MACPAC Report Examines Medicaid MCO Contract Protections for CSHCN
The congressionally created Medicaid and CHIP Payment and Access Commission (MACPAC) recently published a special report, "Access to Care for Children with Special Health Care Needs: The Role of Medicaid Managed Care Contracts." The report summarizes research on Medicaid managed care contract provisions relevant to access to care for children and youth with special health care needs (CSHCN) in the 34 states where managed care organizations (MCOs) enroll CSHCN in their standard Medicaid plans. Researchers searched the contracts for 29 pre-selected provisions considered relevant to access to services and providers for CSHCN. The provisions related to: 1) Identification, Screening and Outreach; 2) Care Management; 3) Network Adequacy and Standards; 4) Care Continuity and Relaxing of Authorization Rules; and 5) Expertise, Provider Education, and State Monitoring. Researchers also reviewed the literature and interviewed researchers, advocates, and Medicaid and MCO officials. Among the findings:
- While there is considerable variation in the presence and specificity of access provisions across states, the majority of state MCO contracts do not specifically target CSHCN in most access-related contract provisions; they are more likely to address the general population or all enrollees with special health care needs.
- The requirement that MCOs identify CSHCN is the only CSHCN-specific provision found in the majority of contracts. Identification of CSHCN appears in the majority (22) of state contracts reviewed, reflecting a federal rule that requires identification of all enrollees with special health care needs. For each of the remaining provisions that were the subject of the study, fewer than half of state contracts specifically target CSHCN.
- Care management provisions mostly refer to all individuals with special health care needs (ISHCN) and only infrequently address CSHCN specifically.
- Access-related provisions related to network adequacy and timely access to care typically apply to all enrollees; they do not establish or require different provider geo-access (travel time/distance) standards for CSHCN.
- Continuity of care provisions, expedited authorizations, and standards for timely referrals to out-of-network providers typically do not address CSHCN or ISHCN specifically, but often affect these populations. Most contracts use general language (not specific to children or individuals with special health care needs) in requiring MCOs to extend out-of-network provider relationships during transitions to managed care (21 states), and conduct expedited authorizations (29 states) and/or ensure out-of-network coverage (28 states) under certain circumstances. Provisions allowing new enrollees to continue with an existing provider or an active course of treatment are generally time limited, though some contracts suggest or require that health plans establish single case agreements or invite non-network providers into their networks.
- MCO contracts generally do not require CSHCN-specific access-to-care reporting and monitoring. Many contracts require MCOs to track and/or report data (e.g., grievances, utilization) on CSHCN (6 states) or ISCHN (16 states). However, very few contracts require reporting to the state on network adequacy for CSHCN (3 states) or surveying of families of CSHCN about their satisfaction or access-to-care experiences (3 states). [Emphasis added.]
- States and MCOs can face challenges in operationalizing certain contract requirements and otherwise ensuring access for CSHCN, but many states and MCOs interviewed report implementing strategies for overcoming obstacles. Stakeholders cited shortages of pediatric specialists, difficulty coordinating across multiple programs and providers, and other barriers to maintaining adequate networks and effectively managing children with varied and complex needs.
The researchers recommend further research to evaluate the extent to which managed care contract provisions are fully implemented and monitored, and the impact of CSHCN-specific versus general provisions on the health and welfare of CSHCN and their families.
This study involved contracts based on existing Medicaid managed care rules, but the Centers for Medicare and Medicaid Services (CMS) issued proposed revisions to the rules in June 2015. The proposed rule did not directly address CSHCN, but the final rule - not yet released - could require contract provisions that would help or are specific to CSHCN. Family Voices and a number of other disability and child health groups submitted comments on the proposed Medicaid managed care rule.