Medicaid Managed Care
Access and Quality Requirements Specific to Low-Income and Other Special Needs Enrollees Gao ID: GAO-05-44R December 8, 2004The use of managed care within Medicaid, a joint federal-state program that finances health insurance for certain low-income families with children and individuals who are aged or disabled, increased significantly during the 1990s. By 2003, 59 percent of Medicaid beneficiaries were enrolled in managed care, compared with less than 10 percent in 1991. Medicaid managed care, under which states make prospective payments to managed care plans to provide or arrange for all services for enrollees, attempts to ensure the provision of appropriate health care services in a cost-efficient manner. However, because plans are paid a fixed amount regardless of the number of services they provide, managed care programs require safeguards against the incentive for some plans to underserve enrollees, such as by limiting enrollees' access to care. Access is also affected by other factors, such as physician location and willingness to participate in managed care plans. Safeguards to ensure enrollees have access to care could include requiring plans to maintain provider networks that provide enrollees with sufficient geographic access to providers or requiring managed care plans to develop and monitor certain quality indicators, such as enrollee satisfaction surveys or grievances. The Balanced Budget Act of 1997 (BBA) gave states new authority to require certain Medicaid beneficiaries to enroll in managed care plans and also required the establishment of consumer protections for Medicaid managed care enrollees in areas such as access to and quality of care. In June 2002, the Centers for Medicare & Medicaid Services (CMS) issued final regulations for Medicaid managed care organizations (MCO) to implement these BBA requirements. The BBA directed us to examine the access and quality requirements applicable to MCOs operating under the Medicare program and to private sector MCOs to determine their relevance to the Medicaid MCOs. As discussed with the committees of jurisdiction, we examined the extent to which Medicaid MCO requirements specifically address the needs of enrollees who are low income, have special cultural needs (such as language differences), or have special health care needs (such as chronic illnesses or disabilities) in comparison to similar requirements applicable to Medicare and private sector MCOs.
Medicaid MCO access and quality requirements specifically address the needs of managed care enrollees who are low income or have special cultural or health care needs, to an equal or greater extent than requirements applicable to Medicare and private sector MCOs. Regarding low-income enrollees, neither Medicare nor private sector requirements specifically address their needs as distinct from those of other enrollees. However, we identified one area that is key to access for low-income enrollees--transportation. Medicaid regulations and Medicare guidelines require that when developing their provider networks MCOs take into account the means of transportation--such as public transportation--enrollees use to access health care providers. No such explicit requirement applies to private sector MCOs. Regarding the cultural and language characteristics of enrollees, Medicaid regulations are more specific than Medicare and private accreditation requirements. While all requirements broadly state that services must be delivered in a "culturally competent manner," only the Medicaid regulations require that the primary language spoken by each individual be identified at the time of enrollment and that each managed care enrollee be provided with the names of and non-English languages spoken by contracted health care providers in the enrollee's service area. Additionally, Medicaid regulations require states to make oral interpretation services available and require that each MCO make these services available free of charge to each enrollee and potential enrollee. Regarding enrollees with special health care needs, Medicaid requirements are generally comparable to Medicare and private accreditation requirements. All require that individuals with special health care needs--such as chronic illnesses or disabilities--be identified and provided with appropriate services for managing these conditions.
GAO-05-44R, Medicaid Managed Care: Access and Quality Requirements Specific to Low-Income and Other Special Needs Enrollees
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December 8, 2004:
The Honorable Charles E. Grassley:
Chairman:
The Honorable Max Baucus:
Ranking Minority Member:
Committee on Finance:
United States Senate:
The Honorable Joe Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
Subject: Medicaid Managed Care: Access and Quality Requirements
Specific to Low-Income and Other Special Needs Enrollees:
The use of managed care within Medicaid, a joint federal-state program
that finances health insurance for certain low-income families with
children and individuals who are aged or disabled, increased
significantly during the 1990s. By 2003, 59 percent of Medicaid
beneficiaries were enrolled in managed care, compared with less than 10
percent in 1991.[Footnote 1] Medicaid managed care, under which states
make prospective payments to managed care plans to provide or arrange
for all services for enrollees,[Footnote 2] attempts to ensure the
provision of appropriate health care services in a cost-efficient
manner. However, because plans are paid a fixed amount regardless of
the number of services they provide, managed care programs require
safeguards against the incentive for some plans to underserve
enrollees, such as by limiting enrollees' access to care. Access is
also affected by other factors, such as physician location and
willingness to participate in managed care plans. Safeguards to ensure
enrollees have access to care could include requiring plans to maintain
provider networks that provide enrollees with sufficient geographic
access to providers or requiring managed care plans to develop and
monitor certain quality indicators, such as enrollee satisfaction
surveys or grievances.
