Department of Health and Human Services 
OFFICE OF 
 
  INSPECTOR GENERAL 
 
 
 
 
 
 
 
A C :  
CCESS TO  ARE  
 
 
P A
ROVIDER  VAILABILITY IN 
 
 
M M C  
EDICAID  ANAGED  ARE 
Daniel R. Levinson  
Inspector General  
 
December 2014 
OEI-02-13-00670   
EXECUTIVE SUMMARY:  ACCESS TO CARE:  PROVIDER AVAILABILITY IN 
MEDICAID MANAGED CARE  
OEI-02-13-00670 
 
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 managed 
care. This report determines the extent to which providers offer appointments to enrollees 
and the timeliness of these appointments.  A companion report issued earlier this year, 
State Standards for Access To Care in Medicaid Managed Care, OEI-02-11-00320, found 
that State standards for access to care vary, and that they are often not specific to certain 
provider types or to areas of the State.  Additionally, States have different strategies to 
assess compliance with access standards.  
 
HOW WE DID THIS STUDY  
 
We based this study on an assessment of availability of Medicaid managed care providers.   
The assessment included calls to a stratified random sample of 1,800 primary care 
providers and specialists to assess availability and timeliness of appointments for enrollees.   
 
WHAT WE FOUND 
 
We found that slightly more than half of providers could not offer appointments to 
enrollees. Notably, 35 percent could not be found at the location listed by the plan, and 
another 8 percent were at the location but said that they were not participating in the plan.  
An additional 8 percent were not accepting new patients.  Among the providers who  
offered appointments, the median wait time  was 2 weeks.  However, over a quarter had 
wait times of more than 1 month, and 10 percent had wait times longer than 2 months.  
Finally, primary care providers were less likely to offer an appointment than specialists; 
however, specialists tended to have longer wait times. 
 
WHAT WE RECOMMEND 
 
Together, these findingsalong with those from our companion reportcall for the 
Centers for Medicare & Medicaid Services (CMS) to work with States to improve the 
oversight of managed care plans.  We recommend that CMS work with States to  (1) assess 
the number of providers offering appointments and improve the accuracy of plan 
information, (2) ensure that plans networks are adequate and meet the needs of their 
Medicaid managed care enrollees, and (3) ensure that plans are complying with existing 
State standards and assess whether additional standards are needed.  CMS concurred with 
all three of our recommendations. 
   
   
TABLE OF CONTENTS 
 
Objectives.................................................................................................... 1 

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

Methodology ............................................................................................... 4 

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

Half of providers could not offer appointments                                to 

enrollees .......................................................................................... 8 

Among the providers who offered appointments, the               

median wait time was 2 weeks; however, over a quarter              had 

wait times of more than 1 month  ................................................. 10 

Primary care providers were less likely to offer an        appointment 

than specialists; however, specialists      tended to have 

longer wait times  ........................................................................... 11
  
Conclusion and Recommendations ........................................................... 13 

Agency Comments and OIG response .......................................... 16 

Appendix................................................................................................... 18 

A: Providers Excluded From  Analysis .......................................... 18 

B: Projected Population ................................................................ 19 

C: Point Estimates and Confidence Intervals ................................ 20 

D: Agency Comments  ................................................................... 24 

Acknowledgments ..................................................................................... 27
 
           
   
   
OBJECTIVES 
1. 	  To determine the extent to which providers could offer appointments 
to Medicaid managed care enrollees.  
2.	   To assess wait times for appointments for Medicaid managed care 
enrollees.  
3.	   To describe any differences in the availability of primary care 
providers and specialists. 
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 
combined spent almost $460 billion on the program.2  Each State designs 
and administers its own Medicaid program within broad Federal 
guidelines. Most States provide some or all Medicaid services through 
Medicaid managed care, which covers nearly three-quarters of 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   As a result, Medicaid is expected to provide 
coverage for as many as 18 million more people by 2018.5  In addition, 
____________________________________________________________ 
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, Report to the Congress on  
Medicaid and CHIP, March 2014.  Accessed at http://www.macpac.gov/reports 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  (March 23, 2010), as amended by the Health Care and 
Education Reconciliation Act  of 2010, P.L. No. 111-152  (March 30, 2010), collectively  
referred to as the ACA.   
5 Congressional Budget  Office, The Budget and Economic Outlook: 2014 to  2024. 
Accessed at http://www.cbo.gov/publication/45010  on August 26, 2014. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                1 
   
