Department of Health and Human Services 

OFFICE OF 

 
  INSPECTOR GENERAL 

 
 
 
 
 
 
S S
TATE  TANDARDS FOR 

 
 
A C
CCESS TO  ARE IN 

 
 
M M C
EDICAID  ANAGED  ARE 

 
Suzanne Murrin 
 
Deputy Inspector General  

for Evaluation and Inspections
  
 
September 2014 

OEI-02-11-00320 
  
EXECUTIVE SUMMARY:  STATE STANDARDS FOR ACCESS TO CARE IN 
MEDICAID MANAGED CARE 
OEI-02-11-00320 
 
WHY WE DID THIS STUDY 
 
Examining access to care takes on heightened importance as enrollment grows in Medicaid 
managed care programs.  Under the Patient Protection and Affordable Care Act, States can opt to 
expand Medicaid eligibility, and even States that have not expanded eligibility have seen 
increases in enrollment.  Most States provide some of their Medicaid servicesif not all of 
themthrough managed care.  The Office of Inspector General received a congressional request 
to evaluate the adequacy of access to care for enrollees in Medicaid managed care.  This report 
describes the standards that States establish for access to care in their Medicaid managed care 
programs and how States determine compliance with these standards.  A companion report 
determines the extent to which providers offer appointments to enrollees and the timeliness of 
these appointments.  
 
HOW WE DID THIS STUDY  
 
We surveyed State Medicaid agency officials in the 33 States with comprehensive, full risk 
Medicaid managed care and collected documentation from each State on its standards for access 
to care.  We also conducted structured interviews with external quality review organizations and 
the Centers for Medicare & Medicaid Services (CMS). 
 
WHAT WE FOUND 
 
State standards for access to care vary widely.  For example, standards range from  
requiring 1 primary care provider for every 100 enrollees to 1 primary care provider for 
every 2,500 enrollees. Additionally, standards are often not specific to certain types of providers 
or to areas of the State.  States have different strategies to assess compliance with access 
standards, but they do not commonly use what are called direct tests, such as making calls to 
providers. Further, most States did not identify any violations of their access standards over a 
5-year period. The States that found the most violations were those that conducted direct tests of 
compliance.  Among the States that identified violations, most relied on corrective action plans 
to address the violations; six imposed sanctions.  Finally, our review found that CMS provides 
limited oversight of State access standards.  
 
WHAT WE RECOMMEND 
 
We recommend that CMS (1) strengthen its oversight of State standards and ensure that States 
develop standards for key providers, (2) strengthen its oversight of States methods to assess plan 
compliance and ensure that States conduct direct tests of access standards, (3) improve States 
efforts to identify and address violations of access standards, and (4) provide technical assistance 
and share effective practices. CMS concurred with all four of our recommendations. 
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................8 

State standards for access to care vary widely and are often              

not specific to certain types of providers or areas of the State ........8 

States have different strategies to assess compliance with       

access standards, but do not commonly use direct tests ................13 

Most States did not identify any violations of access          

standards over a 5-year period; States that found the most 

violations conducted direct tests of compliance ............................15 

Most States that identified violations relied on corrective          
action plans to address them; six States imposed sanctions ..........17 

CMS provides limited oversight of State standards for              

access to care..................................................................................17 

Conclusion and Recommendations ............................................................19 

Agency Comments and OIG Response..........................................21 

Appendices.................................................................................................22 

Appendix A:  State Access Standards:  Maximum                   

Distance or  Time an Enrollee Should Have To  Travel To
   
See a Provider ................................................................................22 

Appendix B: State Access Standards:  Maximum                    

Number of Days an Enrollee Should Have To  Wait for                   
an Appointment  ..............................................................................24 

Appendix C: State Access Standards:  Number of              

Enrollees per Provider ...................................................................26 

Appendix D: Agency Comments  .................................................28 

Acknowledgments......................................................................................30 

 
   
   
OBJECTIVES 
1. 	  To describe State standards for access to care in Medicaid managed 
care.  
2.	   To assess the methods that States use to determine compliance with 
their access standards.  
3. 	  To determine the extent to which States identify and address violations 
of their access standards.  
4. 	  To assess the Centers for Medicare & Medicaid Services (CMS) 
oversight of States access standards.   
BACKGROUND 
Medicaid is a jointly funded Federal and State health insurance program  
that finances the delivery of medical services to more than 69 million 
people.1  In fiscal year (FY) 2013, the Federal Government and the States 
together spent almost $460 billion for the program.2  Each State designs 
and administers its own Medicaid program within broad Federal 
guidelines. Most States provide some, if not all, Medicaid services 
through managed care, which covers nearly three-quarters of all Medicaid 
enrollees.3  
Examining access to care takes on heightened importance as enrollment 
grows in Medicaid managed care programs.  Under the Patient Protection 
and Affordable Care Act, States have the option to expand eligibility for 
their Medicaid programs.4  In addition, many States that have not 
____________________________________________________________ 
1 Congressional Budget Office, The Budget and Economic Outlook:  2014 to 2024. 
Accessed at http://www.cbo.gov/publication/45010  on August 26, 2014.  
2 The Medicaid and CHIP Payment and Access Commission (MACPAC), Report to the 
Congress on Medicaid and CHIP, March 2014.  Accessed at 
http://www.macpac.gov/reports/2014-03-14_Macpac_Report.pdf?attredirects=0&d=1 on  
August 26, 2014. 
3 Centers for Medicare & Medicaid Services (CMS), Medicaid Managed Care 
Enrollment Report: Summary  Statistics as of  July 1, 2011. Accessed at 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-
Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf on  April 1, 2014.  
4  P.L.  No. 111-148  2001 (Mar. 23, 2010),  as  amended by  the Health  Care  and 
Education Reconciliation Act  of 2010, P.L. No. 111-152  (Mar. 30, 2010), collectively 
referred to as the ACA.   
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   1 
   
