Medicaid Managed Care Fact Sheets

States must ensure that services are provided with "reasonable promptness" (42 U.S.C. § 1396a(a)(8)).

States must ensure that "care and services...be provided in a manner consistent with the simplicity of administration and the best interests of recipients" (42 U.S.C. §1396a(a)(19)).

States managed care contracts must assure that recipients will have their choice of health professional within the plan to the extent possible and appropriate (42 C.F.R. § 434.29).

States must ensure that payments are "consistent with efficiency, economy, and quality of care, and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area (42 U.S.C. § 1396a(a)(30)(A)).

There Can Be Problems:

People with disabilities cannot get to or easily use health care sites.

Medicaid beneficiaries have problems making timely appointments or have to wait too long in the doctor's office.

Non-English-speaking beneficiaries have had to use young children to translate for them because plans lack bilingual staff and providers.

Medicaid beneficiaries have had to travel long distances to reach doctors offices, hospitals, and pharmacies.

Medicaid beneficiaries have had to wait too long for approval of needed services and have had trouble getting speciality care.

Adolescents don't get care because they are enrolled with their parents doctor.

Consumer Protections Are Needed NOW:

States must specify in guidelines and plan contracts:

timelines for initial health assessments for new enrollees (e.g. within 60 days or, in cases of pregnancy or suspected pregnancy, 15 days)

maximum time and distance standards

patient to provider ratios

waiting times for scheduling appointments

waiting times at the waiting room

24 hour/7 day per week access to qualified health providers for emergency treatment and health advice and appointment scheduling for urgent care

existence of wheelchair ramp access, TTY, and other assistive technologies

language access to administrative staff and providers

ability of adolescents to choose their own health plans or providers separate from their families and to continue to use teen clinics and/or school-based health centers as secondary primary care sites.

States should ensure that these standards are included in Requests for Proposals (RFP's)/Requests for Applications (RFA's), plan contracts, and sub-contracts with providers.

States need to test and monitor access by:

employing "testers" who attempt to obtain assistance and services from plans

audits and reviews

complaint hot lines

monitoring use of services by plan enrollees as safety net provider sites (e.g., community clinics)

inspecting provider sites to ensure disabled persons' access

clear grievance processes that members understand how to use

States must obtain from each contractor proof of financial solvency and adequate protection against insolvency (42 C.F.R. § 434.50).

The Medicaid agency has the right to audit and inspect the books and records of a plan or its subcontractors relating to the plan's capacity to bear financial loss (42 C.F.R. § 434.38).

Plans must assure that Medicaid beneficiaries will not be liable for the plan s debts if it becomes insolvent (42 C.F.R. § 434.20). States must arrange for Medicaid services, without delay, for any beneficiaries whose enrollment is terminated from a managed care plan (42 C.F.R. § 434.59).

State Medicaid or insurance laws may require plans to maintain a certain net worth or minimum deposits.

There Can Be Problems:

Medicaid payments can be used for expensive marketing campaigns and/or luxury items for plan owners. When people use services, the plan cannot cover the care.

Some states do not hold Medicaid-participating HMOs to state insurance requirements.

State Medicaid agencies and departments of insurance do not adequately enforce laws regarding solvency.

Community health clinics can have a difficult time meeting reserve requirements (GAO, 1995).

Consumer Protections Are Needed NOW:

Federal solvency standards should be explicitly applied to Medicaid-participating HMOs in their contracts and subcontracts with providers.

Medicaid HMOs should be required to meet state department of insurance standards.

State Medicaid agencies should enter interagency cooperative agreements with the state departments of insurance to assure the rapid exchange of information and efficient use of staff.

States should develop programs that assure that solvency standards will not preclude community health centers from participating in risk-based Medicaid managed care programs.

States should develop contingency plans to assure that beneficiaries care and access to services will not be adversely affected if their health plan becomes insolvent.