   
many States that have not expanded eligibility have also seen increases in 
enrollment.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 determines the extent to which providers offer 
appointments to enrollees and the timeliness of these appointments.  A  
companion report found that State standards for access to care vary, and 
that they are often not specific to certain provider types or to areas of the 
State.7   Additionally, States have different strategies to assess compliance 
with access standards.  
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 
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.  
____________________________________________________________ 
6  MACPAC, Report to the Congress on Medicaid  and CHIP, March 2014.  Accessed  at: 
http://www.macpac.gov/reports  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.  
7 OIG,  State Standards for  Access to Care in  Medicaid Managed Care 
(OEI-02-11-00320).   

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.   

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.  The  MCO pays providers on a fee-for-service basis. 
  
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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 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   
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.15  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.16  Further, each State must submit to CMS regular 
reports describing the implementation and effectiveness of its quality 
strategy.17 
 ____________________________________________________________ 
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   438.6(a).  
 
16 42 CFR    438.202 and 438.207(d). 
 
17 42 CFR   438.202(e)(2).  

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Related Work 
In a companion report, OIG found that States that contract with MCOs 
have established at least one of the following three types of standards for 
access to care: (1) standards that limit the distance or amount of time 
enrollees should have to travel to see a provider; (2) standards that require 
appointments be provided within a certain timeframe; and (3) standards 
that require a minimum number of providers in relation to the number of 
enrollees.18  These standards are often not specific to certain types of  
providers or to areas of the State.  
OIG also found that States have different strategies to assess compliance 
with access standards, but they do not commonly use what are called 
direct tests.  Direct tests seek to reliably measure whether plans comply 
with access standards and commonly include calls to providers.  The 
report recommended that CMS strengthen its oversight of State standards 
and ensure that States develop standards for key providers.  It also 
recommended that CMS strengthen its oversight of States methods to 
assess plan compliance and that it ensure that States conduct direct tests of 
access standards.  
METHODOLOGY 
Scope 
We based this study on an assessment of availability of Medicaid managed 
care providers.   The assessment included calls to a stratified random  
sample of primary care providers and specialists to assess availability and 
timeliness of appointments for new patients.  This study measures the 
availability of specific providers at specific locations in Medicaid 
managed care networks.  It does not attempt to measure whether an 
enrollee would have been able to obtain an appointment elsewhere, such 
as with another provider at the same location.  Further, it focuses solely on 
Medicaid managed care and does not include an assessment of other types 
of Federal or State health care programs or private insurance.  Lastly, this  
study focuses on the earliest routine, non-urgent appointment available for 
new patients. We conducted calls from July through October 2013, which 
preceded States expansion of Medicaid under the ACA. 
 
 
 
