A Guide to Monitoring Medicaid Managed Care

Chapter 4: 
Monitoring Access to Care

This chapter addresses the challenge of monitoring some of the most practical and visible aspects of health care access. To make managed care work, health plans must convey an enormous amount of information, both clinical and administrative, to an increasingly large and diverse number of enrollees. Monitoring how managed care communicates with its members helps you answer the following questions:

1) Do new enrollees get good information about how to access care?

• Do enrollees receive enough information to choose a provider? Do plans have a mechanism in place to consider an enrollee's circumstances when assigning a primary care provider?
• Is enrollment information adequate to assist various linguistic populations in making informed choices?
• Do enrollees learn how to obtain primary and specialty care?

2) Is care available?

• Do plans have enough primary care and specialty providers to adequately serve enrollees?
• Do plans have enough providers to offer enrollees a meaningful choice among providers?
• Are enrollees able to get referrals to specialists? Are referral procedures easy to follow, and can people with ongoing health needs get "standing referrals" to specialists?
• Do enrollees have to travel long distances to see health care providers? Do plans help them secure transportation to medical appointments?
• Can enrollees see their health care providers without long waits?
• Do enrollees get immediate emergency care? Do they encounter problems in getting their plans to authorize emergency treatment?

3) Does care meet the needs of persons with disabilities?

• Are services physically accessible to persons with disabilities?
• Do managed care plans adequately communicate with persons with hearing or visual impairments through every step of health care delivery?

4) Does the plan provide linguistically and culturally competent care?

• Are managed care plans able to communicate with enrollees with limited English proficiency?
• Do health care providers reflect the cultural and linguistic make-up of the Medicaid population?
• Have managed care plans considered the cultural practices and beliefs related to health care of the persons they serve, and do they effectively serve enrollees from various cultures?
• Does the state maintain adequate data to ascertain the cultural and linguistic needs of its Medicaid population?

Federal Requirements Related to Access to Care

Under federal law, Medicaid managed care cannot impair enrollees' access to care. States that obtain 1915(b) waivers and 1115 waivers have had to demonstrate in their waiver applications that providers would be at least as accessible to managed care enrollees as they were under fee-for-service Medicaid. The Balanced Budget Act of 1997 allows states to mandate managed care enrollment for many Medicaid beneficiaries without first obtaining a waiver. The following provisions regarding access are part of the act:

• Easily Understood Informational Materials-The Balanced Budget Act of 1997 1 requires states, enrollment brokers, and Medicaid managed care organizations to provide enrollment notices and informational materials "in a manner and form which may be easily understood by enrollees and potential enrollees. . . ."
• Number of Available Managed Care Entities-States can limit the number of provider agreements with managed care entities if this limitation does not impair Medicaid beneficiaries' access to services. Generally, individuals must be given the choice between at least two managed care entities. However, in a rural area, states can require individuals to enroll in a single managed care organization as long as individuals have a choice between at least two physicians or case managers (to the extent that at least two providers are available in an area).
• Managed Care Network Capacity-Each Medicaid managed care organization must assure the state and the Secretary of the U.S. Department of Health and Human Services that it has the capacity to serve the expected enrollment in its service area, offers an appropriate range of services and access to preventive and primary care, and maintains a sufficient number, mix, and geographic distribution of providers of services.
• Access Standards-As part of states' quality assessment and improvement strategy for Medicaid managed care, states must develop standards for access to care for contracting Medicaid managed care organizations so that covered services are available within reasonable time frames and in a manner that ensures continuity of care and adequate primary care and specialized services capacity.
• Emergency Services-Emergency services must be covered without prior authorization from a managed care organization, regardless of whether the enrollee obtains the services inside or outside of the managed care organization. An "emergency medical condition" is defined as "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."
• External Quality Review-Generally, each contracting Medicaid managed care organization must undergo an independent external review annually (see Chapter 2 for exceptions). Among other factors, reviewers will examine timeliness of services and access to services under the managed care contract. 
• Appropriate and Competent Services-The Balanced Budget Act of 1997 requires states to ensure that Medicaid managed care organizations offer "an appropriate range of services and access to preventive and primary care for the population expected to be enrolled in such service area." Under the act, states must monitor the quality and appropriateness of care and services delivered by managed care organizations through procedures that "reflect the full spectrum of populations enrolled under the contract." The Health Care Financing Agency (HCFA) has proposed rules to implement the Balanced Budget Act that explicitly require linguistic and cultural services. Under the proposed rules, states would need to develop methodologies for estimating the composition of their Medicaid populations with limited English proficiency. The state or its contractors would need to provide materials in languages that meet state-defined population thresholds. Both states and contracting managed care organizations would need to make translation services available to all enrollees and potential enrollees. The proposed rules would require Medicaid managed care organizations to provide services in a "culturally competent manner."  Final rules will likely be issued in 2000.