The Balanced Budget Act of 1997 (BBA) gave states new authority to
require certain Medicaid beneficiaries to enroll in managed care plans
and also required the establishment of consumer protections for
Medicaid managed care enrollees in areas such as access to and quality
of care.[Footnote 3] In June 2002, the Centers for Medicare & Medicaid
Services[Footnote 4] (CMS) issued final regulations for Medicaid
managed care organizations (MCO) to implement these BBA
requirements.[Footnote 5]
The BBA directed us to examine the access and quality requirements
applicable to MCOs operating under the Medicare program[Footnote 6] and
to private sector MCOs to determine their relevance to the Medicaid
MCOs.[Footnote 7] As discussed with the committees of jurisdiction, we
examined the extent to which Medicaid MCO requirements specifically
address the needs of enrollees who are low income, have special
cultural needs (such as language differences), or have special health
care needs (such as chronic illnesses or disabilities) in comparison to
similar requirements applicable to Medicare and private sector MCOs.
To do this, we identified the requirements contained in CMS regulations
for Medicaid MCOs that specifically address the accessibility or
quality of health care services delivered to low-income and other
special needs enrollees. We considered a requirement to specifically
address these target groups if it referenced that group by name or
otherwise targeted a need or characteristic unique to that group. We
compared these specific requirements with comparable requirements
applicable to MCOs operating under the Medicare program and in the
private sector. Medicare MCO requirements are contained in CMS
regulations and in CMS's supplemental guidance in the Medicare Managed
Care Manual. Private sector MCO requirements and supplemental guidance
are contained in manuals developed by two private accrediting
organizations--the National Committee for Quality Assurance (NCQA) and
the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO). We interviewed officials from CMS, NCQA, and JCAHO to clarify
the requirements applicable to managed care plans and to identify any
that specifically address a special needs enrollee group. We also
interviewed officials from the National Academy for State Health Policy
and reviewed literature on the use of quality assurance and access
requirements in Medicaid managed care. We did not evaluate the
implementation of these requirements by individual states or MCOs. We
performed our work in two periods--from October 2003 through December
2003 and from July 2004 through September 2004--in accordance with
generally accepted government auditing standards.
Results in Brief:
Medicaid MCO access and quality requirements specifically address the
needs of managed care enrollees who are low income or have special
cultural or health care needs, to an equal or greater extent than
requirements applicable to Medicare and private sector MCOs. Regarding
low-income enrollees, neither Medicare nor private sector requirements
specifically address their needs as distinct from those of other
enrollees. However, we identified one area that is key to access for
low-income enrollees--transportation. Medicaid regulations and
Medicare guidelines require that when developing their provider
networks MCOs take into account the means of transportation--such as
public transportation--enrollees use to access health care providers.
No such explicit requirement applies to private sector MCOs. Regarding
the cultural and language characteristics of enrollees, Medicaid
regulations are more specific than Medicare and private accreditation
requirements. While all requirements broadly state that services must
be delivered in a "culturally competent manner," only the Medicaid
regulations require that the primary language spoken by each individual
be identified at the time of enrollment and that each managed care
enrollee be provided with the names of and non-English languages spoken
by contracted health care providers in the enrollee's service area.
Additionally, Medicaid regulations require states to make oral
interpretation services available and require that each MCO make these
services available free of charge to each enrollee and potential
enrollee. Regarding enrollees with special health care needs, Medicaid
requirements are generally comparable to Medicare and private
accreditation requirements. All require that individuals with special
health care needs--such as chronic illnesses or disabilities--be
identified and provided with appropriate services for managing these
conditions.
CMS concurred with our findings.
Background:
Since 1965, Medicaid has financed health care coverage for certain
categories of low-income individuals, covering an estimated 53 million
people in fiscal year 2002.[Footnote 8] States administer the program
within broad federal guidelines and have considerable flexibility in
designing certain aspects of the program, including eligibility,
covered services, and provider payment rates.[Footnote 9] States
generally cover Medicaid services for beneficiaries through two major
financing approaches: traditional fee-for-service (FFS), in which the
Medicaid program directly reimburses providers for care provided to
beneficiaries,[Footnote 10] and capitated managed care, in which the
state prospectively pays MCOs a fixed monthly fee per enrollee to
provide or arrange for most health care services.[Footnote 11]
Medicare is a federal program that primarily provides health care
coverage for adults aged 65 and older.[Footnote 12] Medicare
beneficiaries can choose to receive covered services on an FFS basis or
through a Medicare MCO if one offers a plan in the area where they
live.[Footnote 13] In general, MCOs participating in the Medicare
program receive prospective fixed monthly payments for each enrolled
beneficiary in return for providing all Medicare-covered benefits,
except hospice care, and complying with all program requirements. As of
August 2004, 12 percent of Medicare beneficiaries (4.6 million) were
enrolled in a managed care plan.