____________________________________________________________ 
18  OIG,  State Standards for Access to Care in  Medicaid Managed Care 
(OEI-02-11-00320).   
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Identification of Medicaid Managed Care Providers  
We contacted all States to identify those that contracted with Medicaid 
MCOs.   We included only MCOs providing full-risk managed care for a 
comprehensive set of services to the general Medicaid population.19  We  
identified 32 States with 221 MCOs that were active from January 2012 
through July 2013.  From each of the 32 States, we requested a list of all 
providers participating in Medicaid managed care plans.   
We requested information about each provider, such as the address and 
phone number for each location at which the provider was practicing and 
the name of each Medicaid managed care plan in which the provider was 
participating in as of January 1, 2012.20   We also requested information on 
whether the provider was a primary care provider or specialist, as well as 
the providers specialty.   
Using this information, we identified all primary care providers and 
selected specialists participating in Medicaid managed care.  For primary 
care providers, we included pediatricians, obstetricians/gynecologists 
(OB/GYN), as well as family practitioners and general internists.  We also 
included nonphysician practitionerssuch as nurse practitioners and 
midwiveswho were primary care providers.  For specialists, we selected 
nine types of specialists with whom  an enrollee would typically make an 
appointment for a routine consultation in an office setting.  These nine 
specialists were:  allergists/immunologists; cardiologists; dermatologists; 
endocrinologists; gastroenterologists; neurologists; orthopedists; 
otolaryngologists; and urologists. 
Each provider may practice at multiple locations and may participate in 
multiple plans.  A provider may also participate in different plans at  
different locations.  In this report, we use the term provider to refer to a 
provider at a specific location in a specific plan.  In total, we identified 
1.36 million providers who were participating in Medicaid managed care 
as of January 1, 2012. 
From this population of providers, we selected a stratified random sample 
of 1,800 providers, which included 450 providers from each of the 
following four strata: (1) urban primary care providers, (2) rural primary 
____________________________________________________________ 
19 We  excluded noncomprehensive plans,  as these offer a limited range of services under 
managed care.   We also excluded 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. 
20 We  collected all addresses for each provider but included in our analysis only the 
addresses at which the provider was listed as  practicing and offering care to  patients.  We  
refer to these addresses as the providers location.   
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care providers, (3) urban specialists, and (4) rural specialists.  We  
determined whether each provider was in an urban or rural area on the 
basis of the providers ZIP Code.21   We determined our sample size on the 
basis of the outcome of a pretest.22    
Assessment of Provider Availability   
To assess provider availability, we called all 1,800 providers in our sample 
and attempted to schedule an appointment.  These calls took place from  
July through October 2013.  On each call, we confirmed whether the 
provider practiced at the location listed, whether the provider participated 
in the plan, and whether the provider was accepting new patients enrolled 
in the plan. If the providers practice had relocated nearby, we considered 
the provider to be at the location and determined whether the provider was 
able to offer an appointment.  In contrast, if the provider had retired or left 
the practice, we considered the provider to be not participating at the 
location listed and to be unable to offer an appointment.   
During our calls, we asked for the earliest date available for a routine 
appointment with the provider.  We did not provide details about any 
enrollee or schedule appointments.  If asked, we said that we were calling 
on behalf of a new enrollee to determine the earliest available  
appointment.  For primary care providers, we asked about an appointment 
for a new patient visit and/or checkup; for specialists, we asked about an 
appointment for a consultation.23  
We used several criteria for excluding providers from our sample that 
made our estimate of the percentage of providers who could not offer 
appointments more conservative.  For example, when a caller determined 
that a provider was not practicing at a location or participating in a plan, 
we followed up with the plan. If the plan had information indicating that 
the provider was not at the location or not participating in the plan during 
the time of our calls, we excluded this provider from our analysis.  We  
also excluded a provider if we determined during the call that the provider 
was a different type than indicated by the State, such as chiropractors 
____________________________________________________________ 
21  We  used  rural-urban commuting area codes (RUCAs), which classify counties using  
measures of population density, urbanization, and daily commuting distance.  Accessed at  
http://depts.washington.edu/uwruca/  on January 15, 2013.  We  defined an area as urban if 
30 percent or  more of its  workers commute to or live within an area with 50,000 people 
or more.  We considered all  other areas to  be rural.  
22  We  selected a stratified random sample of 120 providers to conduct a pretest.  From the 
results of the pretest, we included additional providers in each strata in  our study sample 
to ensure that  we could  project the results of our analysis at the 95-percent confidence  
level. 
23 For obstetricians, we asked about an appointment for a first prenatal visit at the eighth 
week of  pregnancy. 
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incorrectly identified as orthopedists.  Finally, we excluded providers if 
they practiced at a location at which appointments could not be made, 
such as a hospital where a provider had admitting privileges.  
In total, we excluded 692 of the 1,800 providers from our sample.  We also 
excluded 16 additional nonrespondents for a total sample population of 
1,092 providers.24  See Appendix A for the number of providers excluded 
from our analysis by reason.   
Analysis  
We first determined the percentage of providers who could not offer 
appointments.  We defined this measure to include providers who could 
not be found at the location listed by the plan as well as providers at the 
listed location who said that they were not participating in the plan.  In all 
of these cases, the plans confirmed that these providers were supposed to 
have been participating in the plan at the location at the time of our calls.  
We also included providers who were not accepting new patients.   
Next, we determined the length of wait times for appointments.  For 
providers who offered appointments, we determined the number of days 
between the date of the call and the earliest available appointment date.  
For providers who offered an approximate appointment or a range of 
possible appointment dates, we chose the earliest appointment date 
possible (e.g., if the earliest appointment with a provider was sometime 
in October, we considered the earliest appointment date to be October 1). 
Lastly, we determined whether there were any differences in availability 
and wait times between primary care providers and specialists.25   We did 
the same for urban and rural providers but did not find any differences in 
availability and wait times that were statistically significant.   
We projected the results of our analysis to the population of 778,475 Medicaid 
managed care providers.  See Appendix B for the projected population by 
strata. See Appendix C for the point estimates and confidence intervals.  
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. 
 
