Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Network Standards.


The Balanced Budget Act requires that Medicaid programs generally provide adequate access to care, but states have wide latitude in how this broad requirement is translated into the standards they impose on their MCOs. We reviewed a model Medicaid and CHIP MCO contract for each study stateto determine the provider network requirements that states impose on their plans. Table 6 shows the requirements for appointment wait times (routine and urgent), the maximum number of enrollees allowed per Primary Care Provider (PCP), and any requirements for geographic proximity to a PCP in the study states. State-by-state detail on these requirements is contained in Appendix B, Table 6.

Table 6: Summary of Medicaid Provider Network Access Requirements in Study States, 2010
Standard Minimum Maximum Mode Number of States
with Standard

Source: Review of state contracts.

Note: See Appendix B, Table 6 for state-specific detail.

Appointment Wait Times        
Routine (days) 7 45 30 17
Urgent (days) 1 2 1 18
Maximum Number of Enrollees to Each Primary Care Provider 750 2500 1500 14
Geographic Proximity for Primary Care Providers        
Urban Areas (miles) 5 30 30 19
Rural Areas (miles) 15 60 mins 30 17

There is considerable variation in the number and strength of the standards states impose on MCOs for Medicaid. Standards for routine appointment wait times (an appointment for a condition that is not urgent) vary from only 7 days in Florida to 45 days in Massachusetts and Minnesota, with the mode being about 30 days among the 17 states with a standard specified in their model contract. Three states do not impose a standard for Medicaid. The standard for urgent appointments is much shorter, 1–2 days, among the 18 study states that impose this standard. Similarly, the range in the number of enrollees allowed per PCP varies widely, from 750 to 2,500 per PCP. Six states do not have such a standard in their model contract. Finally, the standard for geographic proximity to PCPs ranges from 5 to 30 miles (or 30 minutes) in urban areas and from 15 miles to 60 minutes in rural areas. All but three states have such standards for Medicaid.

The access standards for CHIP MCOs differ from Medicaid standards in all of the seven states that separately administer their Medicaid and CHIP risk-based managed care programs, except for Texas, where the standards are the same across all the access measures in Table 6, and New York, where the standards are very similar for Medicaid and CHIP. In the remaining five states, there is no clear pattern to differences in the strictness of access standards for Medicaid and CHIP plans. Sometimes standards are stricter for CHIP plans than Medicaid plans, and sometimes the reverse is true. For example, in Virginia routine appointment wait times must be within 30 days for Medicaid and within only 15 days for CHIP. On the other hand, PCPs must be within 15 miles for Medicaid enrollees but within a longer distance, 30 miles, for CHIP.

Equally important is whether and how plans monitor these standards to assure network adequacy. We asked both state officials and plan representatives about how they monitor their provider network requirements. As with the standards themselves, there is wide variation in how states enforce their provider network standards. Half the states require plans to submit monthly or quarterly reports concerning their networks (although the content of reports varies widely), but others require less frequent reporting. Another common method is "secret shopper calling," whereby the states call providers in the plan’s network to request an appointment, posing as a plan enrollee.

We have staff that take the plan’s most current provider directory, and they make calls. They make calls to see if the provider is actually participating in the plan. (State Official)

The frequency, type, and methods of these calls vary within and across states. For example, New York noted that they called everyone in the plan’s most current provider directory twice a year to determine provider participation, and in Pennsylvania monitoring staff are required to complete 55 survey calls quarterly.

We asked states whether their monitoring of access requirements has varied over time. More intensive monitoring over time can occur when there are access concerns for a particular plan.

[Speaking of monitoring intensity and frequency] Some of it is monthly, some of it is quarterly, and some of it is every six months. That’s what we use to monitor the activity and make sure they stay on track. There are quarterly or monthly grievance reports; there are quarterly or monthly claims dashboards. It just depends on how well the health plan is performing and how well they do on all the different types of oversight that we do. (State Official)

However, some states said that state budget restrictions have reduced the size of their monitoring staff and therefore limited what they can do.

One representative of a national-level plan indicated that there is a wide range of sophistication in the type of monitoring states do. While he generally expressed admiration for the most experienced states’ monitoring programs (mentioning Arizona, New York, Tennessee, and Wisconsin specifically), he indicated it can lead to challenges for the plan.

It makes it challenging for the contractor because the states are so well run and they understand their data and our performance pretty well. So it creates a twofold problem [laughs]—(1) they are a great state [i.e. at monitoring] and (2) they are a great state [i.e. at pointing out the plans’ flaws].

Plans also do monitoring of their network providers’ availability in a variety of ways, as illustrated by the following examples:

We have a very comprehensive access program, including mapping [our plan’s provider requirements] against state requirements, secret shopper calls for open/closed practice and availability, and close monitoring of any access grievances that come in.
(Plan Representative)

Through our quality department, we do appointment availability audits for routine, emergent, and urgent appointments. We also do after hours audits for availability, to check that they are actually able to get in contact with a provider (in Spanish also).
(Plan Representative)

As for open panels—we monitor quarterly. We’ll address [the problem] if we have areas that have a higher rate of closed panels. We have people checking when panels are opening or closing. This is the same for appointment waiting times; we survey regularly.
(Plan Representative)

This latter comment highlights an issue that was discussed in interviews with both state and plan representatives. The provider network size may appear to be adequate, but the list of providers can include providers that have closed their panels. For example, there may be providers who serve existing Medicaid patients but will not take new patients. Provider access is also reflected in how long it takes an individual to make an appointment, especially a new patient.

We do monitoring of our providers for the next available appointments to ensure there is access, which is why we went out and expanded community-based providers.
(Plan Representative)

We asked both plan and provider representatives about their impressions of the adequacy of the size of provider networks maintained by Medicaid and CHIP MCOs. While the plans generally asserted that the size of their networks is adequate, providers often had a countervailing opinion. Three provider association representatives thought that their state overestimated the number of providers participating in MCO networks.

It’s hard to get to [the number of providers required by the state]…. In [our state] there are laws that require an adequate network so it’s not in the plan’s best interest to reveal that they don’t have enough. (Provider Association Representative)

In another state, a provider representative said that their state often double-counts the total number of participating providers statewide, counting them once for each plan with which they contract.

The size of provider networks has either remained stable or grown according to the plan representatives that we interviewed. Fifteen said that they have expanded their networks, and the same number said the size has remained essentially stable over the study period. The main reason for expansion is either growth in enrollment or the plan’s expansion into new geographic areas of the state. Only two plans said that the size of their networks has declined. (The remaining eight plans did not discuss this issue in the interview.)

There is a trade-off between having a wide network in order to assure access and being selective about which providers are in the network. We did not hear of plans that have regularly eliminated providers from their network based on findings from quality monitoring, such as their HEDIS scores.

We didn’t pare our network down yet. There is an opportunity to be more selective over time. As we monitor care and access, and when we ensure we have appropriate access, then we can talk about the quality of providers. (Plan Representative)

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