Several federal initiatives have been undertaken to promote quality
within Medicaid and Medicare managed care. In 1991, HCFA began the
Quality Assurance Reform Initiative to provide technical assistance to
state Medicaid agencies aimed at improving the quality of their managed
care programs. In 1996, the agency furthered these efforts with the
Quality Improvement System for Managed Care (QISMC) initiative, which
in part served to develop coordinated quality requirements for Medicare
and Medicaid managed care plans and to assist the federal government
and state agencies in effectively providing health care services to
vulnerable populations. QISMC guidelines served as a program manual for
Medicare managed care plans and were used by states at their discretion
within their Medicaid programs.
In 1997, the BBA made significant revisions to Medicaid managed care.
For example, the BBA provided states additional flexibilities in
administering managed care programs, including the authority to require
enrollment of certain beneficiaries in managed care plans without
seeking a waiver of certain statutory requirements.[Footnote 14] The
act also provided additional safeguards for enrollees by requiring the
establishment of new access and quality standards for MCOs. In June
2002, CMS issued final regulations for Medicaid managed care
implementing the requirements of the BBA. The regulations include
provisions to ensure that states consider the needs of low-income and
other special needs populations when establishing specific requirements
for managed care plans.
Private, commercial managed care plans can voluntarily seek the review
of private accrediting organizations, such as NCQA and JCAHO, although
such accreditation is generally not required to operate a health
plan.[Footnote 15] These organizations review plans' adherence to their
internally developed accreditation requirements, including measures of
access and quality, and grant accreditation to plans that comply with
these requirements, serving as a "seal of approval" on the quality of
plan services. Both NCQA and JCAHO regularly update their accreditation
requirements for MCOs as quality measurement techniques develop and
advance. According to JCAHO and NCQA estimates, between one-third to
one-half of managed care plans nationwide have obtained accreditation.
The various requirements for MCOs used by Medicaid, Medicare, and
private sector accrediting organizations generally address similar
aspects of enrollee access to and quality of care, including
availability of services, coordination and continuity of care, quality
or performance assessment and improvement, and enrollee appeals and
grievances. In recognition of the similarities between public and
private requirements, both Medicaid and Medicare allow information from
private accreditation reviews to be used to assess plan compliance with
certain comparable public sector requirements. For example, Medicare
regulations allow Medicare-participating MCOs that have been accredited
by federally approved accreditation organizations to be deemed
compliant with certain Medicare requirements.[Footnote 16] For
Medicaid, states are permitted to use information obtained from a
Medicare or private accreditation review in place of the state's own
review, as long as the Medicare or private accreditation requirements
are comparable to the state's requirements.[Footnote 17] Medicaid
regulations also allow certain managed care plans that have contracts
with both Medicaid and Medicare to use their Medicare review to satisfy
Medicaid external quality review requirements.
Medicaid Access and Quality Requirements Specifically Address the Needs
of Low-Income and Other Special Needs Enrollees to an Equal or Greater
Extent Than Do Medicare and Private Sector Requirements:
Medicaid MCO access and quality requirements address the needs of low-
income and other special needs populations at least as specifically as
do Medicare and private sector requirements. Regarding low-income
enrollees, neither Medicare nor private sector requirements
specifically reference low-income enrollees as distinct from other
enrollees. However, one area that is key to low-income enrollees'
access to care is transportation, and Medicaid and Medicare
requirements explicitly target low-income enrollees' transportation
needs. For enrollees with special cultural needs, Medicaid requirements
are more specific than Medicare and private accreditation requirements.
Medicaid requirements for enrollees with special health care needs are
comparable to Medicare and private accreditation requirements. (Encl. I
presents Medicaid, Medicare, and private accreditation requirements for
MCOs that address the needs of low-income and other special needs
populations.)
Low-Income Enrollees:
While Medicaid by definition serves a primarily low-income population,
its managed care requirements do not specifically reference low-income
enrollees, similar to requirements applicable to Medicare and private
sector MCOs. However, both Medicaid and Medicare requirements state
that MCOs must consider access to transportation, which uniquely
affects low-income enrollees. Specifically, Medicaid regulations
require MCOs to consider the means of transportation ordinarily used by
enrollees when developing their provider networks. Similarly, Medicare
guidance specifies that MCOs must assess the means of transportation
enrollees rely on, such as public transportation, when developing their
provider networks. Private accreditation requirements specify that an
MCO's provider network should accommodate the geographic distribution
of its members, but do not explicitly require MCOs to take into account
possible differences in access based on means of transportation.
