental services as an additional service outside their state Medicaid contract. See: Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

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Provider Networks and Access to Care
  1. Sandra Decker, “Tw0-Thirds of Primary Care Physicians Accepted New Medicaid Patients in 2011-12: A Baseline to Measure Future Acceptance Rates,” Health Affairs 32, no. 7 (July 2013): 1183-1187, https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2013.0361.

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  2. Esther Hing, Sandra Decker, and Eric Jamoom, NCHS Data Brief no. 195: Acceptance of New Patients with Public and Private Insurance by Office-based Physicians: United States, 2013 (Atlanta, GA: National Center for Health Statistics, Centers for Disease Control and Prevention, March 2015): https://www.cdc.gov/nchs/data/databriefs/db195.pdf.

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  3. The Kaiser Family Foundation State Health Facts. Data Source: Designated Health Professional Shortage Areas Statistics: Designated HPSA Quarterly Summary, as of December 31, 2016, Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, “Primary Care Health Professional Shortage Areas (HPSAs)” accessed February 2018, https://www.kff.org/other/state-indicator/primary-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Percent%20of%20Need%20Met%22,%22sort%22:%22desc%22%7D.

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  4. Tara Bishop, Matthew Press, and Salomeh Keyhani, “Acceptance of insurance by psychiatrists and the implications for access to mental health care,” JAMA psychiatry 71, no. 2 (Feb. 2014): 176-181, https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1785174.

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  5. Amanda Van Vleet and Julia Paradise, Tapping Nurse Practitioners to Meet Rising Demand for Primary Care (Washington, DC: Kaiser Family Foundation, Jan. 2015), http://files.kff.org/attachment/issue-brief-tapping-nurse-practitioners-to-meet-rising-demand-for-primary-care.

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  6. The National Telehealth Policy Resource Center, Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 States and District of Columbia (Sacramento, CA: Center for Connected Health Policy, Fall 2017), http://www.cchpca.org/sites/default/files/resources/Telehealth%20Laws%20and%20Policies%20Report%20FINAL%20Fall%202017%20PASSWORD.pdf. See also: “Telemedicine,” CMS, accessed March 1, 2018, https://www.medicaid.gov/medicaid/benefits/telemed/index.html.

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  7. The share adding providers may be under-represented due to the higher share of non-profit plans in the sample. When looking at for-profit plans, they were more likely to add providers of all types and equally likely to add mental health providers as other types.

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Member Experience and Access to Care
  1. The 2016 Medicaid Managed Care Final Rule indicates MCOs must make their best effort to conduct a health risk assessment within 90 days of enrollment for all new enrollees, including subsequent attempts to contact the enrollee if the initial attempt is unsuccessful. These provisions are effective for plan contracts starting on or after July 1, 2017.

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  2. In June 2015, CMS issued an Informational Bulletin to clarify when and how Medicaid reimburses for certain housing-related activities, including individual housing transition services, individual housing and tenancy sustaining services, and state-level housing related collaborative activities. In January 2018, CMS issued a State Medicaid Director Letter providing guidance on state Section 1115 waiver proposals to condition Medicaid on meeting a work requirement. CMS explicitly stated the demonstration opportunity does not provide states with the authority to use Medicaid funding to finance employment support services. Predating this guidance, a few states implemented voluntary work referral programs. Federal Medicaid funds also cannot be used to finance work referral programs.

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  3. Under federal Medicaid managed care rules, Medicaid MCOs may have flexibility to pay for non-medical services through “in-lieu-of” authority and/or “value-added” services. “In-lieu-of” services are a substitute for covered services and may qualify as a covered service for the purposes of capitation rate setting. “Value-added” services are extra services outside of covered contract services and do not qualify as a covered service for the purposes of capitation rate setting.

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  4. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/, p.22.

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Provider Payment and Delivery System Reform
  1. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/, p.21.

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  2. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/, p.21.

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  3. Due to the over representation of non-profit plans among survey respondents, the share of plans making no APM payments to hospitals may have been overrepresented in the sample. When looking at responding for-profit plans, only 19% of plans reported making no payments through APMs to hospitals.

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  4. Due to the over representation of non-profit plans among survey respondents, the share of plans reporting contracting with an ACO may have been overrepresented in the sample. When looking at responding for-profit plans, 13% of plans reported currently contracting with an ACO, while 51% reported considering contracting with ACOs in the future.

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  5. Survey response option “use for all members as needed.”