____________________________________________________________ 
24 We had  a 98-percent response rate overall; we did not adjust our results for 
nonresponse.   

25 The differences presented in this report are significant at the 95-percent confidence 

interval unless otherwise specified. 
   
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FINDINGS 
Half of providers could not offer appointments to 
enrollees 
Fifty-one percent of providers could  not offer appointments because they 
were not participating at the listed location (i.e., not practicing at the 
location listed or were practicing there but not participating in the plan), or 
were not accepting new patients enrolled in the plan.  This means that 
Medicaid managed care enrollees may not be able to make appointments 
with as many as half of the providers listed by their plans.  See Figure 1.  
 
Figure 1: Availability of Providers, 2013 
 
Source: OIG assessment of provider availability, 2014. 
 
When providers listed as participating in a plan cannot offer appointments, 

it may create a significant obstacle for an enrollee seeking care.  

Moreover, it raises questions about the adequacy of provider networksit 

suggests that the actual size of provider networks may be considerably 

smaller than what is presented by Medicaid managed care plans.  It also 

raises questions about whether these plans are complying with their States 

standards for access to care. 
 
Forty-three percent of providers were not participating in the 
plan at the listed location 
Forty-three percent of providers were not participating in the Medicaid 
managed care plan at the listed location and could not offer appointments.  
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Notably, 35 percent of providers could not be found at the location listed 
and were therefore not participating at the location listed by the plan.  In 
these cases, callers were sometimes told that the practice had never heard 
of the provider or that the provider had practiced at the location in the past 
but had retired or left the practice.  Some providers had left months or 
even years before the time of the call.    
Another 8 percent of providers were at the location listed but said that they  
were not participating in the plan.  In some cases, these providers had 
participated in the plan in the past; in other cases, the providers had never 
participated in the Medicaid managed care plan. 
In all of these cases, the plans confirmed that these providers were 
supposed to have been participating in the plan at the location at the time 
of our calls. Plans typically provide lists of participating providers and 
their locations to enrollees in Medicaid managed care plans, and enrollees 
often refer to these lists when seeking care from primary care providers 
and specialists. Potential enrollees also refer to these lists when selecting 
a plan. By continuing to inaccurately  list these providers as participating, 
plans limit an enrollees ability to find a participating provider at a nearby 
location. 
Additionally, many States rely on information from plans to determine 
plan compliance with State standards for access to care.26  For example, all 
but one of the States we reviewed have standards that establish a 
maximum distance enrollees should have to travel to see a provider, and  
these States often use provider location information from plans to 
determine compliance with their distance standards.  If 43 percent of 
providers are not participating in plans at the locations specified, these 
States may be incorrectly determining plans compliance with their access  
standards. 
Another 8 percent of providers were not accepting new 
patients 
Additionally, 8 percent of providers were participating in the Medicaid 
managed care plan but were not accepting new patients enrolled in the 
plan. As a result, these providers could not offer appointments to 
enrollees. Providers were often not accepting new patients because they 
were leaving the practice, or because they already had too many patients.   
One provider was not accepting new patients with the plan because of 
frequent no-shows. Having a large number of providers who are not 
accepting new patients can also affect enrollees access to care. 
____________________________________________________________ 
26 For more detailed information, see OIG, State Standards for Access to Care in 
Medicaid Managed Care (OEI-02-11-00320).   
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Among the providers who offered appointments, the 
median wait time was 2 weeks; however, over a 
quarter had wait times of more than 1 month 
Forty-nine percent of providers offered appointments for new patients 
enrolled in a Medicaid managed care plan with a median wait time of  
2 weeks.27  Wait times for these appointments varied widely, ranging from  
same-day appointments to an appointment in 9 months.  For 28 percent of 
providers who offered appointments, enrollees had to wait more than a 
month for an appointment.  Ten percent of providers had wait times longer 
than 2 months.  See Figure 2. 
All but two of the States we reviewed have access standards that require 
appointments be provided within a certain timeframe.  For the majority of 
these States, the required timeframe is 1 month or less.28  That more than a 
quarter of providers were unable to offer appointments within a month 
raises further questions about enrollees ability to obtain timely access to 
care. 
Figure 2: Wait Times for Routine Appointments for Enrollees  
60% 
51% 
50% 
40% 
30% 
21% 
18% 
20% 
10% 
5%  5% 
0% 
2 weeks or  > 2 weeks  > 1 month  > 2 months  More than 
less  and  1  and  2  and  3  3 months 
month  months  months
Percentage of  providers who could offer appointments 
 