Enrollees with Special Cultural Needs:
Medicaid, Medicare, and private accreditation requirements all broadly
state that MCOs must consider the cultural needs and preferences of
enrollees. Medicaid regulations require that states ensure each MCO
promotes the delivery of services in a culturally competent manner and
provides communication materials in all of the prevalent languages
within the MCO's service areas. Medicare regulations similarly state
that each MCO must provide services in a culturally competent manner
and require plans that cover service areas with a significant non-
English-speaking population to provide written membership materials in
the language of these populations. Medicare regulations also require
that MCOs focus on racial and ethnic minorities in their quality
assurance programs. In the private sector, NCQA accreditation
requirements encourage MCOs to take into consideration enrollees'
cultural needs when developing their provider network, and JCAHO
accreditation requirements specify that communication between the
managed care plan and its enrollees should occur in the primary
language of the enrollee whenever possible, either directly or through
translation.
Beyond these broad requirements, Medicaid requirements further specify
actions that must be taken to accommodate enrollees' language or
cultural differences. Medicaid regulations are unique in their
requirement that states' quality strategies include procedures to
identify the race, ethnicity, and primary language of each managed care
enrollee at the time of enrollment and to provide this information to
the MCO. The regulations also require that the state, its contracted
representative, or the MCOs inform enrollees of the non-English
languages spoken by contracted health care providers. Additionally,
under Medicaid regulations, states must make oral interpretation
services available and each MCO must make these services available free
of charge to each enrollee and potential enrollee.
Enrollees with Special Health Care Needs:
Medicaid requirements concerning enrollees with special health care
needs are comparable to Medicare and private accreditation
requirements. In all cases MCOs are required to consider the needs of
enrollees who may require alternative methods of communication, such as
enrollees with visual impairments, and provide communication services
necessary to accommodate these enrollees. Medicaid, Medicare, and
private accreditation requirements also all require MCOs to identify
enrollees with special health care needs and provide appropriate
services for managing these conditions. However, the requirements
differ in how those with special health care needs are defined. As a
result, the populations targeted under each could vary depending on how
the requirements are implemented.
Medicaid regulations specify that states must implement means to
identify to MCOs those enrollees who have "special health care needs,"
as defined by the state. The BBA required the Department of Health and
Human Services (HHS) to conduct a study of special needs
populations,[Footnote 18] and in its report HHS focused on six
populations as having special health care needs: children with special
health care needs, children in foster care, individuals with mental
illness or substance abuse, nonaged adults with disabilities or chronic
conditions, older adults with disabilities, and individuals who are
homeless.[Footnote 19] States may use this report as a guide but have
discretion in how they define special needs. Once enrollees with
special health care needs are identified, Medicaid regulations require
that MCOs conduct an assessment of each special needs enrollee to
identify conditions that require regular treatment and monitoring, and
provide these enrollees with direct access to health care providers who
specialize in that condition.[Footnote 20] States also have the option
under the Medicaid regulations of requiring MCOs to develop treatment
plans for each enrollee identified as having special health care needs.
Medicare regulations require MCOs to screen enrollees for "complex or
serious medical conditions." According to a CMS official, the agency
has not identified the specific conditions considered to be complex or
serious and instead MCOs are responsible for identifying these
conditions. MCOs must then develop and implement a treatment plan for
each enrollee identified as having a complex or serious condition,
providing direct access to appropriate specialists.[Footnote 21]
Private accreditation requirements specify that MCOs must identify
enrollees' health care needs and provide appropriate services for
managing identified conditions. NCQA requirements state that MCOs must
identify enrollees with special needs, focusing on those with chronic
conditions and those with identifiable risk factors for specific health
problems.[Footnote 22] NCQA also has requirements specifically focused
on access to and quality of behavioral (mental) health services. MCOs
must provide appropriate services to address identified conditions.
However, NCQA does not require MCOs to develop individualized treatment
plans or provide direct access to specialists. JCAHO requirements
direct MCOs to ensure that care is planned, individualized, and
appropriate for enrollees' assessed health care needs, but JCAHO
applies this standard broadly rather than requiring a separate focus on
any specific group of enrollees. Under JCAHO requirements, MCOs are
required to ensure proper integration and coordination of services but
have flexibility in determining the best manner for achieving this and
are not explicitly required to provide direct access to specialists.