   
expanded eligibility have also seen increases in enrollment.5   As a result, 
Medicaid is expected to provide coverage for as many as 18 million more 
people by 2018.6   
The Office of Inspector General (OIG) received a congressional request to 
evaluate the adequacy of access to care for enrollees in Medicaid managed 
care. This report describes the access standards States establish for their 
Medicaid managed care programs and how States determine compliance 
with these standards.  A companion report determines the extent to which 
providers offer appointments to enrollees and the timeliness of these 
appointments.7  
Medicaid Managed Care 
States have the option to provide either all or some portion of their 
Medicaid services through Medicaid managed care.8   The goal of managed 
care is to decrease Medicaid costs while providing high-quality care to 
enrollees. Additionally, managed care is intended to reduce the States 
financial risk and allow for more predictable Medicaid costs.  
States have different types of managed care arrangements, but the most 
common is full-risk managed care.9  Under this arrangement, managed 
care organizations (MCOs) assume the full financial risk for delivering a  
comprehensive set of services.  These services generally include all 
primary, specialty, and acute medical care.  States pay MCOs a fixed 
monthly fee per enrollee (often referred to as capitation) and the MCO 
____________________________________________________________ 
5 
 MACPAC, Report to the Congress on Medicaid  and CHIP, March 2014.  Accessed  at: 
http://www.macpac.gov/reports/2014-03-14_Macpac_Report.pdf?attredirects=0&d=1  on  
September 8,  2014, and Kaiser Family Foundation,  Medicaid Enrollment: June 2013 
Data Snapshot. Accessed at http://kff.org/report-section/medicaid-enrollment-june-2013-
data-snapshot-appendix-a-table-a-1-total-medicaid-enrollment-by-state/ on September 8,  
2014.  
6 Congressional Budget  Office, The Budget and Economic Outlook: 2014 to  2024. 
Accessed at http://www.cbo.gov/sites/default/files/cbofiles/attachments/45010-
Outlook2014_Feb.pdf on  August 26, 2014. 
7 OIG,  Access to Care:  Provider Availability in Medicaid  Managed Care  
(OEI-02-13-00670), forthcoming.  
8 States may provide Medicaid services through managed care under their  State plans for  
medical assistance in accordance with Social  Security  Act  1932(a) or  under waivers to  
their State plans in accordance with Social Security Act  1115, 1915(a), and 1915(b).   
9
 Another arrangement is primary care case management, which pays providers a nominal  
fee for providing case management services to enrollees assigned to them.  States may 
also contract with MCOs to  provide a limited set of services under managed care, such as  
dental services.   
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   2 
   
   
delivers services through a network of participating providers.10  MCOs 
maintain listingstypically in the form of a provider directoryof all 
participating providers in their networks who provide care to enrollees.  
This report focuses solely on MCOs providing full-risk managed care for a 
comprehensive set of services.  
Federal Regulations Governing Medicaid Managed Care 
Access Standards  
Federal regulations require States to have a written strategy for assessing 
and improving the quality of health care services offered by all MCOs.11   
That strategy must include standards  for access to care that all MCOs must 
meet.  These standards are intended to ensure that each MCO maintains 
a network of providers that is sufficient to provide adequate access to 
Medicaid services covered under the contract between the State and the 
MCO.12   When establishing and maintaining its provider network, each 
MCO must consider (1) the anticipated Medicaid enrollment, (2) the 
expected utilization of services, (3) the numbers and types of providers 
needed, (4) the numbers of network providers who are not accepting new 
Medicaid patients, and (5) the geographic locations of providers and 
Medicaid enrollees.  Regulations also require that each MCO provide 
timely access to care and services.13    
Additionally, regulations require State contracts to ensure that if the MCO 
is unable to provide necessary services to a particular enrollee with 
providers in the managed care network, the MCO must cover these 
services using out-of-network providers at no additional cost to the 
enrollee.14   
External Quality Reviews 
Federal regulations also require States to ensure that external quality 
reviews are conducted annually to evaluate the quality of, timeliness of, 
and access to care furnished by MCOs to enrollees.15  States may conduct 
these reviews themselves or contract with qualified independent entities, 
____________________________________________________________ 
10 42 CFR   438.2.  The MCO is responsible for paying for services delivered to enrollees 

by participating  providers.  In assuming the full financial risk, the MCO must cover the 

cost  of services delivered to enrollees, even if the cost exceeds the amount of capitation 

payment from the State. 
 
11  42 CFR  438.202(a).  

12 42 CFR   438.206(b)(1)  

13 42 CFR   438.206(b)(1)(i)-(v).  The regulations that we outline in this paragraph  of  our 

report are intended to ensure both the adequacy of MCO networks and timely access to 

care.  State standards for access to care ensure that MCOs comply with both of these 

regulatory requirements. 
 
14 42 CFR    206(b)(4).
  
15 42 CFR  438.310370.  

State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   3 
   
   
called external quality review organizations (EQROs).  Among the 
requirements for these reviews is that the State or EQRO must determine 
at least once every 3 years whether each MCO is complying with the 
States access standards.  In addition, the State or EQRO may conduct up 
to five optional activities, such as conducting focused studies on specific 
aspects of quality.   
After completing each review, the State or EQRO must produce a detailed 
technical report with conclusions about the quality of, timeliness of, and 
access to care that the MCO furnishes.  It must also produce an assessment 
of the MCOs strengths and weaknesses related to quality, timeliness, and 
access to care, as well as recommendations for improving the quality of 
care that the MCO furnishes. Finally, it must also assess how effectively 
the MCO has addressed any recommendations made during the previous 
years review. 
Violations 
States must have a plan for monitoring MCO compliance and identifying 
violations of access standards.16  If a State findsthrough onsite visits, 
reviews of complaints, or any other sourcethat an MCO is in violation 
of any regulation, including regulations related to access to care, the State 
may impose sanctions.  These sanctions include imposing monetary 
penalties, appointing temporary management for the MCO, granting 
enrollees the right to terminate their enrollment without cause, suspending 
new enrollment, and suspending payment for enrollment.  States also have 
the authority to impose additional sanctions under State statutes or 
regulations.  
CMS Oversight 
According to Federal regulations, CMS must review and approve all 
contracts that States enter into with MCOs, including contract provisions 
that incorporate standards for access to care.17  In addition, each State 
must submit to CMS its quality strategy, which includes these standards, 
and must certify that its MCOs have complied with its requirements for 
availability of services.18  Further, each State must submit to CMS regular 
reports describing the implementation and effectiveness of its quality 
strategy.19  
 ____________________________________________________________ 
16 42 CFR   438.700726.  

17 42 CFR   438.6(a).  
 
18 42 CFR    438.202 and 438.207(d). 
 
19  42 CFR  438.202(e)(2).  

State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   4 
   
   
Related Work 
In a 2008 report, OIG found that most States use the results of external 
quality reviews and require MCOs to make improvements to their 
standards, processes, and performance on the basis of these reviews.20   
However, more than half of States cited concerns about the external 
quality review process and the quality of reports produced by this process.  
Specifically, States were concerned that external quality review reports 
were missing required elements and information on mandatory activities.  
OIG recommended that CMS provide additional technical assistance and 
written guidance to States and that it work with States to ensure that the 
reports include complete information.  CMS agreed with the 
recommendations and stated that it had implemented both of them. 
METHODOLOGY 
We based this study on data from four sources:  (1) a survey of State 
Medicaid agency officials, (2) documentation and data from States that 
contract with Medicaid MCOs, (3) structured interviews with officials 
 
