Proposed Managed Care rule threatens struggling families’ access to care

By the CDHP team

Over 46 million children — or 6 in 10 kids nationwide — counted on Medicaid and the Children’s Health Insurance Program (CHIP) for medical and dental coverage in 2017. These programs are an important part of improving children’s oral health, as well as their quality of life. When Medicaid or CHIP coverage is at risk of being undermined, CDHP analyzes change through the bigger context of how children and families will feel their effects. Unfortunately, a new proposed rule on Medicaid managed care arrangements would threaten kids’ access to health services. 

In November, the Centers for Medicare and Medicaid Services (CMS) proposed changes to regulations governing the relationship between state Medicaid/CHIP agencies and Managed Care Organizations (MCOs). MCOs take on responsibility for a person’s comprehensive care needs. In exchange, they receive a monthly, per-patient payment by the state. Most MCOs include coverage of pediatric dental services. CMS asserted that their changes were largely to simplify processes for states and their contractors. While we wholeheartedly support streamlining efforts, these changes may, in fact, harm families covered by these programs. 

One change offered by CMS is to relax guidance regarding provider network adequacy. Today, regulations are in place so individuals covered by Medicaid or CHIP are assured they could reasonably access a medical or dental provider. Specifically, the current rule requires states to develop “time and distance” standards for certain providers, including primary care doctors and pediatric dentists.  States determine their specific time and distance standards, which are laid out in their contracts with MCOs.

These proposals could effectively ignore the obstacles a family may face in finding a medical or dental provider.

CMS now proposes that states be allowed to define which specialists must be considered “accessible,” and that states be free to define accessibility using any quantitative measure they choose. Removing some federal oversight and standard measures, these proposals could effectively ignore the obstacles a family may face in finding a medical or dental provider.

Our concerns on these changes are influenced by two more pieces of context:

1. Children and families covered by Medicaid and CHIP already have a hard time finding oral health providers. A report in 2000 by the Government Accountability Office showed that finding a willing provider was the most commonly cited problem reported by those enrolled in Medicaid and CHIP As the report notes, “Some low-income people live in areas where dental providers are generally in short supply, but many others live in areas where dental care for the rest of the population is readily available.” The situation is improving in some regions of the country, but challenges persist in many communities. While the American Dental Association encourages their members to participate in Medicaid, only 39% of their members do. Access to care is further complicated by how many people enrolled in Medicaid those professionals see.

2. Medicaid patients have very little recourse if they cannot find providers — and their opportunities are being further limited. In the past, states have been responsible for reporting on provider accessibility under the Medicaid Access Rule. The rule also requires states to address any inequities in Access Monitoring Review Plans (AMRPs). But, in March 2018, CMS also proposed changes to the Medicaid Access Rule . Under those changes, almost a dozen states would be exempted from addressing dental care in their AMRPs. If finalized, this new regulation would remove an important, public facing layer of oversight for families confronting challenges getting their children necessary oral health care.

Furthermore, the U.S. Supreme Court has already determined that “the Medicaid Act implicitly precludes private enforcement.” In other words, if someone, whether provider or patient, believed their Medicaid program was not being administered appropriately — including around issues of provider accessibility — they could not bring a lawsuit against it.

On top of all this, the proposed Medicaid Managed Care rule would also change how states and MCOs communicate with people enrolled in Medicaid. Here are some of the proposed revisions that particularly concern CDHP:

  • Current policy requires that if a Medicaid plan determines it will no longer cover a provider, the individuals or families under their care must be informed within 15 days of that decision. In a dramatic shift, CMS seeks to shorten this timeframe, giving families just 30 days notice before their provider is no longer covered. 
  • States currently follow strict guidelines supporting health literacy for people with disabilities and individuals who may not speak English. For example, they must provide printed materials in specific, large font sizes and in a variety of languages. Under the proposed rule, states would be provided with more vague, subjective guidance that key information be “conspicuously visible.”
  • Finally, the new rule would let states forego monthly updates in printed directories of health providers, if they instead make them available on a mobile-enabled website. While it may sound reasonable to shift a database resource online, estimates provided by CMS themselves note that over one-third of low-income households lack access to smartphones and high-speed internet. Discontinuing printed provider directories would impede many families from accessing key information.

Flexibility is important for programs like Medicaid and CHIP. It allows state agencies to respond creatively to the unique needs and concerns of local families and providers. But standards are also critical to treat enrolled children or families fairly, guide state actions, and promote improvement when needed.

Collectively, these changes in communications and to provider network standards would create even more obstacles to care. They would especially be felt by families already struggling to find dental providers who accept Medicaid and CHIP coverage. We will continue to work with CMS, our partners, and others to strengthen and preserve access to medical and dental coverage as a key part of improving the oral health and overall wellbeing of children and families.

Read CDHP's formal comments submitted in January 2019 on the “Medicaid Program; Medicaid and Children's Health Insurance Plan (CHIP) Managed Care”.

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