Agency Comments:
In its written comments on a draft of this report, CMS concurred with
our findings. (See encl. II for a copy of CMS's comments.)
We are sending copies of this report to the Administrator of CMS and
upon request to other interested parties. In addition, this report will
be available at no charge on the GAO Web site at http://www.gao.gov.
The information presented in this report was developed by Randy DiRosa,
Elizabeth T. Morrison, Margaret Smith, and Kara Sokol. Please call me
at (202) 512-7118 if you have any questions concerning this
information.
Signed by:
Kathryn G. Allen:
Director, Health Care--Medicaid and Private Health Insurance Issues:
Enclosures:
Private and Public Managed Care Access and Quality Requirements and
Guidance that Address the Needs of Low-Income and Other Special Needs
Enrollees:
Table 1 presents public and private managed care access and quality
requirements that target the needs of low-income and other special
needs populations. Requirements for Medicaid MCOs are contained in CMS
regulations published in the Code of Federal Regulations.[Footnote 23]
Requirements for Medicare MCOs are similarly contained in published
regulations, as well as in supplemental guidance published by CMS in
the Medicare Managed Care Manual.[Footnote 24] Accreditation
requirements and guidance for private sector MCOs are issued by NCQA
and JCAHO.
Table 1: Public and Private Managed Care Access and Quality
Requirements and Guidance Targeting Low-Income and Other Special Needs
Enrollees:
Medicaid; Low-income enrollees: In establishing and maintaining its
provider network, each MCO, prepaid inpatient health plan (PIHP), and
prepaid ambulatory health plan (PAHP) must consider the expected
utilization of services, taking into consideration the characteristics
and health care needs of specific Medicaid populations represented in
the plan. Each plan must also consider the geographic location of
providers and Medicaid enrollees, considering distance, travel time,
means of transportation ordinarily used by Medicaid enrollees, and
whether provider locations provide physical access for enrollees with
disabilities;
Medicaid; Enrollees with special cultural needs: The state, its
contracted representative, or the managed care plans must provide
enrollees with the names, locations, telephone numbers of, and non-
English languages spoken by current contracted providers in the
enrollees' service areas, including identification of providers that
are not accepting new patients;
Medicaid; Enrollees with special cultural needs: State quality
strategies must include procedures that identify the race, ethnicity,
and primary language spoken of each Medicaid enrollee. States must
provide this information to the MCO or PIHP for each Medicaid enrollee
at the time of enrollment.
Medicaid; Enrollees with special cultural needs: The state must ensure
that each MCO, PIHP, and PAHP participates in the state's efforts to
promote the delivery of services in a culturally competent manner to
all enrollees, including those with limited English proficiency and
diverse cultural and ethnic backgrounds.
Medicaid; Enrollees with special cultural needs: The state, MCOs,
PIHPs, and PAHPs must make available written information in each
prevalent non-English language in their service area.
Medicaid; Enrollees with special cultural needs: The state must make
oral interpretation services available and must require each MCO, PIHP,
and PAHP to make these services available free of charge to each
enrollee and potential enrollee. This requirement applies to all non-
English languages.
Medicaid; Enrollees with special cultural needs: The state must notify
enrollees and potential enrollees and require each MCO, PIHP, and PAHP
to notify its enrollees that oral interpretation is available for any
language and that written information is available in prevalent
languages and how to access these services.
Medicaid; Enrollees with special health care needs: States' quality
strategies must include procedures that assess the quality and
appropriateness of care and services furnished to all enrollees and to
enrollees with special health care needs.
Medicaid; Enrollees with special health care needs: States must
identify enrollees with special health care needs to MCOs, PIHPs, and
PAHPs, as those enrollees are defined by the state. Each plan must
implement mechanisms to assess each special needs enrollee in order to
identify any ongoing special conditions that require treatment or
regular care monitoring. States may require plans to develop treatment
plans for enrollees with special health care needs. Health plans must
have a mechanism to allow identified special needs enrollees direct
access to a specialist, as appropriate for the enrollees' condition.
Medicaid; Enrollees with special health care needs: States must ensure
that each plan has mechanisms to assess quality and appropriateness of
care provided to special needs enrollees.
Medicaid; Enrollees with special health care needs: Written material
must be available in alternative formats and in an appropriate manner
that takes into consideration the special needs of those who, for
example, are visually limited or have limited reading proficiency.