from EQROs, and (4) structured interviews with CMS officials.  
Scope 
We contacted all States to identify those that contract with Medicaid 
MCOs. We focused solely on MCOs providing full-risk managed care for 
a comprehensive set of services.  We did not include other managed care 
arrangements, such as partial-risk plans, as these models typically offer a 
limited range of services under managed care.21   We identified 33 States 
with 227 MCOs that were active from January 1, 2012, through January 1, 
2013.22  Further, we did not include in this study plans that served only 
specific populations, such as foster children, enrollees with long-term care  
needs, or enrollees who are eligible for both Medicaid and Medicare.  
Additionally, we focused our analysis on access standards for primary care 
providers and specialists. 
____________________________________________________________ 
20 OIG,  External Quality Reviews in Medicaid Managed Care (OEI-01-06-00510), 
June 2008.  
21  We excluded  partial-risk managed care models, such as primary care case management 
programs, prepaid inpatient  health plans, and prepaid ambulatory  health  plans, as these 
programs do not provide a full range of services under managed care.  In addition,  we 
excluded comprehensive Programs for All-Inclusive Care for the Elderly, as these 
programs provide services to  both Medicaid and Medicare  enrollees.  Finally, we 
included Health Insuring Organizations, which are county-level  MCOs  in California.  
22 A given MCO may have more than one managed care plan.  For the purposes of this  
report, we use the term plans to refer both to MCOs and to their plans.  We also refer to  
the District of Columbia as a State. 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   5 
   
   
Survey of State Medicaid Officials 
We surveyed State Medicaid agency officials in the 33 States. Our 
questions focused on each States standards for access to care as of 
January 1, 2013, as well as how each State determines compliance with its 
standards.  In addition, we asked how often each State had identified plans 
that were not meeting State standards during a 5-year period (i.e., 
January 1, 2008, through January 1, 2013) and what actions, if any, the 
State took against those plans.  We conducted this survey electronically in 
April and May 2013.  
State Documentation and Data   
We requested documentation and supporting data from the 33 States.  
Specifically, we asked each State for documentation of (1) its standards for 
access to care as of January 1, 2013; (2) the methods that it uses to assess 
plan compliance with standards; (3) any violations of standards that it 
identified over a 5-year period (January 1, 2008, through January 1, 2013); 
and (4) any actions that it took in response to these violations.  
Structured Interviews with EQROs  
In February 2014, we conducted structured interviews with officials from  
the three largest EQROs.  In 2013, these three organizations contracted 
with 20 of the 33 States in this study to conduct all or part of their external 
quality reviews.23  Our questions focused on how these organizations 
conduct external quality reviews and the methods they used to determine 
whether plans comply with State access standards. 
Structured Interviews with CMS Officials  
Throughout the course of the study, we conducted structured interviews 
with CMS officials responsible for Medicaid managed care.  These 
interviews focused on CMSs role in  developing State access standards, in  
monitoring compliance with standards, and in identifying and responding 
to violations of standards. We also asked about CMSs oversight of the 
external quality reviews. 
Analysis  
To determine each States standards for access to care, we analyzed the 
survey responses and supporting documentation submitted by States.  We  
focused our analysis on standards for access to primary care providers and 
specialists. Our analysis did not include standards for access to other 
____________________________________________________________ 
23 CMS Center for Medicaid and Childrens Health Insurance Program Services, Findings  
from  External  Quality Review Technical Reports.  Accessed at 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-
Care/External-Quality-Review-Technical-Reports.html on  August 25, 2014. 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   6 
   
   
types of providers, such as behavioral health providers, dentists, hospitals, 
and pharmacies. 
Next, we identified the various methods that States use to assess 
compliance with their access standards, either through their plans, through 
their EQROs, or on their own. Additionally, we determined the number of 
States that identified violations of their access standards over a 5-year 
period and analyzed each States responses to these violations.  As we did 
in our analysis of the access standards, we included only violations related 
to primary care providers and specialists; we did not include violations of  
standards for other types of providers.  We also did not include violations 
that were unrelated to access, such as those involving billing issues.  For 
each State that identified violations, we analyzed survey responses and 
State documentation to determine the  action taken to address violations. 
Finally, to assess CMSs oversight of State standards, we analyzed CMS 
officials responses to interview questions.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   7 
   
   
FINDINGS 
State standards for access to care vary widely and are 
often not specific to certain types of providers or areas 
of the State 
Medicaid regulations require that States establish access standards to 
ensure that each plans provider network is adequate and meets the needs 
of its enrollees. However, States have considerable latitude in the 
standards they establish for their plans.   
The three most common types of access standards are (1) standards that 
limit the distance or amount of time enrollees should have to travel to see 
a provider; (2) standards that require appointments to be provided within a 
certain timeframe; and (3) standards that require a minimum number of 
providers in relation to the number of enrollees.   
Of the 33 States with risk-based managed care plans, 32 established 
standards regarding provider distance or time, 31 established standards 
regarding appointment availability, and 20 established standards regarding 
provider-to-enrollee ratios. All but one State has at least two of these 
types of standards. In addition, 22 States established other types of 
standards.  
State standards vary widely and are often not specific to providers who are 
important to the Medicaid population, such as pediatricians, obstetricians 
and high-demand specialists.  In addition, these standards often apply to 
all areas within a State and do not take into account differences between 
urban and rural areas. Without standards for specific provider types or 
areas, States may not be able to hold plans accountable for ensuring 
adequate access to care. 
Thirty-two States limit the distance or time enrollees should 
have to travel to see a provider 
Thirty-two States have standards that establish a maximum distance or 
time enrollees should have to travel to see a provider.  These standards are 
intended to ensure that enrollees can access care with a network provider 
within a reasonable distance from their residence.  
All of these 32 States have standards that apply to primary care providers. 
These standards vary from State to State.  Standards for the maximum 
distance to a primary care provider range from 5 miles (as specified by 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   8 
   
   
2 States) to 60 miles (as specified by 3 States).24  The standards for 
maximum travel time to see a primary care provider range from a low of 
30 minutes to a high of 60 minutes. 
Fourteen of the thirty-two States do not have distance or time standards 
that apply to specialists.  In the remaining 18 States, standards for 
specialists range from 15 miles in 1 State to as many as 100 miles in 
2 States. 
Additionally, 17 of the 32 States do not have standards that distinguish 
between urban and rural areas. In the remaining 15 States, the standards 
for rural areas are often two times greater than those for urban areas.  (See 
Table 1.) For example, Hawaii requires that enrollees be able to find a 
provider within 30 minutes in urban areas and within 60 minutes in rural 
areas. See Appendix A for a description of States standards regarding 
distance and travel time. 
Table 1: Standards for Distance and Travel Time Among the States That 
Distinguish Between Urban and Rural Areas, 2013  
Shortest    Longest   
  Distance/Time  Distance/Time 
Among States   Among States  
Distance to  Urban Areas   6 Miles  30 Miles 
Primary Care 
Provider  Rural Areas   15 Miles  60 Miles 
Travel Time to  Urban Areas  30 Minutes  30 Minutes 
Primary Care 
Provider  Rural Areas   30 Minutes  60 Minutes 
Source: OIG analysis of State data, 2014. 
 