Source: OIG assessment of provider availability, 2014. 
____________________________________________________________ 
27  Five percent of providers  were accepting new patients enrolled in the plan, but did not 
offer a specific appointment date without more information about the enrollee (e.g., 
Medicaid identification number).   Although  these providers are counted as offering  
appointments, they are excluded from the wait-time analysis because we could  not obtain 
an appointment date.  
28 In most cases, these States standards require the plan to ensure that an enrollee can get 
an appointment within the given timeframe.  
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In some circumstances, long wait times can have a significant impact on 
patient care. For example, a number of obstetricians had wait times of 
more than 1 month, and one had wait times of more than 2 months for an 
enrollee who was 8 weeks pregnant. Such lengthy wait times could result 
in a pregnant enrollee receiving no prenatal care in the first trimester of  
pregnancy.29  
A small number of providers required patients to submit 
medical records prior to scheduling an appointment or would 
not accept patients with certain medical conditions 
Enrollees ability to obtain timely access to care may also be affected by 
providers who offer appointments only under certain circumstances.  A 
small number of primary care providers required medical records prior to 
scheduling appointments.  These providers first review the medical 
records and then accept patients on a case-by-case basis.  A few providers 
would not accept patients with certain medical conditions, such as chronic 
pain. In one example, a specialist would offer an appointment only if the 
patient had a body mass index (BMI) under 40.  By requiring enrollees to 
submit medical records or meet certain criteria, providers may be further 
limiting enrollees ability to access care.  
Primary  care providers were less likely to offer an 
appointment than specialists; however, specialists 
tended to have longer wait times 
Primary care providers were less likely to offer appointments than 
specialists. Only 44 percent of primary care providers offered 
appointments, compared to 57 percent of specialists.  See Figure 3. 
Among primary care providers, family practitioners and general internists 
were less likely to offer appointments than pediatricians:  40 percent of 
family practitioners and general internists offered appointments compared 
to 53 percent of pediatricians. Among the different types of specialists, 
the ability to offer appointments ranged from 68 percent of 
gastroenterologists to 54 percent of cardiologists; however, the differences 
among specialists were not statistically significant.30 
 
 ____________________________________________________________ 
29  The Agency for Healthcare Research and  Quality recommends at least one prenatal 
visit in the first trimester.  Accessed at http://www.guideline.gov/content.aspx?id=38256  
on September 18, 2014. 
30 Except for cardiologists, the 95-percent confidence intervals for these estimates exceed 
plus or minus 10 percent because of small sample sizes.   
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Figure 3: Percentage of Providers Who Could Offer a New  Patient 
Appointment, by Provider Type   
60%  57%
50% 
44% 
40% 
30% 
20% 
10% 
0% 
Primary Care Providers  Specialists 
 
Source: OIG assessment of provider availability, 2014. 
 