Medicare + Choice; Low-income enrollees: MCOs must maintain and monitor
a network of appropriate providers that is sufficient to provide
adequate access to covered services to meet the needs of the population
served. Supplemental guidance states that MCOs must ensure that
providers are distributed so that no member residing in the service
area must travel an unreasonable distance to obtain covered services
and that MCOs must establish and maintain provider network standards
that assess other means of transportation that members rely on such as
public transportation;
Medicare + Choice; Enrollees with special cultural needs: Each MCO must
ensure that services are provided in a culturally competent manner to
all enrollees, including those with limited English proficiency or
reading skills, and diverse cultural and ethnic backgrounds;
Medicare + Choice; Enrollees with special cultural needs: MCOs' quality
assurance programs must include a separate focus on racial and ethnic
minorities.
Medicare + Choice; Enrollees with special cultural needs: For MCOs that
serve areas with a significant non-English speaking population,
marketing materials--including such things as membership communication
materials and letters to members about changes in providers, premiums,
and benefits--must be provided in the languages of these individuals.
Medicare + Choice; Enrollees with special health care needs: Each MCO
must have procedures that allow it to identify enrollees with complex
or serious medical conditions, assess those conditions and use medical
procedures to diagnose and monitor them on an ongoing basis, and
establish and implement a treatment plan that is appropriate and
includes an adequate number of direct access visits to specialists.
Medicare + Choice; Enrollees with special health care needs: MCOs other
than preferred provider organizations (PPO) must conduct performance
improvement projects; required clinical areas for performance
improvement projects include prevention and care of acute and chronic
conditions, high-volume services, high-risk services, and continuity
and coordination of care.
Medicare + Choice; Enrollees with special health care needs:
Supplemental guidance states that MCOs must ensure that all services,
both clinical and nonclinical, are accessible to all enrollees,
including those with limited reading skills and hearing incapacity.
NCQA; Low-income enrollees: The organization ensures that its network
has sufficient numbers and types of primary care and specialty care
practitioners;
NCQA; Low-income enrollees: The organization has quantifiable and
measurable standards for the number and geographic distribution of
primary care and specialty care practitioners.
NCQA; Low-income enrollees: Enrollees with special cultural needs: The
organization assesses the cultural, ethnic, racial, and linguistic
needs of its members and adjusts the availability of practitioners
within its network, if necessary;
NCQA; Enrollees with special health care needs: The MCO, which
possesses data about the health status of its enrollees and which has a
responsibility for meeting their health needs, actively intervenes to
assist its enrollees and practitioners in managing chronic conditions.
NCQA; Enrollees with special health care needs: The MCO identifies the
two chronic conditions that its disease management programs address.
Annually, the MCO identifies enrollees who qualify for its disease
management programs and provides eligible enrollees with written
program information regarding how to use the services.
NCQA; Enrollees with special health care needs: The MCO identifies
specific enrollees who, according to demographic and other identifiable
health factors, may be at risk for specific health problems and urges
them to use appropriate health promotion and prevention services.
Supplemental guidance provides examples of how MCOs may target their
health promotion and prevention services, including sending mammogram
reminders to all women aged 50 and older and reminders to individuals
with chronic diseases to get influenza and pneumonia immunizations.
NCQA; Enrollees with special health care needs: The MCO has standards
for behavioral health access to (1) care for a non-life-threatening
emergency within 6 hours, (2) urgent care within 48 hours, and (3) an
appointment for a routine office visit within 10 business days.
NCQA; Enrollees with special health care needs: The MCO collaborates
with behavioral health specialists and uses information at its disposal
to coordinate medical and behavioral (mental) health care.
NCQA; Enrollees with special health care needs: Enrollees undergoing
active treatment for a chronic or acute medical condition have access
to their discontinued practitioners (practitioners who are no longer
contracting with the MCO) through the current period of active
treatment or for up to 90 calendar days, whichever is shorter.
NCQA; Enrollees with special health care needs: The organization
provides translation services within its enrollee services telephone
function based on the linguistic needs of enrollee. Supplemental
guidance states that this may include installing TDD/TYY lines.
JCAHO; Low-income enrollees: Member health care services provided
throughout the network are readily available, accessible, and
appropriate to the scope and levels of care required by the member
population;
JCAHO; Low-income enrollees: The network accommodates the geographic
distribution of its members.
JCAHO; Enrollees with special cultural needs: The managed care network
communicates with members. Supplemental guidance states that verbal and
written communication should occur in the primary language of the
member whenever possible, either directly or through translation;
JCAHO; Enrollees with special cultural needs: Health care services
provided are appropriate to the heath care needs, as influenced by
sociocultural characteristics, of the population served. Supplemental
guidance states that sociocultural characteristics may include age,
gender, years of schooling, marital status, ethnicity, nationality,
sexual orientation, linguistic group, and religious affiliation.
