Medicaid managed care programs need more oversight: OIG

Standards for accessing care vary widely

With up to 18 million new people expected to enroll in Medicaid by 2018, the Centers for Medicare and Medicaid Services (CMS) needs to exercise tighter control over the program to ensure that patients have adequate access to quality care, a new government report concludes.

After examining Medicaid managed care organizations in 33 states throughout the country, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) found widely varying standards for access to care, ranging from one primary care provider (PCP) per 100 Medicaid enrollees to one PCP per 2,500 enrollees. In addition, standards often are not specific to certain types of providers, or to population density.

“State standards vary widely and are often not specific to providers who are important to the Medicaid population, such as pediatricians, obstetricians, and high-demand specialists,” the report says. “In addition, these standards often apply to all areas within a state and do not take into account differences between urban and rural areas. Without standards for specific provider types or areas, states may not be able to hold plans accountable for ensuring adequate access to care.”

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

In terms of distance to a PCP, and among the 15 states that distinguish between urban and rural areas in their standards, standards ranged from six to 30 miles in urban areas and 15 to 60 miles in rural areas. Waiting times for a routine PCP appointment varied from 10 to 45 days, and 10 to 60 days to see a specialist.

Among the states with standards for the number of enrollees per PCP, for four states the required ratio is one PCP for one to 599 enrollees, for nine states the ratio is one to between 600 and 1999 enrollees, and for seven states the ratio is one to 2000 enrollees or more.             

The report found further that only a handful of states use direct tests, such as actually calling providers, to determine how well programs are complying with access standards. Instead, these states rely on outside contractors to assess plan compliance, most of whom use methods such as on-site visits, enrollee satisfaction surveys, and reviews of policies and procedures.  

            The report recommends that CMS:

  • strengthen its oversight of state standards and ensure that states develop standards for key providers,

  • strengthen its oversight of states’ methods to assess pan compliance and ensure that state conduct direct tests of access standards,

  • improve states’ effort to identify and address violations of access standards, and

  • provide technical assistance and share effective practices.

In an official response to the report, CMS Administrator Marilyn Tavenner said CMS agrees with all the recommendations and is taking steps to implement them.


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