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Current Medicaid Policy Debate, MCOs, and Access to Care
  1. Julie Paradise and MaryBeth Musumeci, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (Washington, DC: Kaiser Family Foundation, June 2016), https://www.kff.org/report-section/cmss-final-rule-on-medicaid-managed-care-issue-brief/.

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  2. Kaiser Family Foundation, Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers?
    (Washington, DC: Kaiser Family Foundation, Feb. 2018), https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/?utm_source=web&utm_medium=trending&utm_campaign=waivers.

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  3. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

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  4. Unlike current law where eligible individuals have an entitlement to coverage and states are guaranteed federal matching dollars with no pre-set limit, the proposals considered would have eliminated both the entitlement and the guaranteed match to achieve budget savings and to make federal funding more predictable. To achieve budget savings, federal funding limits would be capped below what federal funding is projected to be under current law. Under a block grant, states would receive a pre-set amount of federal funding for Medicaid, regardless of enrollment. Under a per capita cap, federal funding per enrollee would be capped. For both block grants and per enrollee cap, federal spending would increase by a pre-set index (e.g., inflation or inflation plus a percentage) over time. To generate federal savings, the total amount of federal spending would be less than what is expected under current law.

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  5. On March 14, 2017, the CMS sent a letter to state governors that signaled a willingness to use Section 1115 authority to “support innovative approaches to increase employment and community engagement” and “align Medicaid and private insurance policies for non-disabled adults.” In a speech delivered on November 7, 2017, CMS Administrator Seema Verma reaffirmed the Administration’s commitment to approving proposals that promote work and community engagement. On November 7, 2017, the CMS also posted revised criteria for evaluating whether Section 1115 waiver applications further Medicaid program objectives. Expanding coverage of low-income individuals is no longer reflected in the revised criteria. On January 11, 2018, CMS posted new guidance for state Section 1115 waiver proposals to condition Medicaid on meeting a work requirement.

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  6. CMS’ major goals in revising the regulations were to align Medicaid and CHIP managed care requirements with other major health coverage programs where appropriate; enhance the beneficiary experience of care and strengthen beneficiary protections; strengthen actuarial soundness payment provisions and program integrity; promote quality of care; and support efforts to reform the delivery systems that serve Medicaid and CHIP beneficiaries.

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  7. Required by the Administrative Procedures Act (APA).

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  8. On June 30, 2017, CMS released an Informational Bulletin indicating they would use “enforcement discretion” to work with states on achieving compliance with the new managed care regulations, except for specific areas that “have significant federal fiscal implications.”

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Discussion
  1. Health Management Associates and Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018 (Lansing, MI: Health Management Associates and Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

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  2. Tara Bishop, Matthew Press, and Salomeh Keyhani, “Acceptance of insurance by psychiatrists and the implications for access to mental health care,” JAMA psychiatry 71, no. 2 (Feb. 2014): 176-181, https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1785174.

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  3. Julie Paradise and MaryBeth Musumeci, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (Washington, DC: Kaiser Family Foundation, June 2016), https://www.kff.org/report-section/cmss-final-rule-on-medicaid-managed-care-issue-brief/.

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  4. If a state permits an exception to its provider-specific network adequacy standard, the criteria by which the exception will be evaluated and approved must be specified in the MCO, PIHP, or PAHP contract and be based, at a minimum, on the number of providers in the relevant specialty who practice in the plan’s service area. In addition, states must monitor enrollee access to that provider type on an ongoing basis and include their findings in their annual program report to CMS.

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  5. Julie Paradise and MaryBeth Musumeci, CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions (Washington, DC: Kaiser Family Foundation, June 2016), https://www.kff.org/report-section/cmss-final-rule-on-medicaid-managed-care-issue-brief/.

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  6. Debra Lipson, et al., Promoting Access in Medicaid and CHIP Managed Care: A Toolkit for Ensuring Provider Network Adequacy and Service Availability (Baltimore, MD: Division of Managed Care Plans, Center for Medicaid and CHIP Services, CMS, U.S. Department of Health and Human Services, April 2017), https://www.medicaid.gov/medicaid/managed-care/downloads/guidance/adequacy-and-access-toolkit.pdf.

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Methods
  1. Two additional MCOs were identified post-data collection as having been eligible for inclusion in the survey. These two plans were not included in the final sample frame nor were they invited to participate during the data collection period; however, they are included in the final data file and response rate calculations.

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  2. Based on analysis of universe of plans for which enrollment data is known. See https://www.kff.org/data-collection/medicaid-managed-care-market-tracker/ for data on MMC plan enrollment.

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.