JCAHO; Enrollees with special cultural needs: Education provided [to
enrollees] supports active member participation in health care and
decision making about health care options and their consequences.
Supplemental guidance states that this provision is intended to include
consideration of variables such as members' beliefs, values, literacy,
and language.
JCAHO; Enrollees with special health care needs: Health care services
are appropriate in scope to meet the health care needs of the
population served.
JCAHO; Enrollees with special health care needs: The network's
preventive services are appropriate to the needs of the community or
population served. Supplemental guidance states that MCOs should assess
the population served and use this assessment to determine the
prevalence of important risk factors, chronic conditions, communicable
and environmentally induced health problems, and diseases.
JCAHO; Enrollees with special health care needs: The network determines
and provides the appropriate health care disciplines and specialists to
meet enrollee health care needs.
JCAHO; Enrollees with special health care needs: The network ensures
that assessments appropriate to the enrollees' health care needs are
conducted, and that assessment scope and intensity are appropriate to
the enrollees' health care needs.
JCAHO; Enrollees with special health care needs: The network has a
process to ensure that care is planned, individualized, and evaluated.
JCAHO; Enrollees with special health care needs: Enrollees are informed
of specific health care needs that require follow-up.
JCAHO; Enrollees with special health care needs: The network
communicates with enrollees. Supplemental guidance states this includes
addressing the needs of enrollees with hearing, speech, and visual
impairments.
Sources: CMS, NCQA, and JCAHO.
[End of table]
Comments from the Centers for Medicare & Medicaid Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Centers for Medicare & Medicaid Service;
Administrator:
Washington, DC 20201:
DEC 3 2004:
TO: Kathryn G. Allen:
Director, Health Care -Medicaid And Private Health Issues:
FROM: Mark B. McClellan. M.D., Ph.D., Administrator:
SUBJECT: Government Accountability Office Draft Report: "Medicaid
Managed Care. Access and Quality Requirements Specific to Low Income
and Other Special Needs Fnrollees (GAO-04-1052R):
Thank you for the opportunity to review and comment on the draft report
entitled "Medicaid Managed Care: Access and Quality Requirements
Specific to Low Income and Other-Special Needs Enrollees (GAO-04-
1052R).
The Centers for Medicare & Medicaid Services (CMS) concurs with GAO's
findings that Medicaid access and quality requirements specifically
address the needs of low income and other special needs enrollees to an
equal or greater extent than other programs. It is important to note
that the Medicaid regulations accomplish this while giving each State
the flexibility to determine how to comply in ways that best meet the
needs and circumstances within the State.
The report does not contain any recommendations nor does it reference
the Medicaid payment rules which are based on the development of
actuarially sound rates in risk contracts. States account for the
potentially higher costs of individuals with special health care needs
in setting appropriate capitation rates for managed care entities.
Again, thank you for the opportunity to review this draft report.
[End of section]
(290330):
FOOTNOTES
[1] Managed care enrollment figures for 2003 include individuals
enrolled in plans that provide both comprehensive benefits, such as
managed care organizations (MCO), and limited benefits, such as prepaid
ambulatory health plans (PAHP).
[2] Throughout this report we use the term enrollees to refer to all
Medicaid beneficiaries, Medicare beneficiaries, and privately insured
individuals who are enrolled in managed care plans.
[3] Pub. L. No. 105-33, § 4701, 111 Stat. 251, 489; § 4705(a), 111
Stat. at 498.
[4] CMS was previously known as the Health Care Financing
Administration (HCFA). We use the term HCFA to refer to the agency
prior to its renaming on July 1, 2001, and CMS for references to the
agency after that date.
[5] 67 Fed. Reg. 40989 (June 14, 2002).
[6] Medicare is the federal program that finances health coverage for
individuals aged 65 and older, certain disabled individuals, and
individuals with end-stage renal disease (ESRD). Medicare managed care
plans are offered by private managed care organizations under contract
with the Medicare program to provide care to Medicare beneficiaries.
[7] BBA, § 4705(c), 111 Stat. at 500.
[8] Categories of individuals eligible for Medicaid include pregnant
women and children with family incomes below specific limits and
individuals with limited income and assets who are age 65 or older or
disabled.
[9] The federal share of Medicaid funding varies by state and is based
on a state's per capita income in relation to the national per capita
income. By statute, the federal share of Medicaid expenditures across
individual states may range from 50 to 83 percent.