Thirty-one States require that appointments be provided within 
a certain timeframe 
Thirty-one States have standards that specify the maximum number of 
days an enrollee should have to wait for an appointment.  These standards 
are intended to ensure that enrollees receive care with a network provider 
within a reasonable timeframe. 
All of these 31 States have standards for primary care providers.  
However, these standards vary widely. As shown in Table 2, the 
standards for the maximum wait time for a routine-care appointment with 
a primary care provider range from a low of 10 days to a high of 45 days.  
All but 2 of these 31 States also have standards for urgent-care 
____________________________________________________________ 
24 Eleven  of the thirty-two States have standards that require at least two  providers within  
the specified distance or travel time.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   9 
   
   
appointments; these standards range from 1 to 2 days for an appointment 
with a primary care provider. 
Of the 31 States with appointment standards, 10 States do not specify the 
maximum number of days an enrollee should have to wait for a routine 
appointment with a specialist.  In the remaining 21 States, the standards 
for maximum wait time for a routine appointment with a specialist range 
from 10 days to 60 days.  See Appendix B for a description of States 
standards for wait times for appointments. 
Table 2: Standards for Wait Times for Appointments, 2013  
Shortest Wait Times  Longest Wait Times 
  Among States   Among States  
Routine 
10 Days   45 Days  
Primary Care  Appointments 
Providers  Urgent 
1 Day  2 Days  
Appointments 
Routine 
10 Days   60 Days  
Appointments 
Specialists  
Urgent 
1 Day  4 Days  
Appointments 
Source: OIG analysis of State data, 2014.  
 
In addition, 15 States established specific standards for prenatal 
appointments.  For example, Nebraska requires that an initial prenatal 
appointment be provided within 14 days if the enrollee is in her first 
trimester, 7 days for the second trimester, and 3 days for a high-risk 
pregnancy. 
Twenty States require a minimum number of providers based 
on the number of enrollees 
Twenty States have established standards that require a minimum number 
of providers in a plans network in relation to the number of enrollees.  
These standards seek to ensure that plans provider networks are sufficient 
in size to serve their enrollees.  
All of these 20 States have standards for minimum numbers of primary 
care providers; however, as shown in Chart 1, these standards vary 
considerablyfrom 1 primary care provider for every 100 enrollees to 
1 for every 2,500 enrollees. 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   10 
   
   
Chart 1:  Standards for Number of Enrollees per Primary  Care Provider, 
by Number of States, 2013   
9 States 
7 States 
s
e
t
a
t
S
  f
o
  r
e
b 4 States 
m
u
N
 
1599  6001999  2000 or  more 
Number  of Enrollees per Primary  Care  Provider 
   
Source: OIG analysis of State data, 2014. 
 
Eight of these twenty States have different standards for minimum  
numbers of physician and nonphysician primary care providers.  For 
example, New York requires 1 primary care physician per 1,500 enrollees 
and 1 certified nurse practitioner per 1,000 enrollees.  In addition, five 
States have standards for specific types of primary care providers, such as 
obstetricians and pediatricians.  For example, Illinois has standards for 
obstetricians (1 obstetrician per 300 pregnant enrollees) and womens 
health providers (1 womens health provider per 2,000 female enrollees).  
Massachusetts has a standard for pediatricians (1 pediatrician per 
200 child enrollees). 
Only 4 of the 20 States require plans to have a minimum number of 
specialists in relation to their number of enrollees.  Two of these States 
have standards that apply to all specialistsNevada requires 1 specialist 
for every 1,500 enrollees, and Colorado requires 1 specialist for every 
2,000 enrollees. The remaining two States have standards for more than 
15 different types of specialists. For example, Wisconsins standards for 
minimum numbers of specialists range from 1 cardiologist per 
1,000 enrollees to 1 urologist per 3,000 enrollees.  Tennessees standards 
for minimum numbers of specialists range from 1 orthopedic surgeon per 
15,000 enrollees to 1 allergist/immunologist per 100,000 enrollees.  See 
Appendix C for a description of States standards for provider-to-enrollee 
ratios.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   11 
   
   
Twenty-two States have other standards for access to care 
In addition to having the three most common types of standards, 22 States 
also have other types of standards for access to care.  These standards vary 
and commonly include the following: 
 	  In-office wait time:  Eleven States have standards that limit the 
amount of time that an enrollee may wait in a providers office 
before being seen by a provider. For example, New Jersey 
specifies that an enrollee must be seen by a primary care provider 
within 45 minutes of the scheduled appointment time.  To 
minimize in-office wait time, two States have standards that limit 
the number of appointments a primary care provider can schedule 
in an hour. For example, Illinois allows no more than six 
scheduled appointments per hour for each primary care provider.   
 	  Access to multilingual care: Six States have standards that require 
plans to provide enrollees with access to interpreter services or 
multilingual providers. For example, the District of Columbia  
requires its plans to provide non-English-speaking enrollees with 
access to free interpreters during appointments.   
 	  Twenty-four-hour telephone access to providers: Six States have 
standards that require enrollees to have telephone access to 
providers 24 hours a day, 7 days a week.  For example, Indiana 
requires that enrollees have 24-hour access to either their primary 
care provider or the providers clinical staff through a tollfree 
telephone number. 
 	  Access-related performance measures:  Although a number of 
States provide incentive payments based on a plans success in 
meeting key performance measures related to access, one State 
Ohiohas incorporated these performance measures into its 
access standards.25  For example, the State requires that 83 percent 
of enrollees 1 to 19 years old have had a primary care visit within 
the previous year. 
____________________________________________________________ 
25 These measures are based on nationally recognized performance measures found in the  
Healthcare  Effectiveness Data  and Information Set  (HEDIS), which  was developed by  
the National Committee for Quality Assurance.  HEDIS measures allow for assessment 
and comparison of health plans across many dimensions of care and service, including 
access. Many States use HEDIS measures to  assess plan performance but  do not include  
them as part of their State standards for access.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   12 
   
   
States have different strategies to assess compliance 
with access standards, but do not commonly use 
direct tests  
All States have developed strategies for how they assess plan compliance 
with access standards.  These strategies include reviews of reports from  
plans and external quality reviews. In some cases, States conduct their 
own tests of plan compliance.   
While States use different strategies, they do not often use direct tests.  
Direct tests seek to reliably measure whether plans comply with access 
standards.  These tests can also determine the accuracy of information 
maintained by plans.  Such tests are important because States have 
established standards that rely heavily on provider information from plans 
and this information is often inaccurate or out of date.26  Direct tests 
commonly include telephone calls to providers that either assess 
compliance with a specific standard, such as wait times for appointments, 
or assess the accuracy of provider information, such as whether a provider 
is participating in a plan. 
All States rely on reports from managed care plans, but these 
reports vary widely 
All States rely on managed care plans to help assess whether plans comply 
with State access standards. However, States differ widely in what they 
require their plans to report. Such reports range from an annual 
self-attestation that a plan is complying with standards to direct tests of  
plan compliance.   
For example, several States rely on reports from plans that include 
numbers of network providers, but there was no evidence that the plan had 
validated the accuracy of those numbers.  In some cases, these reports do  
not even include the network providers names or contact information.  In 
contrast, other States require their plans to conduct direct tests, including 
making calls to their own network providers. 
States also use external quality reviews, but these reviews 
often do not include direct tests of compliance 
Federal regulations require States with Medicaid managed care programs 
to provide for an external, independent review of their plans. These 
reviews must determine plan compliance with access standards at least 
once every 3 years. Most States contract with an EQRO to conduct all or 
____________________________________________________________ 
26 OIG,  Access to Care: Provider Availability in Medicaid Managed Care  
(OEI-02-13-00670), forthcoming.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   13 
   
