You asked for a summary of the law that governs access to care under the Medicaid program, including the contracts that the Department of Social Services (DSS) maintains in the HUSKY program.

SUMMARY

Federal Medicaid law contains what has been dubbed an “equal access provision,” which requires state Medicaid payments to be both consistent with principles of economy and efficiency as well as ensure that program enrollees have the same access to care that is available to the general public.

Federal regulations address the issue in greater detail in the context of Medicaid managed care contracts. They prescribe how the entities (e.g., managed care organization, MCO) should develop their networks and show how these networks are adequate.

The state's HUSKY law also includes language regarding access. It generally requires each managed care plan (includes MCOs and other health care providers) to include sufficient numbers of appropriately trained and certified pediatric providers and specifies the provider types.

The contracts DSS maintains with MCOs likewise contain provider network adequacy and maximum member enrollment language. This includes provider-to-member ratios and expectations for access to specialists. And they include provisions for sanctions when these requirements are not met.

ACCESS PROVISIONS FOR ALL MEDICAID SERVICE DELIVERY MODELS

The federal law that most directly addresses access, the so-called “equal access provision,” requires states to reimburse health care providers at a rate that is low enough to ensure efficiency and economy yet high enough to attract a sufficient number of providers to ensure enrollees have access to health care services to the same extent they are available to the general public in the same geographic area (42 U.S.C § 1396a(a)(30)(A)). A state's Medicaid plan state must provide such assurances in writing.

Additionally, federal regulations require the state Medicaid agency to arrange for Medicaid services to be provided without delay to any Medicaid enrollee of (1) an MCO, prepaid inpatient health plan (PIHP, see below), prepaid ambulatory health plan (PAHP), or primary care case management (PCCM) whose contract is terminated and (2) who is disenrolled from any of these for reasons other than ineligibility for Medicaid (42 CFR § 438.62).

ACCESS UNDER MANAGED CARE

Federal Law—Managed Care Organizations (MCO) and Prepaid Inpatient Health Plans (PIHP)

Background. DSS' current plan is to provide care to HUSKY and Charter Oak enrollees either through MCOs or a consortia of health care providers. Many HUSKY enrollees have voluntarily signed up for one of the three new plans with which DSS has contracts. But many enrollees are still covered through what DSS is calling a PIHP arrangement. (This was the result of the governor terminating the full-risk contracts DSS maintained with MCOs in November 2007.) Under federal regulations, a PIHP is an entity that (1) provides medical services to Medicaid enrollees under contract with the state agency on the basis of prepaid capitation payments; (2) provides, arranges for, or otherwise has responsibility for providing any inpatient hospital or institutional services for its enrollees; and (3) does not have a comprehensive risk contract (42 CFR § 438.2).

In Connecticut, DSS's PIHP is a limited-risk contract DSS maintains with Anthem to provide several functions (member services, case management, network development, and outreach and education). DSS pays Anthem a nominal per-member, per month fee, and Anthem's providers are reimbursed based on DSS' fee schedule for services (as opposed to the MCO model, in which the MCOs set the reimbursement rates).

Network Development. Federal regulations require states, through their contracts, to ensure that each MCO and PIHP has a contracted provider network that is sufficient to provide access to all services covered under the state's plan. When developing its network, the MCO or PIHP must consider the following:

1. anticipated Medicaid enrollment;

2. expected service utilization based on the Medicaid population's characteristics and health care needs;

3. the number and types of providers needed to provide contracted Medicaid services;

4. the number of network providers not accepting new Medicaid patients; and

5. the geographic location of providers and Medicaid enrollees, considering distance, travel time, transportation, and disability access (42 CFR § 438.206).

