Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans

Managed care organizations (MCOs) cover nearly two-thirds of all Medicaid beneficiaries nationwide,¹ making managed care the nation’s dominant delivery system for Medicaid enrollees. As the entities responsible for providing comprehensive Medicaid benefits to enrollees by contracting with providers, plans play a critical role in shaping access to care for Medicaid enrollees. Many plan actions are dictated by state policy or contracting requirements; however, plans also have some flexibility to design payment and delivery systems and structure enrollees’ experiences using their coverage. To understand how Medicaid managed care plans approach access to care and the challenges they face in ensuring such access, the Kaiser Family Foundation conducted a survey of plans in 2017. Highlights from the full survey report are below:

KFF conducted a national survey of #Medicaid managed care organizations to understand how plans approach access to care. #Managedcare is the dominant delivery system for Medicaid beneficiaries, with #MCOs covering nearly two-thirds of enrollees.

Most plans surveyed are focused on serving the Medicaid population, serve a broad range of enrollee groups, and provide a range of services. Most (70%) plans responding to the survey have been participating in the Medicaid program for 10 or more years, a plurality (45%) are private non-profit, and the vast majority (73%) do not operate statewide.² Medicaid enrollees comprise at least 75% of total health plan enrollment for nearly two-thirds of plans surveyed (64%). Among plans enrolling Medicaid expansion adults, only 38% also offer an Affordable Care Act (ACA) marketplace product. Most plans include prescription drugs (93%), non-emergency medical transportation (NEMT, 77%), dental services³ (66%), or long-term services and supports (LTSS, 63%) in their contract with the state; however, plans are likely to subcontract these services for at least some of their enrollees.

Plans reported challenges in recruiting specialists but pointed to provider supply shortages rather than low participation rates as a challenge to network adequacy. The most common activities that plans reported for monitoring network capacity were member/provider complaints or call center reports, feedback from regular member survey data such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS), and monitoring out-of-network visits. Plans are more likely to cite market-wide provider supply shortages in certain specialties or certain geographic areas than low provider participation in Medicaid as a top challenge in ensuring access to care. A majority of plans said that they either already use or plan to use enhanced payment rates for hard-to-recruit provider types, and about a third of plans reported using or planning to use enhanced payment rates for providers in rural or frontier areas. More than two-thirds (68%) of plans reported using telemedicine in at least one clinical area.

Plans are making efforts to engage high-risk members in their care, and nearly all plans surveyed also undertake activities to promote healthy behaviors or address social determinants of health. Most plans reported actively conducting health assessments or data analytics to engage members, particularly high-need members, in care. Almost all plans reported offering incentives for “healthy behaviors,” with the most common incentives for well-child care, prenatal visits, and postpartum care. Almost all plans (91%) reported activities to address social determinants of health, with housing, nutrition/food security, and education reported as top targets. Reflecting state and federal eligibility rules, plans reported relatively short enrollment duration for pregnant women, and plans in states that have adopted 12-month continuous eligibility for children reported longer enrollment duration among children.

Nearly all responding plans have adopted at least one “alternative payment system” for quality, cost, or access outcomes, and survey respondents also are using a range of activities to coordinate and integrate care. Almost all plans (93%) still make fee-for-service (FFS) payments to at least some providers. Ninety-eight percent of plans reported using at least one alternative payment model (APM) for at least some providers. The vast majority of plans (93%) use incentives and/or bonus payments tied to performance measures. Fewer plans reported using bundled or episode-based payments (38%) or shared savings and risk arrangements (44%). Twenty-eight percent of plans reported contracting with an ACO. Physical and behavioral health integration ranks as the top priority for plans in ensuring access to care for members.

Plans reported concern about the potential access consequences of efforts to restructure Medicaid financing or implement new Medicaid waiver provisions. Likely reflecting long plan duration in the Medicaid market and focus on serving the Medicaid population, only a small share of responding plans indicated that they are likely to rethink their Medicaid participation if the ACA expansion is repealed or they are faced with limits on capitation rates. However, plans did report concern about the implications of current policy debates for member access. Plans were almost universally negative when responding to an open-ended question about federal Medicaid financing reform proposals (block grants or per capita caps). Responses described a multitude of anticipated beneficiary impacts, such as decreased enrollment, decreased or reduced benefits, and provider rate cuts that may lead to reduced provider participation/access. Some plans also specifically indicated that a block grant or per capita cap may put them at risk financially, lead to negative margins, or compromise the actuarial soundness of capitation rates. When asked to choose what, if any, potential impact various waiver provisions being considered or proposed by states would have on plans or enrollees, a majority of plans indicated that such provisions would have an effect on enrollee access to care or continuity of coverage. A majority of plans reported needing at least some additional guidance to implement many of the 2016 Medicaid managed care final rule provisions. However, nearly three-quarters of plans reported that the change in Administration has not caused them to put a hold on activities to implement provisions of the Medicaid managed care rule.

Looking Ahead: Managed care plans are on the front lines of efforts to facilitate access to care for Medicaid enrollees. In this role, plans both work directly with providers and enrollees and undertake efforts to facilitate connections between providers and enrollees. While many of these activities stem from contract provisions between states and plans, others are plan-initiated. Some of the goals of enrolling Medicaid beneficiaries in managed care plans are to promote coordinated care, help emphasize preventive care, and facilitate efforts to adopt “whole-person” delivery models that aim to address patients’ physical, mental, and social needs; however, policy changes under discussion that disrupt enrollment continuity or duration may inhibit plans’ ability to implement or realize these goals. While MCOs in this survey have long experience serving Medicaid enrollees, they face an uncertain future as they navigate how to move forward with new initiatives in the context of potential budget cuts, waivers, and changes to federal regulations.