   
part of these reviews. In these contracts, States specify the methods 
EQROs should use to determine plan compliance.  
The methods that EQROs commonly use to assess plan compliance 
include reviewing plan policies and procedures and conducting onsite 
interviews of plan personnel. In addition, EQROs are often contracted by 
States to evaluate results from enrollee satisfaction surveys and to evaluate 
plans performance on key health care measures, like how many children 
receive immunizations on a timely basis.27  One EQRO official noted that 
these methods can provide a sense of how a plan performs with regard to 
access but do not directly measure compliance with access standards.  
EQROs also use information from planssuch as provider network 
liststo assess compliance, but officials cited variation in the quality of 
such information as a concern.  
EQROs less commonly use direct tests to determine plan compliance.  
EQRO officials explained that States  often do not contract with them for 
such tests because they can be resource intensive. Officials noted, 
however, that such tests are particularly effective for assessing  
compliance.  One State, for example, contracts with its EQRO to conduct 
data validation surveys to determine the accuracy of the provider data that 
each plan maintains.   
Eight States report conducting their own direct tests of plan 
compliance 
Only eight States report conducting their own direct tests to assess 
whether plans comply with access standards.  For example, several States  
conduct secret shopper calls during which the caller pretends to be a 
patient. These calls are used to confirm specific information about 
providers, such as whether they are accepting new patients or how far in 
advance they can schedule appointments.  States also report contacting 
providers to verify plan information.  For example, one State conducts 
provider surveys to ensure that providers are listed correctly in the 
directory and are participating in the plan.  
In addition to assessing compliance with the access standards, calls to 
providers can also help States identify other barriers to access.  One State 
Medicaid official noted that there were barriers to access that would never 
have been discovered without conducting secret-shopper calls.  For 
____________________________________________________________ 
27 Enrollee satisfaction is commonly measured through a national survey instrument, the 
Consumer Assessment of Healthcare Providers and Systems (CAHPS).  Key health care 
measures are commonly collected through HEDIS.  Although CAHPS and  HEDIS are 
both standardized tools, the information collected through the two can vary across States 
or plans.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   14 
   
   
example, some providers request and review enrollees medical records 
prior to making appointments. 
Most States did not identify any violations of access 
standards over a 5-year period; States that found the 
most violations conducted direct tests of compliance 
Only 11 of the 33 States with risk-based managed care plans identified at 
least one violation of their access standards between January 1, 2008, and 
January 1, 2013.28  See Table 3 below. The remaining States found no 
violations. When States fail to identify violations of their access 
standards, they are unable to correct problems and improve access to care 
for enrollees. 
Table 3: Number of Violations of Access Standards, 2008 to 2013*  
Number of   Percentage of  All 
State   Violations Reported  Violations Reported  
for 20082013   for 20082013  
Ohio  76  32%  
New York   63  27%  
Georgia  41  18%  
California  14  6%  
Florida  11  5%  
Texas  8  3%  
West Virginia   7  3% 
District of Columbia  5  2%  
Maryland  5  2%  
Massachusetts  2  1%  
Washington  2  1% 
     Total   234  100%  
*Includes violations related to primary care providers and specialists. 
Source: OIG analysis of State data, 2014.  
 
When violations were found, they most commonly involved problems 
with meeting standards for distance and time, for appointment availability, 
and for provider-to-enrollee ratios. Many of these violations also involved 
plans that had inaccurate provider information, such as wrong addresses or 
incorrect provider participation data. The accuracy of provider 
information is important because State standards rely heavily on this 
____________________________________________________________ 
28 
 This analysis includes violations related to primary care providers and specialists.  It 
does not include violations related to  other types of providers, such as behavioral health  
providers, dentists, hospitals, and pharmacists.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   15 
   
   
information.  For example, to assess compliance with a States distance 
standard, a plan may submit information to the State about where its 
network providers are located in relation to its enrollees. If this provider 
information is inaccurate (e.g., because some providers are not at the 
reported addresses or do not participate in the plan), then States may fail to 
identify violations and correct problems regarding access to care.   
 
Examples of Violations and Their Effects on Enrollees 
  Access to Care  
 
  One State found that in one of its plans, there were no  
participating urologists within 75 miles of an enrollee and that the 
 
plan did not provide appropriate referrals or an explanation of how 
the enrollee could receive care. 
 
 
Another State found that for one of its plans, appointments for 
 
enrollees could not be made with 45 percent of the primary care 
  providers listed as participating in a specific region.   
 
  Another State found significant deficiencies in the number of 
 
specialists participating in 1 of its plans, identifying 30 counties in 
 
  which enrollees lacked access to certain types of specialists.   
 
 
 
Source:  OIG analysis of State data, 2014. 
 
Just three StatesOhio, New York, and Georgiaidentified more than 
three-quarters of all violations. In these three States, the State or its 
EQRO conducted direct tests of plan compliance, including making calls 
to providers. For example, Ohio contracted with its EQRO for the EQRO 
to call providers to validate plan provider information.  In addition, the 
State made calls to each plans enrollee-services department to assess 
whether plans were providing timely assistance to enrollees.   
Similarly, New York contracted with its EQRO to conduct secret-shopper 
calls to providers to measure their access and availability as well as the 
accuracy of their information in provider directories.  New York used the  
results from these surveys to determine the percentage of each plans 
providers that were actually participating in the plan and accepting new 
enrollees. The State then cited each plan that had a provider-participation 
rate below 75 percent with a violation. 
In Georgia, the State identified violations during quarterly secret-shopper 
calls to providers to determine appointment wait times and confirm the 
accuracy of information included in plan reports and directories.   
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   16 
   
