Addressing Provider Access Barriers in Communities of Color Access to Care in Medicaid January 23, 2015

Access to Care in Medicaid2 Medicaid Public health program for low- income people Jointly funded and regulated by federal and state governments

Access to Care in Medicaid3 People of Color 59% of Medicaid beneficiaries 37% of U.S. population

Medicaid enrollment by race / ethnicity Access to Care in Medicaid4

5 Access: Medicaid assistance shall be furnished with reasonable promptness to all eligible individuals

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10 Ensuring access to care in Medicaid

Access to Care in Medicaid11 Who regulates access (federal level): Congress CMS Federal courts

Access to Care in Medicaid12 Who regulates access (state level): State legislature State Medicaid agency State Insurance agency* Managed care companies* State courts

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Access to Care in Medicaid14 Medicaid Reimbursement 15 states will extend ACA pay increase for PCPs through 2015 Dental rate increases in 6 states upped participation by 30-50%

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Access to Care in Medicaid16 Essential Community Providers West Virginia requires Medicaid plans to contract with family planning clinics. Ohio Ryan White providers for people with HIV / AIDS to participate in Medicaid.

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Access to Care in Medicaid18 Special Rules for Children’s Services “Early and Periodic Diagnosis, Screening, and Treatment” or EPSDT requirement. In 2014, 3 states expanded services for youth with autism.

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Access to Care in Medicaid20 Physician Extenders 10 states + Puerto Rico cover freestanding birth centers. In 2014 Maine began to cover independent dental hygienists and denturists.

Access to Care in Medicaid21. StateProvider Medicaid Beneficiary

Access to Care in Medicaid22. State Managed Care Organization ProviderMedicaid Beneficiary

Access to Care in Medicaid23 Medicaid Managed Care: 70% of Medicaid beneficiaries 38 states + DC use Medicaid managed care

Access to Care in Medicaid24 Medicaid Managed Care: Access December 2014 OIG Report found that half of listed Medicaid Managed Care providers did not have any appointments available.

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Access to Care in Medicaid26 Provider Participation Virginia requires plans to include pediatric subspecialists in their networks. Wisconsin requires plans to meet specific provider-patient ratios.

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Access to Care in Medicaid28 Geographic Access Pennsylvania plans must provide specialty care within 30 mins (urban) or 60 mins (rural). Michigan plans must make pharmacy available within 30 minutes or 30 miles.

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Access to Care in Medicaid30 Timely Access Minnesota plans must provide preventive care appointments within 45 days. California plans must make mental health appointments available within 10 days.

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Access to Care in Medicaid32 Out-of-network Access Maryland plans must provide out-of-network specialty care to children with special health needs.

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Access to Care in Medicaid34 Disability Access California plans must complete a facility site review for all contracted providers.

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Access to Care in Medicaid36 Linguistic & Cultural Access Virginia plans must provide interpreter services as a separate covered benefit. Illinois plans must ensure that providers complete cultural competency training.

Access to Care in Medicaid37 Addressing access problems: Managed Care company complaint* Medicaid fair hearing State Insurance Agency process* Federal agency complaint Litigation

Questions? Abbi Coursolle Staff Attorney, LA Office National Health Law Program T: (310)

Resources: Medicaid Managed Care: NHeLP’s Medicaid Managed Care Model Provisions on Network Adequacy: issue-3 issue-3 NHeLP’s Recommendations for Advocates on Network Adequacy Provisions in Medicaid Managed Care: OIG Report on State Access Standards for Medicaid Managed Care: pdfhttp://oig.hhs.gov/oei/reports/oei pdf General Network Adequacy: Families USA Report on Network Adequacy and Health Equity: 214_web.pdf 214_web.pdf Families USA Example Standards for Health Insurance Provider Networks: pdf pdf NHeLP Factsheet on Network Adequacy Laws in Covered California Plans: Access to Children’s Services in Medicaid: CMS Guide: Coverage in the Medicaid Benefit for Children and Adolescents: Topics/Benefits/Downloads/EPSDT_Coverage_Guide.pdf Topics/Benefits/Downloads/EPSDT_Coverage_Guide.pdf NHeLP Paper on EPSDT Services for Children with Autism: guidance-on-epsdt-services-for-children-with-asdhttp:// guidance-on-epsdt-services-for-children-with-asd NHeLP Paper on Hearing Services for Children on Medicaid: brief-hearing-services-for-children-on-medicaidhttp:// brief-hearing-services-for-children-on-medicaid Access to Care in Medicaid39

Resources (cont’d): Language Access in Medicaid: CMS Letter on Funds for Language Services in Medicaid: pdf pdf NHeLP Report on Medicaid Reimbursement Mechanisms for Language Services: NHeLP’s Language Servcies Resource Guide: resource-guide-for-health-care-providershttp:// resource-guide-for-health-care-providers Disability Access in Medicaid: NHeLP’s Medicaid Managed Care Model Provisions on Language and Disability Access: NHeLP Q&A on Medicaid Managed Care and Disability Protections: DREDF Legal Position Paper on Medicaid Healthcare Accessibility for People with Disabilities: Access to Reproductive Health Services in Medicaid: NHeLP Q&A on Medicaid Coverage of Reproductive Health Services: NHeLP Paper on Sexuality Education in Health Care Delivery for Medicaid: Kaiser Family Foundation Report on State Medicaid Coverage of Perinatal Services: Access to Care in Medicaid40

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