How States Ensure Access and Quality of Care to Medicaid Managed Care Enrollees

Research Objective: To describe the methods that states use to ensure that Medicaid managed care enrollees have adequate access to a primary care provider, and to understand how they currently evaluate the quality of that care.

Study Design: We interviewed state Medicaid and CHIP officials, health plans, and provider groups in 20 states. We also reviewed managed care contracts and collected HEDIS and CAHPS data.

Principal Findings: All states have adopted specific standards regarding primary care provider availability. Most of the 20 states in our study held similar standards regarding appointment wait times, geographic proximity to enrollees, and PCP–to-enrollee ratios. It was common for states to allow health plans to monitor these provider networks and provide information on their compliance directly to the state (13 out of 14 states answering the question said that they obtained regular reports on network availability from their health plans). Only 3 states called provider offices directly to verify availability. States monitored quality of care through grievances, survey data (CAHPS), HEDIS, and encounter data. The extent to which this data was audited and verified varied.

Conclusions: In order for states to better understand the experiences of their Medicaid managed care enrollees, they must take a direct approach to provider network monitoring and create processes to ensure that quality data is robust.