   
Most States that identified violations relied on 
corrective action plans to address them; six States 
imposed sanctions 
The 11 States that identified violations most commonly relied on 
corrective action plans (CAPs) to address them.  States either issue CAPs 
to plans or approve CAPs developed by plans.  These CAPs, which are 
used for both new and repeat violations of standards, outline the steps 
necessary to make plans compliant.  To ensure that plans implement 
CAPs, States use (1) requirements in their contracts with plans, 
(2) conference calls with plan staff, and (3) site visits to plan offices.  
Some States contract with their EQROs to monitor completion of CAPs.   
Six of the eleven States that identified violations reported imposing 
sanctions in response to violationsin some cases, in addition to CAPs.  
These sanctions include issuing monetary penalties and blocking new 
enrollees from signing up with plans.  For example, after identifying one 
plan that failed to resolve access deficiencies, one State blocked new 
enrollment to that plan and transferred its existing enrollees to other plans 
in the State.  
CMS provides limited oversight of State standards for 
access to care 
Federal regulations require CMS to review and approve all State contracts 
with MCOs, including provisions that incorporate access standards.  CMS 
uses a checklist to confirm that States have access standards, but officials 
reported that they do not assess whether these standards are adequate to 
ensure access to care.  CMS officials further explained that setting the 
standards is primarily a State responsibility, but given how much these 
standards vary, there would be some utility in having more uniformity 
among State standards.  One EQRO official also recommended that 
increased uniformity among State standards could improve access.  
Another EQRO official said that CMS could require States to have 
standards for certain types of providers, such as pediatricians, 
obstetricians, or high-demand specialists.  This would enable States to 
maintain flexibility in setting their standards, but would help ensure access 
to key provider types that are essential to serving the Medicaid population.   
CMS officials also reported that they generally do not assess the adequacy 
of States methods for monitoring compliance with standards.  However, 
CMS does play a role in the oversight of external quality reviews.  For 
example, CMS has developed the protocols that States and EQROs use to 
conduct the reviews. These protocols do not require States or EQROs to 
use direct tests to assess plan compliance.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   17 
   
   
Lastly, CMS officials reported that until recently, they have not kept track 
of violations identified by States or EQROs, nor have they monitored State 
responses to such violations. Officials reported that in 2013 they began 
tracking violations identified in the technical reports that were prepared as 
part of the external quality reviews, and that they are in the process of 
hiring a contractor to evaluate the external quality review process and 
make recommendations for improvement.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   18 
   
   
CONCLUSION AND RECOMMENDATIONS 
Access to health care services for enrollees in Medicaid managed care is 
essential. Without adequate access, enrollees would not receive the 
preventative care and treatment necessary to achieve positive health 
outcomes and improved quality of life.  To ensure that Medicaid managed 
care enrollees have adequate access, States must have standards for access  
to care. They must also determine whether managed care plans comply 
with these standards. 
Our review found that State access standards vary widely.  For example, 
standards range from requiring 1 primary care provider for 
every 100 enrollees to 1 primary care provider for every 2,500 enrollees.  
Additionally, they are often not specific to certain types of providers or 
areas of the State. Without standards for specific providers or areas, States 
may not be able to hold plans accountable for ensuring adequate access to 
care. In addition, States have different strategies to assess compliance 
with standards, but do not commonly use direct tests, such as calls to 
providers. Further, most States did not identify any violations of their 
access standards over a 5-year period; States that found the most 
violations conducted direct tests. When States fail to identify violations of 
their access standards, they do not correct problems and improve access to 
care for enrollees.  Among the States that identified violations, most relied 
on CAPs to address the violations; six imposed sanctions.  Finally, our 
review found that CMS provides limited oversight of State standards for 
access to care. 
These findings show that CMS and States need to do more to ensure that 
all States have adequate access standards and strategies for assessing 
compliance.  This will help to ensure that enrollees in Medicaid managed 
care have access to the services they need.  With Medicaid expanding and 
enrollment expected to reach as many as 87 million people by 2018, 
ensuring adequate access to care is increasingly important.   
We recommend that CMS: 
Strengthen its oversight of State standards and ensure that 
States develop standards for key providers 
CMS should strengthen its oversight of State standards and work with 
States to ensure that they have adequate standards in place to meet the 
needs of their Medicaid managed care populations.   
As a part of this effort, CMS should issue guidance to strengthen State 
standards. In addition, CMS should require States to develop standards 
for a core set of providers that are important to the Medicaid managed care 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   19 
   
   
population, including primary care providers, pediatricians, obstetricians 
and other high-demand specialists.  It should also work with States to 
ensure that standards are specific to urban and rural areas when 
appropriate. 
Strengthen its oversight of States methods to assess plan 
compliance and ensure that States conduct direct tests of 
access standards  
CMS should strengthen its oversight of States methods to assess plan 
compliance with access standards.  CMS should work with States to 
ensure that these methods accurately determine plan compliance.   
As part of this effort, CMS should require that States or their EQROs 
conduct direct tests of their access standards.  These tests could include 
calls to providers or other methods to determine compliance with 
standards or to validate the plan data used to determine compliance.  CMS 
should revise its protocols for external quality reviews to instruct States or 
EQROs to conduct these tests.   
Improve States efforts to identify and address violations of 
access standards 
Given how few States identified violations of access standards over a 
5-year period, CMS should work with States to improve how States 
identify and address violations of access standards.  Additionally, CMS 
should use the information it has started to collect to track violations and 
ensure that States are addressing them appropriately.   
Provide technical assistance and share effective practices 
CMS should provide technical assistance to States to ensure the adequacy 
of their access standards, their methods for testing them, and their methods 
for identifying and addressing violations. CMS should share effective 
practices with all States to improve access for Medicaid managed care 
enrollees.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   20 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all four of our recommendations.  Regarding our 
recommendation for it to strengthen its oversight of State standards, CMS 
concurred and stated that it is considering options to set forth expectations  
for network access standards through additional guidance to States.  
Regarding our recommendation for it to strengthen its oversight of States  
methods to assess plan compliance and to ensure that States conduct direct 
tests of access standards, CMS concurred, noting that it will engage 
collaboratively with States to identify best practices for testing plan 
compliance rather than endorse a particular method.   
Regarding our recommendation for it to improve States efforts to identify 
and address violations of access standards, CMS concurred and stated that 
it believes that existing regulations provide an adequate array of remedies 
for States to pursue for plans noncompliance with access standards.  CMS 
added that it believes that flexibility should remain with the States to 
determine which compliance actions should be applied.  CMS also stated 
that when it becomes aware of potential issues, it shares that information 
with the appropriate State and monitorson an ongoing basisthe States 
actions to remedy the situation.  Regarding our recommendation for it to 
provide technical assistance and share effective practices, CMS concurred 
and noted that it has been providing technical assistance to States through 
existing contract resources. CMS added that it would continue such 
activities in the future as resources allow.   
We support CMS efforts to provide effective oversight of Medicaid 
managed care, and we encourage it to continue to work with States to 
ensure access to care for managed care enrollees.  In its comments, CMS 
did not address whether it intends to issue guidance about requiring States 
to develop standards for core provider types and to conduct direct tests of 
their access standards.  OIG requests that CMS provide in its Final 
Management Decision details on how it intends to address these issues.      
For the full text of CMSs comments, see Appendix D.  
 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   21 
   
