Last November, the Centers for Medicare & Medicaid Services (CMS) proposed changes to its Medicaid Managed Care Rule. As I explained at the time, these proposals can be seen as part of a broader effort by the agency to weaken access protections for children, parents, and other Medicaid beneficiaries, not just in managed care, but also in fee-for-service. Because of the importance of managed care to children and parents enrolled in Medicaid—nationally, the large majority are enrolled in managed care organizations (MCOs) that are responsible for ensuring that they receive the services they need—Georgetown University’s Center for Children and Families (CCF) filed comments on the proposed changes.
The CCF comments focused primarily on the proposed dilution of the measure of MCO provider network adequacy. Since Medicaid MCOs rarely pay for services furnished to their enrollees by providers that do not participate in their provider networks, the key to access for MCO enrollees is whether an MCO’s provider network has enough providers participating who will actually treat the MCO’s enrollees so that those enrollees can get the services they need. In May 2016, after a thorough development process and public comment period, CMS issued a Managed Care Rule that required, at a minimum, that states establish time and distance standards for measuring MCO network adequacy (for example, how much travel time to the nearest participating primary care physician). Each state had the flexibility to determine its own time and distance minimum requirements for each provider group (e.g. primary care physicians, specialist, hospitals, etc.)
– Georgetown University Health Policy Institute