[10] We define FFS systems to include traditional FFS, in which a
provider bills the program for services provided to an eligible
beneficiary, as well as primary care case management (PCCM) systems, in
which a physician, physician group practice, or similar entity
contracts with the state to locate, coordinate, and monitor primary
health services for Medicaid beneficiaries for a nominal monthly, per
capita case management fee (usually around $3). Within PCCM, delivered
services are typically reimbursed on an FFS basis.
[11] States generally rely on two major types of managed care plans to
provide health care services to their Medicaid beneficiaries: MCOs,
which provide beneficiaries with a comprehensive range of services; and
prepaid health plans, which include prepaid inpatient health plans and
prepaid ambulatory health plans and provide a more limited array of
services. Prepaid inpatient health plans are limited service plans that
provide some coverage of a beneficiary's inpatient hospital or
institutional care, such as a mental health plan; prepaid ambulatory
health plans are plans that provide limited services, such as a dental
plan, and do not cover any inpatient services.
[12] Certain individuals under 65 who are disabled or have ESRD are
also eligible for the Medicare program. These beneficiaries represented
about 15 percent of Medicare's 40 million beneficiaries in 2002.
[13] Information presented in this report reflects the Medicare +
Choice regulations. The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) created the Medicare Advantage program,
which will replace Medicare + Choice as the managed care program for
Medicare See Pub. L. No. 108-173, § 201, 117 Stat. 2066, 2176. Final
regulations for the Medicare Advantage program had not been issued as
of December 6, 2004.
[14] Prior to BBA, states were required to obtain a federal waiver of
certain statutory requirements, such as guaranteeing beneficiaries'
freedom to choose among participating providers, before they could make
managed care enrollment mandatory for Medicaid beneficiaries. BBA gave
states the authority to make managed care enrollment mandatory for most
beneficiaries more routinely through an amendment to their state
Medicaid plan, but still requires states to seek waivers for mandatory
managed care programs that enroll beneficiaries eligible for both
Medicare and Medicaid (dual eligibles), Indians who are members of
federally recognized tribes, and children with special needs.
[15] Certain purchasers of health coverage may require an MCO to be
accredited. For example, according to NCQA, many states require health
plans that serve state employees to earn accreditation.
[16] Accreditation can be used by a Medicare-participating MCO to
receive deemed status in the following six categories: access to
services; advance directives; antidiscrimination; confidentiality and
accuracy of enrollee records; provider participation; and quality
assurance. CMS continues to review the nondeemed areas such as
grievance and appeals, beneficiary enrollment, and marketing.
[17] According to NCQA, 30 states recognize NCQA accreditation as
sufficient to demonstrate health plan compliance with certain
regulatory requirements.
[18] BBA, § 4705(c)(2), 111 Stat. at 500.
[19] Department of Health and Human Services, Safeguards for
Individuals with Special Health Care Needs Enrolled in Medicaid Managed
Care (Washington, D.C.: Nov. 6, 2000).
[20] The term direct access describes an arrangement in which a managed
care enrollee is not required to obtain a referral from a primary care
physician or some other authorization prior to seeing a specialist.
[21] In August 2004, CMS issued a proposed rule to implement the
Medicare Advantage program as established by MMA (See 69 Fed. Reg.
46866 (Aug. 3, 2004)). The proposed rule would eliminate the
requirement that Medicare managed care plans identify individuals with
complex or serious conditions and instead would generally require each
plan to have a chronic care improvement program that identifies and
monitors those with "multiple or sufficiently severe chronic
conditions." Additionally, the proposed rule would establish optional
Medicare Advantage plans for special needs individuals that would limit
enrollment to dual eligibles (Medicare beneficiaries who are also
entitled to Medicaid), enrollees who are institutionalized (such as
enrollees who reside in nursing homes), and enrollees who have a severe
and disabling condition and meet requirements specified by CMS.
[22] NCQA considers chronic conditions to include diseases or
conditions that are usually of slow progress and long continuance (for
example, hypertension, asthma, and diabetes) and which require ongoing
care.
[23] 42 C.F.R. Part 438 (2003). CMS's State Medicaid Manual is being
revised to include guidance for implementing requirements of the
Medicaid managed care regulations.
[24] 42 C.F.R. Part 422 (2003); CMS's Medicare Managed Care Manual,
www.cms.hhs.gov/manuals/116_mmc/mc86toc.asp; downloaded on August 5,
2004. MMA replaced Medicare + Choice with the Medicare Advantage
program. Final regulations establishing requirements for managed care
plans under the Medicare Advantage program have not been issued. CMS's
Medicare Managed Care Manual will be updated to include Medicare
Advantage requirements once the final regulations are issued.