Network Requirements. MCOs and PIHPs must deliver ongoing primary care and coordinate health care services for their enrollees (42 CFR § 438.210). They are also required to provide women with direct access to an in-network women's health specialist to provide routine and preventive health care services. This is in addition to the women's designated source of primary care if that provider is not a women's health specialist (42 CFR § 438.206). Enrollees with special health care needs must have direct access to a specialist as appropriate for the individual's health care condition (42 CFR § 438.208). Enrollees must also be able to obtain a second opinion from an in-network provider or to have arrangements made to obtain one from an out-of network provider at no cost (42 CFR § 438.206).

If the MCO or PIHP is unable to provide any contracted services to its enrollees, they must adequately cover those services out of network in a timely fashion, for as long as it is unable to provide them, at no additional cost to the enrollee. The entity is responsible for negotiating payment to out-of-network providers to which the enrollee is referred (42 CFR § 438.206).

States must also ensure their contracts with MCOs and PIHPs comply with certain timely access requirements and ensure their providers comply with these requirements. Providers must meet state standards for timely access to care and services, considering the urgency of the service need. Network providers must offer office hours at least equal to those offered to commercial enrollees or Medicaid fee-for-service participants, if the provider accepts only Medicaid patients. Contracted services must be made available 24 hours per day, seven days per week when medically necessary. Entities must establish mechanisms to ensure and monitor provider compliance and must take corrective action when noncompliance occurs (42 CFR § 438.206).

Finally, MCOs and PIHPs must demonstrate that their providers are credentialed. Contracts must also require these entities to participate in the state's efforts to promote culturally competent service delivery, although it doesn't specifically require the state or the entity to provide culturally competent care (42 CFR § 438.206).

Demonstrating Network Adequacy. Federal law requires each Medicaid MCO to provide the state and the U.S. Department of Health and Human Services secretary adequate assurances that it has sufficient capacity to serve the expected enrollment in its service area (42 U.S.C § 1396u-2(b)(5)). To meet this obligation, states must require MCOs and PIHPs to document in a state-specified format that meets its standards for access to care (42 CFR § 438.207).

Supporting documentation must show that the MCO or PIHP offers an adequate range of preventive, primary, and specialty services care for the anticipated number of enrollees in the service area. The network must contain providers who are sufficient in number, mix, and geographic distribution to meet the anticipated needs of enrollees. The regulations do not specify how to determine the anticipated number and needs of enrollees or who must make that determination (42 CFR § 438.207).

An entity must submit this documentation when it enters into a state contract. It must also submit this documentation any time that a significant change, as defined by the state, occurs in the entity's operations that would affect adequate capacity and services. Significant changes include changes in services, benefits, geographic service area, or payments or the entity's enrollment of a new population (42 CFR § 438.207).

States are required to certify to the Centers for Medicare and Medicaid Services (CMS) that each MCO or PIHP has complied with state standards for service availability and must make all documentation available to CMS upon request (42 CFR § 438.207).

State Law

State law requires each HUSKY managed care plan to include a sufficient number of appropriately trained and certified pediatric care clinicians, including primary, medical subspecialty, and surgical specialty physicians. They must also include sufficient providers of necessary related services such as dental services, mental health services, social work services, developmental evaluation services, occupational and physical therapy services, speech therapy and language services, school-linked clinic services, and other public health services. (Dental and behavioral health services are no longer part of the contracts DSS maintains with managed care organizations. These services are provided under different contracts) (CGS § 17b-296).

Contract Requirements

DSS' contract with the MCOs includes network adequacy and maximum enrollment language. It requires DSS to evaluate the adequacy of an MCO's provider network on a quarterly basis using ratios of enrollees to specific types of providers. These ratios cannot be less than the access ratio based on the Medicaid fee-for-service delivery system for a similar population.

Table 1 illustrates the ratios for the three types of primary care providers.

Table 1: HUSKY MCO Provider: Member Ratios

The contract further provides that once the number of members in a given county equals or exceeds 90% of the established capacity, DSS must evaluate adequacy on a monthly basis.

