The 16 states we reviewed often structured their Medicaid and SCHIP  service delivery systems differently. In Medicaid Managed Care, States Focused More on Setting Plan Network Requirements than on Monitoring Plans or Analyzing Service Utilization

In attempting to ensure access to care in Medicaid managed care, states  focused more on setting requirements for managed care plans than on  monitoring compliance with these requirements or on analyzing  beneficiaries’ use of services. State  requirements for plans’ physician networks varied widely in their  specificity, from broad statements that health plans must have “adequate”  physician networks serving their enrolled members to very specific  standards that set, for example, a maximum average number of  beneficiaries per PCP or a maximum time frame for scheduling a first  appointment. Among other things, the regulations require states to ensure that  participating plans    maintain and monitor their networks of providers to provide adequate and  timely access to all services covered under their contracts with the states,  including monitoring the numbers of network providers who are not  accepting new Medicaid patients;    ensure that network providers offer hours of operation that are no less  than the hours offered to commercial enrollees or comparable to those of  Medicaid FFS;    make services included in the contract available 24 hours a day, 7 days a  week, when medically necessary; and    establish mechanisms to ensure compliance by providers with state  standards for access to care. For Medicaid FFS, State Requirements for Providers and Monitoring of Service Utilization Were More Limited

For states’ FFS-based Medicaid delivery systems, which continue to serve  the majority of children in half of the states we reviewed, requirements for  participating providers and monitoring of provider availability were  significantly more limited than for managed care. For traditional FFS  programs, beneficiaries may seek care from any providers participating in  the Medicaid program and may change providers at any time if they are  dissatisfied. Most Traditional FFS Programs Set Few Goals Regarding the Number of Providers, and Conducted Minimal Monitoring of Service Utilization

Despite the potential for low FFS rates to limit the number of providers  willing to participate in the program, the nine states we reviewed with  traditional FFS programs did not set specific goals for the number of  physicians participating in their Medicaid programs and did not actively  monitor the number and location of providers. States also did little to monitor service utilization by Medicaid  beneficiaries participating in traditional FFS care despite having a ready  source of data in their claims payment systems. Three states also included  information related to primary and preventive services use. Although most of these states also had  significant shares of their Medicaid beneficiaries in managed care, they set  significantly fewer provider network requirements for their distinct SCHIP  programs than for Medicaid and did less monitoring of providers enrolled  in their SCHIP programs and of children’s use of services in SCHIP. States with SCHIP Programs Distinct from Medicaid Set Few Provider Requirements

The seven states that chose to serve all or most of their SCHIP  beneficiaries through programs that were distinct from Medicaid used  managed care delivery systems almost exclusively. This held true for their use of encounter data as  well as for HEDIS measures and CAHPS beneficiary satisfaction survey  data. Additionally, HHS provided  technical comments, which we incorporated as appropriate. State Comments

Several states provided clarifying comments regarding their oversight of  access to care in Medicaid and SCHIP. Overall, however,  states with distinct SCHIP programs reported fewer efforts to monitor  children’s access and use of services than in their Medicaid managed care  programs. Medicaid and SCHIP: States’ Enrollment and Payment Policies Can  Affect Children’s Access to Care. Children’s Health Insurance Program: State Implementation Approaches  Are Evolving.
Why GAO Did This Study

Over 25 million children have health insurance coverage through Medicaid or the State Children's Health Insurance Program (SCHIP). Coverage alone, however, does not guarantee that services will be available or that children will receive needed care. GAO was asked to evaluate states' efforts to facilitate and monitor access to primary and preventive services for children in these jointly funded federal-state programs. The study surveyed 16 states, covering over 65 percent of the Medicaid and SCHIP population. GAO analyzed requirements relevant to managed care and fee-for-service (FFS) delivery systems, including the number and location of physicians and their availability to see beneficiaries, monitoring of health plan or physician compliance with these requirements, and collection and analysis of beneficiary service utilization data.

What GAO Found

Overall, states imposed more access-related requirements on participating providers and more actively monitored children's use of services in their Medicaid managed care programs than in their Medicaid FFS or SCHIP programs. Medicaid managed care: State requirements for managed care plans ranged from very broad provisions that health plans must have "adequate" physician networks for serving their enrolled members to very specific standards, such as the number and geographic proximity of physicians and maximum time frames within which a new beneficiary receives a first appointment. States less often verified data that plans submitted to show compliance with these requirements or independently monitored physicians' availability. In one instance of verification, a state found that a third of a health plan's physician network was not accepting new Medicaid patients, thus limiting access for new beneficiaries. The value of plan-submitted data that states used to monitor children's use of services was often compromised by continuing problems with their completeness and reliability. Furthermore, information derived from beneficiary satisfaction surveys was not necessarily representative of all Medicaid managed care beneficiaries. Medicaid FFS: Most states did not set goals for or analyze the availability of participating primary care physicians even though a majority of Medicaid-eligible children in half of the states reviewed are still served in FFS programs. In most FFS programs, beneficiaries may seek care from any providers participating in the Medicaid program and may change providers at any time if they are dissatisfied. However, when FFS payment rates are lower than those paid by other purchasers--which was the case in most states reviewed--providers can be discouraged from participating in Medicaid and thus restrict beneficiaries' access. States did little to monitor the use of services by Medicaid-eligible children in FFS programs despite having a ready source of data in their claims payment systems. SCHIP: Nine of the 16 states used the same providers, administrative systems, and monitoring approaches for their SCHIP programs as they did for Medicaid. The remaining 7 states, whose SCHIP programs were distinct from Medicaid and used managed care almost exclusively, set few requirements for or monitored providers' availability to SCHIP-eligible children. States with distinct SCHIP programs also reported fewer efforts to monitor children's use of services than in their Medicaid programs. Comments on our report from the Department of Health and Human Services highlighted new federal requirements for state oversight of managed care, and design differences between Medicaid and SCHIP that can affect monitoring approaches. States we reviewed provided clarifying or technical comments regarding their oversight of access, which we incorporated in the report as appropriate.