The median wait time for specialists was twice as long as that 
for primary care providers 
Although primary care providers were less likely to offer appointments, 
specialists had longer wait times.  Specialists offered appointments with 
wait times that were twice as long as those offered by primary care 
providers. The median wait time for an appointment with a specialist was 
20 days, compared to just 10 days for a primary care provider.   
Moreover, 34 percent of specialists who offered appointments had wait 
times longer than 1 month, and 11 percent had wait times longer than 
2 months.  Specialists gave a variety of reasons for long wait times.  For 
example, in some cases callers were told that the providers practiced only 
one day a week or once a month at their offices.  One provider practiced 
even less often, and his first opening was almost 3 months away; another 
provider closed his office entirely during the winter.  In other cases, 
providers were highly sought after for their specialization, which could 
explain the longer wait times.  For example, one neurologist who 
specialized in Tourettes and tic disorders had a wait time of 9 months. 
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CONCLUSION AND RECOMMENDATIONS 
Our findings demonstrate significant vulnerabilities in provider 
availability, which is a key indicator for access to care.  These findings 
also raise serious questions about the abilities of plans, States, and CMS to 
ensure that access-to-care standards are met.  Without adequate access, 
enrollees cannot receive the preventive care and treatment necessary to 
achieve positive health outcomes and improved quality of life.   
Notably, 51 percent of providers were either not participating in the plan at 
the location listed or not accepting new patients enrolled in the plan.  
When providers listed as participating in a plan cannot offer appointments, 
it creates a significant obstacle for an  enrollee seeking care.  Moreover, it 
suggests that the actual size of provider networks may be considerably 
smaller than what is presented by Medicaid managed care plans.   
Among the providers who offered appointments, the median wait time was 
2 weeks.  However, over a quarter had wait times of more than 1 month, 
and 10 percent had wait times longer than 2 months.  Long wait times can 
have a significant impact on patient care.  It also raises questions about 
whether these plans are complying with their States standards for access 
to care, as most States have access standards that require appointments be 
provided within 1 month or less.  That so many providers could not offer 
appointments within a month raises concerns about enrollees ability to 
obtain timely access to care.   
Together, these findingsalong with those from our companion report 
call for CMS to work with States to improve the oversight of managed 
care plans. In our companion report, we recommended that CMS 
strengthen its oversight of State standards and States methods to assess 
plan compliance.  This report expands on these recommendations and 
provides additional recommendations about how CMS should further 
ensure access to care for Medicaid managed care enrollees.   
We recommend that CMS: 
Work with States to assess the number of network providers 
who can offer timely appointments and to improve the 
accuracy of plan information   
CMS should work with States to ensure that they routinely test the 
availability of network providers. These tests could include calls to 
providers or other methods to determine whether providers are able to 
offer care in a timely manner.  In addition, tracking the availability of 
network providers over time will help ensure that enrollees have access to 
care as coverage expansions under the ACA take effect. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                13 
   
   
CMS should also work with States to develop strategies for improving the 
accuracy of plan data. These strategies should ensure that plans are 
effectively identifying providers who are no longer actively participating.   
CMS should work with States to ensure that plans have detailed steps for 
how they verify providers participation.  This could be achieved through 
such means as using claims data to identify those who have not submitted 
claims for enrollees for a significant amount of time or by contacting 
providers directly by phone or by mail. As part of its approval of MCO 
contracts with States, CMS should ensure that plans have controls to 
ensure that provider information is accurate and up to date. 
Work with States to ensure that plans networks are adequate 
and meet the needs of their Medicaid managed care enrollees 
CMS should work with States to use the data from their testing to assess 
the robustness of their networks. CMS should ensure that States and plans 
continually monitor their networks to identify any barriers that are 
impeding access to care.   For example, States should monitor whether 
there are shortages of specific provider types, such as 
obstetricians. Similarly, States should monitor whether there are shortages 
in specific geographic areas. States should also monitor their networks for 
other barriers to care, such as providers who require patients to submit 
medical records prior to scheduling appointments or providers who do not 
accept patients with certain medical conditions. If such barriers are 
identified, CMS should work with States to address them and increase 
plans networks as needed to ensure timely access to care for enrollees.  
Work with States to ensure that plans are complying with 
existing State standards and to assess whether additional 
standards are needed 
CMS should work with States to use the data from their testing to reassess 
whether plans arein factcomplying with State standards for access to 
care. If plans are found to not be in compliance, CMS should work with 
States to take actions to ensure that any instances of noncompliance are 
addressed. 
CMS should also work with States to determine whether each State needs 
to modify its existing standards or develop additional standards to address 
gaps in provider availability.  For example, if a State discovers that 
specialists have particularly long wait times for appointments, and the 
State does not have any wait-time standards that are specific to specialists,  
the State should consider revising its standards.  Similarly, if States are 
uncovering access issues among key provider types, such as obstetricians, 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                14 
   
   
the State should consider developing additional standards that apply 
specifically to those providers.  
   