Other federal laws and regulations that pertain to access in Medicaid managed care include the following:

• Physical Accessibility-Section 504 of the Rehabilitation Act of 1973 forbids denying individuals with disabilities an equal opportunity to receive Medicaid benefits and services. Persons covered by the act are those with physical or mental impairments that limit major life activities, such as caring for oneself, walking, seeing, hearing, speaking, or breathing. This Act is enforced by the Office for Civil Rights, U.S. Department of Health and Human Services.
• Nondiscrimination-Title VI of the 1964 Civil Rights Act prohibits discrimination by a federally assisted program due to a person's limited English proficiency. The U.S. Department of Health and Human Services has interpreted this to mean that persons of limited English proficiency must be provided with interpreters when necessary; cannot be restricted from participating in a program or activity due to language barriers; and cannot be subject to unreasonable delays in service.
• Transportation To Health Care- Federal regulations require Medicaid agencies to "ensure necessary transportation . . . to and from providers." As part of states' obligation to furnish Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for children covered by Medicaid, state Medicaid agencies "must offer to the family or [Medicaid] recipient, and provide if the recipient requests, necessary assistance with transportation."

State Requirements Regarding Access To Care

States commonly detail access standards in their Medicaid managed care contracts. For an overview, see Families USA's Guide to Access to Providers in Medicaid Managed Care, 1998, fact sheet available on www.familiesusa.org/pubs/acssfsht.htm; to find out how your state contract compares to contracts in other states, see Sara Rosenbaum, et al., Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, Third Edition (Washington, DC: George Washington University Center for Health Services Research and Policy, 1999). Some key issues that states have addressed follow:

a. Primary Care Providers

Enrollees depend heavily on their primary care providers' availability and expertise. Primary care providers have the authority to refer enrollees for specialty care and treatment. If primary care provider arrangements are flawed or if access to primary care providers is impaired, an enrollee's whole program of care is in jeopardy. States commonly set guidelines regarding the minimum number of providers from which members must be allowed to choose. States may also establish minimum full-time provider-to-patient ratios and maximum travel time and distances from beneficiaries' homes to providers offices. Long waits for appointments and long waits in provider offices are one indication that a plan's provider network is inadequate to serve enrollees. Long waits may discourage beneficiaries from seeking medical care. States often set maximum wait times for appointments and maximum wait times in the providers' offices. Managed care enrollees may fail to select a primary care provider. Some states require that plans consider the following factors in making provider assignments: the member's previous provider, primary language, and special health needs, and geographic location of potential providers relative to the member's home.

b. Specialists

For a person with a complicated health condition, specialty care is every bit as necessary as the most basic health care services. The ability of managed care to guarantee appropriate specialty networks is a key element to monitor for access. Some states set general guidelines for specialists' availability, requiring plans to guarantee the availability of sufficient numbers of specialists to serve a particular population. When an enrollee needs a specialty service that the plan cannot provide but that Medicaid covers, the plan should refer the enrollee to an out-of-network specialist. Usually, managed care enrollees must obtain referrals to specialists from their primary care provider. Some states require plans to explain referral practices in their member handbooks and orientation sessions. To ease the referral process for people who need ongoing specialty care, some states require plans to provide standing referrals for patients in ongoing treatment, and some states permit certain specialists to act as primary care providers.

c. Transportation to health care

In many states, the responsibility to furnish transportation is passed on to contracting Medicaid managed care organizations that, in turn, may have subcontracts with medical transportation companies. If states do not adequately delineate transportation responsibilities and oversee the transportation arrangements, beneficiaries may encounter difficulties in obtaining transportation to services that are covered by Medicaid but "carved out"-that is, provided either through a separate behavioral health care organization or on a fee-for-service basis.

d. Linguistic access and cultural competency

Although most state Medicaid managed care contracts require that written plan materials be furnished in languages other than English, many state contracts are silent on other aspects of linguistic access and cultural competency. Some states have required managed care plans to include multilingual providers within their networks, some specify that interpreter services be provided for clinical encounters and/or for administrative encounters for persons who have limited English proficiency. A few states require the use of professional interpreters, rather than family or friends, for technical, medical, or treatment information. Most states require special services for persons with speech, language, hearing, or vision-related disabilities. 