   
APPENDIX A 
State Access Standards:  Maximum Distance or Time an Enrollee Should 
Have to Travel to See a Provider  
Table A-1: Distance and Time Standards by  State, 2013  
Standards for Distance or Time Between Providers and Enrollees Residences  
State  
Primary Care Providers   Specialists  
Within 5 miles for 95 percent of enrollees 
residing within boundary of metropolitan 
Arizona  Phoenix or Tucson  No standard  
(There is no standard for enrollees outside of 
these two areas)  
California  Within 30 minutes or 10 miles  No standard  
Colorado   Within 30 minutes or 30 miles  Within 30 minutes or 30 miles  
Delaware   Within 30 minutes or 30 miles  Within 100 miles  
District of  Within 30 minutes travel time via public 
No standard  
Columbia  transportation or  within 5 miles  
Florida   Within 30 minutes  Within 60 minutes  
Urban: Within 8 miles*   Urban:  Within 30 minutes or 30 miles 
Georgia 
Rural:  Within 15 miles*   Rural: Within 45 minutes or 45 miles  
Urban: Within 30 minutes  Urban: Within 30 minutes 
Hawaii 
Rural:  Within 60 minutes    Rural:  Within 60 minutes     
Illinois  No standard   No standard  
Within 60 miles for selected specialists*;  
Indiana  Within 30 miles  
within 90 miles for other specialists  
Urban:   Within 30 minutes or 30 miles 
Kentucky  No standard  
Rural:  Within 45 minutes or 45 miles  
Urban:  Within 30 minutes or 10 miles  
Maryland   No standard  
Rural:  Within 30 minutes or 30 miles  
Massachusetts  Within 30 minutes or 15 miles*  No standard  
Michigan  Within 30 minutes or 30 miles  No standard  
Minnesota  Within 30 minutes or 30 miles   Within 60 minutes or 60 miles  
Urban:  Within 30 minutes or 30 miles *  
Mississippi   No standard  
Rural:  Within 60 minutes or 60 miles*  
Urban:  Within 15 miles for general surgeons; 
Urban: Within 10 miles   within 25 miles for other selected specialists  
Missouri  Basic:  Within 20 miles   Basic:  Within 30 miles for general surgeons; 
Rural:  Within 30 miles    within 50 miles for other selected specialists  
Rural:  Within 60 miles for general surgeons; 
within 100 miles for other selected specialists  
* Denotes standards  that require at least two providers within the specified distance or travel time. 
 Denotes States  that have additional  standards for  specific  types of primary care providers, such as obstetricians. 
 
                                                                                                                                                                                     continued  on  next page 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   22 
   
   
 
Table A-1: Distance and Time Standards by  State, 2013 (continued) 
Standards for Distance or Time Between Providers and Enrollees Residences  
State  
Primary Care Providers   Specialists  
Urban:  Within 30 miles*  
Nebraska   Rural:  Within 45 miles   Within 90 miles for high-demand specialists  
Frontier: Within 60 miles  
Nevada   Within 25 miles  No standard  
Urban:  Within 6 miles for 90 percent of 
enrollees*   Within 60 minutes or 45 miles for 90 percent of 
New Jersey   the enrollees in each county or approved 
Rural:  Within 15 miles for 85 percent of 
enrollees*   subcounty service area  
Urban:  Within 30 miles for 90 percent of 
enrollees 
Rural:  Within 45 miles for 90 percent of 
New Mexico  No standard  
enrollees 
Frontier:  Within 60 miles for 90 percent of 
enrollees 
Urban: Within 30 minutes 
New York   Within 30 minutes or 30 miles  
Rural: Within 30 minutes or 30 miles 
If medically necessary care is not within  If medically necessary care is not within 
Ohio  
30 miles, MCO must provide transportation   30 miles, MCO must provide transportation  
Urban: Within 30 minutes for selected 
Urban: Within 30 minutes*  specialists*  
Pennsylvania 
Rural:  Within 60 minutes*  Rural:  Within 60 minutes for selected 
specialists*  
Rhode Island   Standard varies by  plan*   Standard varies by plan*  
South Carolina   Within 30 miles   No standard  
Urban:  Within 30 minutes or 20 miles   Within 60 miles for 75 percent of enrollees; 
Tennessee  
Rural:  Within 30 minutes or 30 miles   within 90 miles for all enrollees  
Texas   Within 30 miles   Within 75 miles  
Utah   Within 40 minutes or 40 miles*  No standard  
Urban:  Within 30 minutes or 15 miles*   Urban: Within 30 miles  
Virginia  Rural:  Within 60 minutes or 30 miles*   Rural:  Within 60 miles  
Urban:  Within 10 miles for 90 percent of 
enrollees in the service area* 
Washington  No standard  
Rural:  Within 25 miles for 90 percent of 
enrollees in the service area  
Within 30 minutes for high-demand specialists*; 
West Virginia   Within 30 minutes* 
within 60 minutes for other specialists 
Urban: Within 10 miles for enrollees residing 
in Milwaukee, Racine, or Kenosha  
Wisconsin  No standard  
Rural:  Within 20 miles for enrollees residing in 
the remainder of the service areas  
 
* Denotes standards  that require at least two providers within the specified distance or travel time. 
 Denotes States  that have additional standards for specific types of primary  care providers, such as obstetricians. 
 
 
Source:  OIG analysis of State data, 2014.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   23 
   
   
APPENDIX B 
State Access Standards:  Maximum Number of Days an Enrollee Should 
Have to Wait for an Appointment  
Table B-1: Appointment  Standards by  State, 2013  
Maximum  Appointment Wait Times (Days)  
State   Primary Care   Specialist  
Routine Care   Urgent  Care   Routine Care   Urgent  Care  
Arizona  21  2  45  3 
California  10*  2  15*  4 
Colorado   30  2  No standard  No standard  
Delaware  21  2  21  2 
District of Columbia  30  No standard   30  No standard  
Florida  30  1  30  1 
Georgia  14   1   30   No standard  
Hawaii  21  1  28  1 
Illinois  35  1  No standard   1 
Indiana  No standard   No standard   No standard   No standard  
Kentucky  30  2  30  2 
Maryland  30  2  30  2 
Massachusetts  45   2  60   2 
Michigan  No standard   No standard   No standard   No standard  
Minnesota  45  1  No standard  No standard  
Mississippi  30  1  No standard  No standard  
Missouri  30  1  30  1 
Nebraska  14*   2   30*   3  
Nevada  14  2   30   3  
New Jersey   28  1  28  1 
New Mexico  30  1  21  No standard  
New York   28  1  42  1 
Ohio   42  1  No standard  No standard  
15* for selected 
Pennsylvania  10*  1   specialists;   1  
10* for others  
*Denotes business days 
Continued on next page  
 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   24 
   
   
Table B-1: Appointment  Standards by  State, 2013 (continued)  
Appointment Wait Times (Days) 
State   Primary Care   Specialist  
Routine Care   Urgent  Care   Routine Care   Urgent  Care  
Rhode Island   30  1  30  1 
South Carolina   42  2  No standard   No standard  
Tennessee  21  2  30  2 
Texas  14   1  30   1 
Utah  30  2  30  2 
Virginia  30   1  No standard   1 
Washington  30   2  No standard   No standard  
West Virginia   21  2  No standard   2 
Wisconsin  14  No standard   No standard   No standard  
* Denotes business days. 
Routine care includes nonurgent well-care visits; urgent care includes visits for conditions that require more immediate attention, but do not 
constitute an emergency.  
Standards that do not specify which type(s)  of provider(s)  they apply to are counted as applying both to primary care  providers and to  
specialists. 
 