The contract also permits DSS to establish a maximum enrollment level for members of the MCO on a county-specific basis. It must notify the MCO in writing at least 30 days before the maximum goes into effect. The MCO can subsequently increase the maximum by providing signature pages of newly enrolled providers, and DSS has 30 days to review the request.

Specialists. Additionally, DSS must measure access to specialists by examining and reviewing confirmed complaints received by the MCOs, the enrollment broker (an administrative services organization with which DSS contracts that helps HUSKY clients enroll in a particular MCO), DSS, or the HUSKY hotline. The contract enumerates the steps DSS must take when complaints come in, including referring them to the named MCO. DSS sends a “Complaint Report” to an MCO when it receives a certain number of “confirmed” access complaints from members during a quarter regarding a particular specialty. In determining whether to confirm a complaint, DSS must consider several factors, such as the member's PCP or other referring provider's medical opinion regarding how soon the member needs to see the specialist and the severity of the member's condition. DSS can amend the specialist provisions in the contract, particularly as they relate to the network's adequacy of dermatologists, neurologists, orthopedists, and other specialists.

Sanctions. In addition to sanctions for general noncompliance with the contract, DSS can impose sanctions when it determines that the MCO's provider network is incapable of accepting additional enrollment and lacks adequate access to providers. These include suspending new enrollments. If DSS determines that it has received sufficient confirmed complaints of specialist access problems to initiate a statewide default enrollment freeze, it must advise the MCO of this and its intention to impose the freeze in 30 days unless the MCO submits a satisfactory resolution of the issue in a corrective action plan. The MCO can ask to meet with DSS before it imposes the freeze. A freeze must remain in effect for at least three months. Before DSS can lift the freeze it must determine that the access problem has been resolved.

Geographic Coverage. The contract requires MCOs to serve members statewide. It also requires each MCO to ensure that its provider network includes access for each member to PCPs appropriate for his or her age or obstetric-gynecologic providers. The providers must be available within 15 miles.

The contract states that DSS will randomly monitor geographic access by reviewing the mileage to the nearest town containing a PCP for every town in which the MCO has members. If DSS finds that more than 2% of members reside in towns beyond the 15 miles, DSS can impose a strike towards a Class A sanction. (If a contractor receives three strikes for noncompliance with the contract that does not rise to a more serious level (Class A), DSS can impose a sanction of up to $2,500 for the first three strikes (DSS MCO Contract, § 6.05(a)1).

If an MCO does not have a network provider capable of providing medically necessary contract services to a particular member, the contract requires it to adequately and timely cover the services through an out-of-network provider for as long as medically necessary and the MCO's network providers are unable to provide the services and at no additional cost to the member.

Each month, the MCOs must provide DSS with a list of all network providers (DSS Contract MCO, § 3.09, et. seq.).

ACCESS UNDER FEE-FOR-SERVICE (FFS) MEDICAID

Federal law does not require state Medicaid fee-for-service programs to enroll a certain number of Medicaid providers. As stated earlier, the equal access provision requires a state's Medicaid state plan to ensure that payments are sufficient to enlist enough providers. Federal regulations also require that the plan specify the amount, duration, and scope of each service that it provides for individuals eligible for Medicaid. And they require each service to be sufficient in amount, duration, and scope to reasonably achieve its purpose (42 CFR § 440.230).

The Medicaid provider agreements that DSS maintains with FFS providers likewise do not include minimum enrollment expectations.

Primary Care Case Management. Although care under the PCCM model is provided on a fee-for-service basis, because there is a contract between the state Medicaid agency and the primary care provider “manager,” additional federal regulations governing network adequacy apply. Specifically, they require the contactor to restrict enrollment to recipients who live “sufficiently near” one of the manager's delivery sites to reach the site within a reasonable amount of time. And they require the contractor to provide for arrangements with, or referrals to, sufficient numbers of physicians and other practitioners to ensure that services can be furnished promptly and without compromising the quality of care (42 CFR § 438.6(k)).

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