How States Can Improve Access to Care for Children Under the Medicaid Managed Care Rule

Next month, states face new federal requirements for establishing and maintaining Medicaid managed care provider networks. As they work to comply with these new rules, states have an opportunity to strengthen access to care for children and youth with special health care needs (CYSHCN).

Medicaid and beautiful childrequirements, which address how enrollees access care and the scope of provider networks, are scheduled to go into effect July 1, 2018. The network adequacy provisions of the rule, in particular, may have implications for how CYSHCN can access care.

As outlined in a recently published NASHP analysis, the rule requires states to develop and implement network adequacy standards in their Medicaid managed care programs, including time and distance standards, for certain types of providers:

  • Pediatric dental
  • Pediatric primary care
  • Pediatric behavioral health, including mental health and substance use disorder services
  • Pediatric specialist
  • OB/GYN
  • Adult primary care
  • Adult specialist
  • Adult behavioral health, including mental health and substance use disorder services
  • Hospital
  • Pharmacy
  • Long-term services and supports that require the enrollee to travel to the provider

In requiring network adequacy standards – yet avoiding dictating the specific time and distance standards themselves — the rule recognizes that states differ in their geographic conditions and provider capacity. It thereby gives states flexibility to establish standards in a way that fits their unique needs.

Many CYSHCN, especially those with complex needs, typically use multiple specialty providers and home- and community-based providers. By including these provider types in network adequacy standards, states can help ensure access to pediatric and specialty services for CYSHCN.

NASHP recently analyzed how states provide managed care services to CYSHCN enrolled in Medicaid. Several states have implemented network adequacy policies in their Medicaid managed care programs. Of the six states NASHP studied, all of the states include time and distance standards for generalist, specialist, and behavioral health care providers. These standards varied for urban, rural, and frontier areas in geographically diverse states. For example:

  • Colorado’s Accountable Care Collaborative Phase II program specifies that enrollees must have access to primary care providers (PCPs) within 30 miles or 30 minutes in urban areas, 45 miles or 45 minutes in rural areas, and 60 miles or 60 minutes in frontier areas.
  • Texas requires MCOs to establish networks in its STAR Kids program so that enrollees have access to two age-appropriate PCPs within 30 miles (or 20 miles in more densely-populated areas). Texas also requires that managed care organizations (MCOs) contract with telehealth providers to ensure access to specialty care in rural areas.
  • In Virginia’s CCC Plus program, MCOs must offer enrollees a choice of at least two providers of each provider service type located within 60 minutes of their residences, and a choice of at least two specialists within a 30-mile radius in urban areas and no more than a 60-mile radius in rural areas.

In addition to network adequacy requirements, state Medicaid agencies and MCOs use other strategies to ensure that CYSHCN have access to specialty providers. One approach is an analysis of fee-for-service claims data to identify the providers that enrollees have used in the past. The state then makes efforts to enroll those providers who have a history with these children in MCO networks. This strategy is employed by MCOs in Ohio and by the Texas Medicaid agency, which has used the method to help ensure that “significant traditional providers” are included in its MCO networks. Virginia’s Medicaid agency works with the state’s 13 hospital health systems to ensure that they contract with at least three of the participating Medicaid MCOs in the hospital system’s geographic area.

As states work to comply with the network adequacy requirements spelled out in the managed care final rule, they have an opportunity to strengthen access to care among all of their CYSHCN.

For more information about how states are organizing their Medicaid managed care programs to ensure access to care for CYSHCN, visit NASHP’s recent analysis of six state programs.