Source:  OIG analysis of State data, 2014. 

State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   25 
   
   
APPENDIX C 
State Access Standards:  Number of Enrollees per Provider  
Table C-1: Provider-to-Enrollee Standards by State, 2013  
Number of Enrollees per 
State   Number of Enrollees per Specialist  
 Primary Care Provider  
Arizona  No standard   No standard  
California  2,000 enrollees  No standard**  
Colorado   2,000 enrollees  2,000 enrollees 
Delaware   2,500 enrollees  No standard  
District of Columbia  No standard   No standard  
Florida   1,500 enrollees  No standard  
Georgia  No standard   No standard  
Hawaii  300 enrollees   No standard  
Illinois  2,000 enrollees*  No standard**  
Indiana  No standard   No standard  
Kentucky  1,500 enrollees  No standard  
2,000 adult enrollees 
Maryland   No standard**  
1,500 enrollees under 21  
Massachusetts  200 enrollees*  No standard  
Michigan  750 enrollees   No standard  
Minnesota  No standard   No standard  
Mississippi  No standard   No standard  
Missouri  No standard   No standard  
Nebraska   No standard   No standard  
Nevada   1,500 enrollees  1,500 enrollees 
New Jersey   2,000 enrollees*  No standard**  
New Mexico  1,500 enrollees  No standard  
New  York   1,500 enrollees  No standard  
Ohio   No standard   No standard  
Pennsylvania  1,000 enrollees  No standard  
Rhode Island   1,500 enrollees   No standard  
South Carolina   No standard   No standard  
 
* Denotes States  that have additional  standards for  specific  types of primary care providers, such as obstetricians and pediatricians. 
** Denotes States that have additional standards  that apply to all providers, but are not specific  to specialists (i.e., 1 provider per  
2,000 enrollees).  
continued on next page 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   26 
   
   
 
 
Table C-1: Provider-to-Enrollee Standards by State, 2013 (continued)  
Number of Enrollees per 
State   Number of Enrollees per Specialist  
 Primary Care Provider  
Tennessee   2,500 enrollees  Standard varies by specialty type  
Texas   No standard   No standard  
Utah   No standard   No standard  
Virginia  1,500 enrollees*  No standard  
Washington  No standard   No standard  
West Virginia   500 enrollees*  No standard  
Wisconsin  100 enrollees   Standard varies by specialty type   
 
* Denotes States  that have additional  standards for  specific  types of primary care providers, such as obstetricians and pediatricians. 
** Denotes States that have additional standards  that apply to all providers, but are not specific  to specialists (i.e., 1 provider per  
2,000 enrollees).  
 
Source:  OIG analysis of State data, 2014. 
 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   27 
  APPENDIX D 
Agency Comments 
(,"""4""~""'..,  DE	PARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
...,~ 	
Administrator 
Washington, DC 20201 
DATE:  AUG 15 2014 
TO: 	 Daniel R. Levinson 

lnspectorAGeneral 

FROM: 	 M~Trienrrer 

Admmistratol\ 

SUBJECT: 	 Office of Inspector General (OIG) Draft Report: "State Standards for Access to Care 
in Medicaid Managed Care" (OEI-02-11-00320) 
Thank you for the opportunity to review and comment on the above-referenced OIG draft report. 
The purpose of this report was to survey states with comprehensive, risk-based managed care to 
collect documentation and data on managed care program access standards. 
Managed care has become an important delivery system in the Medicaid program. As many of 
our beneficiaries are enrolled in managed care plans, the Centers for Medicare & Medicaid 
Services (CMS) takes seriously our role in ensuring that states are providing effective oversight 
ofthese plans. 
OIG Recommendation 
The OIG recommends that CMS strengthen its oversight of State standards and ensure that States 
develop standards for key providers. 
CMS Response 
The CMS concurs generally that its oversight of state network access standards for managed care 
networks is important to the effective delivery of Medicaid services to enrollees. We are 
considering options to set forth CMS' expectations for network access standards and expect to 
address this issue through the development of additional guidance to states. 
OIG Recommendation 
The 010 recommends that CMS strengthen its oversight of States' methods to assess plan 
compliance and ensure that States conduct direct tests of access standards. 
CMS Response 
The CMS concurs generally that it is important for states to document ongoing oversight of 
health plan compliance with provider access standards. CMS will engage collaboratively with 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)  28  Page 2-Daniel R. Levinson 
states to identify best practices for testing health plan compliance with provider access standards, 
rather than endorse a particular method, as the assessment ofprovider access is best conducted 
through multi-pronged strategies. 
OIG Recommendation 
The OIG recommends that CMS improve States' efforts to identify and address violations of 
access standards. 
CMS Response 
The CMS concurs generally that states' ongoing oversight ofhealth plan compliance with 
provider access standards and remediation of identified violations are key to the operation of an 
effective Medicaid managed care program. To that end, CMS believes that existing regulations 
in subpart I of 42 CFR part 438 provide an adequate array ofremedies for states to pursue for 
health plan non-compliance with access standards and that flexibility should remain with the 
states to determine which compliance actions should be applied to its contractors.  When CMS 
becomes aware ofpotential issues with a health plan's network, we share that information with 
the state and monitor the state's actions to remedy the situation on an ongoing basis. CMS will 
continue to track compliance information from external quality review organizations' reports and 
contract review to determine if expectations for oversight and compliance actions are 
appropriate. 
OIG Recommendation 
The OIG recommends that CMS provide technical assistance and share effective practices. 
CMS Response 
We concur. The CMS has been providing technical assistance to states that seek information on 
provider access standards through existing contract resources.  As resources allow in the future, 
we would continue such activities. 
The CMS thanks OIG for the work done on this issue and looks forward to working with OIG in 
the future. 
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)  29   
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New  York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional 
Inspectors General.  
Vincent Greiber served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Marissa Baron, Marisa Beatley, and 
Hailey Davis.  Office of Evaluation and Inspections staff who provided 
support include Janna Sayer from the Atlanta regional office and 
Deborah Cosimo from the Dallas regional office.  Central office staff who 
provided support include Kevin Farber, Kevin Manley, and 
Christine Moritz.  
State Standards for Access to Care in Medicaid Managed Care (OEI-02-11-00320)   30 
   
Office of Inspector General

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.