States often require cultural competency, but as mentioned earlier, the term is undefined. Pennsylvania's contract is exceptional in its level of detail: HMOs and providers cannot present barriers to access based on cultural differences. They must be willing and able to make distinctions between traditional and non-traditional treatment methods that may be equally or more effective for a particular patient and consistently provide quality care across a variety of cultures. California perhaps goes the furthest of any state, requiring linguistic services for populations exceeding numerical thresholds at key points of contact and requiring managed care organizations to assess the cultural and linguistic needs of their enrollees and submit a plan to meet those needs. California maintains data about the primary languages spoken by Medi-Cal beneficiaries (California's name for Medicaid) and is thus able to furnish enrollment/disenrollment reports and other data by language group.

Sources of Data

• Consumer Surveys-Managed care plans and/or state Medicaid agencies should ask questions about access as part of their consumer satisfaction surveys. The Consumer Assessment of Health Plans (CAHPS®), a national survey instrument used in a number of states to assess Medicaid managed care, asks many questions related to access. It explores satisfaction with primary care providers and specialty care providers and problems finding these providers. It also asks about problems getting help by phone, delays in getting appointments, problems accessing emergency care, waits in doctor offices, difficulties communicating with health providers due to language barriers, problems understanding health providers, problems getting health plan approvals, the adequacy of information for choosing a plan, and the comprehension level of written materials.

  Find out whether the results of any surveys conducted in your state show problems with access to care. If neither your state Medicaid agency nor the contracting managed care plans ask questions about access, you might suggest areas of inquiry or recommend that they use CAHPS®. Also find out whether surveys are administered in languages other than English. Work is underway to translate the CAHPS® survey into Spanish and to ensure that the questions are culturally appropriate for Spanish-speaking Medicaid beneficiaries.

• Site Reviews and Compliance Reviews-State Medicaid agencies typically conduct site reviews of managed care organizations prior to entering into a contract with them and periodic audits or compliance reviews to determine whether the managed care organizations are adhering to the terms of their contract. Compliance reviews may involve site visits to the managed care organization's headquarters and to some providers offices, phone calls to test the availability of providers, and a review of written materials submitted by the managed care plan. Find out whether your state reviews physical accessibility of health care facilities, linguistic capacity of health care providers and managed care member services departments, overall access to providers and services, and cultural competence. Check with contract compliance officers in your Medicaid agency to find out how they conduct reviews and what data are available.
• Data on Participating Providers-Your state Medicaid agency probably receives regular reports from managed care plans regarding their provider networks. Find out whether these reports include data about the number of providers available to Medicaid beneficiaries and the number accepting new patients and the percentage of providers' practice devoted to Medicaid (that is, the number of full-time-equivalent physicians serving the population) and their specialty areas and linguistic capability. Compare information to data on Medicaid managed care enrollees to ensure that the state is enforcing standards regarding the adequacy of provider networks.

  Many states use a computer program called Geoaccess that maps the distances between Medicaid providers and beneficiaries' residences. Find out if your state uses such a program to monitor compliance with standards regarding geographic accessibility of providers.

• Enrollment and Disenrollment Data-Some states collect data on reasons that people disenroll from their Medicaid managed care organizations and on the primary languages of enrollees and disenrollees. Find out whether reasons for disenrollment collected by your state include language barriers and find out whether persons with limited English proficiency account for a disproportionate share of those seeking to change plans.
• External Quality Reviews-Find out what measures of access are examined by external quality review organizations in your state. Some states validate HEDIS data submitted by plans as part of their external quality review. HEDIS includes a set of standardized measures that many Medicaid managed care plans use to report on their performance related to quality and access. HEDIS access measures include the following: Medicaid enrollees continuously enrolled for a year who had ambulatory or preventive visits; continuously enrolled children in different age groups with age-appropriate visits; number of primary care physicians, OB/GYNs, and dentists who serve Medicaid enrollees, accept new members with or without restrictions, or do not accept new members; and initiation of prenatal care. In some states, external quality reviewers examine managed care organizations' procedures to determine whether they comply with state and federal access standards. You can obtain copies of the external quality review organization's scope of work and its findings from your Medicaid agency.
• Complaint and Grievance Data-Complaints and grievances filed with the managed care plans, the state Medicaid agency, the contractor (if any) responsible for enrollment, or the state insurance commissioner may reveal problems with access to care. Find out whether your state compiles and categorizes data regarding complaints and grievances. Does your state have ombuds programs or other sources of consumer assistance that are knowledgeable about problems Medicaid beneficiaries encounter in accessing care?
• Member Handbooks and Informational Materials-You can conduct your own review of member handbooks and other informational material to determine whether they adequately explain how to obtain care, whether they are clear, whether they are translated into languages other than English, and whether they are available in alternative formats for people who cannot read printed material.

Questions you can ask about the member handbook the include the following:

1) Does it explain how to obtain transportation to medical appointments? Does the handbook notify members that the plan or state Medicaid agency can help them obtain transportation for their children's medical appointments?

2) Does it explain how to choose a primary care provider and how to obtain referrals to specialists?

3) Does it explain how quickly members can expect to receive initial appointments, routine care, sick care, urgent care, and referrals?

4) Does it correctly explain when members can get care in an emergency room without prior authorization and what an emergency is under federal law?

5) Does it explain how to obtain prescription drugs?

6) Does it explain how to complain about problems with access to care?

• Internal Studies Conducted by Managed Care Plans-Find out whether managed care plans in your state are conducting any internal quality improvement studies regarding the accessibility of their services or cultural and language barriers encountered by enrollees.

Step-by-Step Analysis

Advocates and community organizations should document problems with provider networks so that managed care organizations and government officials can address individual and systemic problems. This section offers some strategies for analyzing the data and taking action.

Step One: Identify Areas to Investigate

Draw from concerns reported to community-based organizations or from surveys conducted by your organization or others to identify areas to investigate.

Step Two: Investigate the Data Sources

You may need to draw from a number of the data sources listed in the section above to determine whether health plans offer accessible care. Some data are collected by the state and are publicly available. Other data are collected by plans and may be considered "proprietary information," even if they are provided to the state. If you are on a consumer advisory committee to a plan, you may be able to advocate that the plan collect and use data to improve access to care.

Step Three: Test Accuracy of Information in Member Handbooks and Provider Directories

A review of member handbooks and provider directories can help to find out how well each explains how to obtain care. Make test calls to plan member services to find out what the plan staff tells members. Make test calls to providers to verify the accuracy of information in provider directories.

• Do member services departments have TDD equipment available and make provisions for interpreters, and does the staff speaks the languages of sizable linguistic subpopulations of enrollees?
• How does the plan handle after-hours calls?
• Can member services representatives speak threshold languages or readily provide interpreters/translators?
• Are providers listed in provider directories really accepting new Medicaid beneficiaries? How long does it take to obtain appointments?
• How many providers are available to serve various linguistic groups?

Step Four: Collect Access Information from Medicaid Beneficiaries and Consumer Organizations

Advocates often go beyond state data to learn about access problems. Often, groups such as Legal Services or Head Start will have anecdotal evidence that persons are having problems obtaining care, though states have limited data about access. Among the many projects advocates have undertaken to monitor access are:

• Surveying beneficiaries about their experiences in managed care (Families USA can assist with model survey instruments);
•  Developing a "problem report form" that community groups can use to document access problems that come to their attention;
• Interviewing key informants, including emergency room personnel, child protective service workers, and Head Start health coordinators, to learn about any problems they encounter as they try to get care for consumers.

(See Chapter 1, Do-It-Yourself Monitoring Projects, and Chapter 5, for more details.)

Developing and Presenting Recommendations

If you have identified concerns in the course of your investigations, advocate for both better monitoring of access and stronger access standards. Join with other advocates to bring your concerns to the plan, the state, and HCFA. Also consider filing a complaint with the Office for Civil Rights of the U.S. Department of Health and Human Services. Fact sheets on the Office for Civil Rights website, explain civil rights and how to complain.

Endnotes

1  Social Security Act § 1932 (a); 42 USC 1396u-2

2  Social Security Act § 1932 (5)(a).

3  As of Spring 2000, the federal government has not issued further regulations regarding these assurances. In a December 17, 1997 letter to State Medicaid Directors, HCFA instructed states to "identify the methodology and processes you will utilize to verify that beneficiaries have access to an adequate number of geographically accessible providers under the program" when amending state plans to implement mandatory managed care programs.

4  Social Security Act § 1932 and April 18, 2000 letter from HCFA to Medicaid Directors.

5  Social Security Act §§ 1932 (b)(5) and § 1932 (c)(1)(A).

6  Federal Register, September 29, 1998, U.S. Department of Health and Human Services, Health Care Financing Administration, "Medicaid Managed Care Proposed Rule amending Medicaid Regulations 42 C.F.R. §§ 438.10 and § 438.306."

7 1964 Civil Rights Act, Title VI as amended, 42 U.S.C.§ 2000d et seq, 45 CFR Part 80, and cited in letter from An Le and Jeanne Finberg, Consumers Union, San Francisco, CA, and John Affeldt, Public Advocates, to J. Douglas Porter, Acting Deputy Director, and Joseph Kelly, Chief, Medi-Cal Managed Care Division, California Department of Health Services, January 22, 1997.

8  42 C.F.R.§§ 431.5 and § 440.170

9  42 CFR § 441.62.

10For an example of an advocacy organization's analysis of member handbooks, see the May 1998 MedCAP study, Member Handbooks for Medi-Cal HMOs: How Useful Are They? which offers a detailed look at California Medi-Cal managed care plans' materials.