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                15 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with all three of our recommendations.   
CMS concurred with our first recommendation to work with States to 
assess the number of network providers who can offer timely 
appointments and improve the accuracy of plan information.  CMS stated 
that it will continue to work with States to reinforce their regulatory 
obligations to provide timely care and to identify proven best practices.  
CMS is considering how best to strengthen its and States oversight of 
provider networks and ensure that enrollees have access to up-to-date 
information on the network.  It is also considering establishing  
expectations of States regarding assessing network access under managed 
care, the frequency with which an MCOs provider directory should be 
updated, and the increased use of electronic communication methods to 
improve data timeliness and accuracy.  Finally, CMS will collaborate with 
States and MCOs to consider best practices for the various mechanisms  
designed to connect enrollees with providers in a timely fashion.   
CMS noted that although the provider directory is one resource used by 
enrollees, there are many other supports that plans provide, such as 
managed care call centers, care coordinators, ombudsman offices, and 
community health centers.  Additionally, CMS noted that managed care 
enrollees would not need to make a "cold call" to set up an appointment.  
Although we recognize that many enrollees may receive additional 
support from plans in finding a provider, the vast majority of States 
reported to OIG that they provide a plan directory to enrollees upon 
enrollment so that they may select a primary care provider.   As a result, we 
continue to stress the importance of accurate provider information.  
CMS concurred with our second recommendation to work with States to 
ensure that plans networks are adequate and meet the needs of their 
Medicaid managed care enrollees.  CMS added that it would engage 
collaboratively with States and MCOs to identify and share best practices 
for ongoing, effective network analysis as well as support services that 
States and MCOs can provide. Further, CMS will remind States of the 
availability of technical assistance that can support States efforts.  Finally, 
CMS will identify issues associated with network adequacy during its 
waiver implementation, monitoring efforts, and renewals reviews, and 
bring them to each States attention when warranted. 
CMS concurred with our third recommendation to work with States to 
ensure that plans are complying with existing State standards and to assess 
whether additional standards are needed.  Finally, CMS will encourage 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                16 
   
   
States to use its technical assistance resources when researching or 
developing standards. 
We support CMSs efforts to provide increased oversight of Medicaid 
managed care, and encourage it to continue to work with States to ensure 
access to care for managed care enrollees.    
For the full text of CMSs comments, see Appendix D.  
 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                17 
   
   
APPENDIX A 
Providers Excluded from Analysis 
 
Table A-1: Providers Excluded from Analysis, by  Reason    
Number of 
Reason  Providers 
Plan had information indicating that the provider  was not at the location or not participating 
in the plan during the time of our calls.  348  
Provider practiced at a location at which appointments could not be made, such as a 
hospital where the provider had admitting privileges.   166  
Provider was associated  with a plan that was not providing Medicaid managed care during 
the time of our calls.1   75  
Provider was not one of our provider types   75  
Provider did not have a valid address   28 
      Total   692  
1 One plan became inactive, and another plan was mistakenly identified as serving Medicaid enrollees. 
Source:  OIG analysis of State Medicaid data, 2014.  
 
 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                18 
   
   
APPENDIX B 
Projected Population   
Table B: Projected Population  
Primary Care 
Area   Providers  Specialists   Total 
Urban  398,392   283,079   681,471  
Rural  68,154   28,850   97,004 
     Total  466,546   311,929   778,475  
Source:  OIG analysis of State Medicaid data, 2014. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                19 
   
   
APPENDIX C 
Point Estimates and Confidence Intervals   
Table C-1: Providers Who Could Not Offer Appointments, by Type, 2013 
95-percent confidence limit 
Point 
(%)  
Sample  Estimate 
Data Element  Size  (Percentage)  Lower  Upper 
Could Not Offer Appointment 
All Providers   1,092  50.6%  46.7%   54.5% 
Not Participating in Plan  
 All Providers   1,092  43.0%  39.2%   47.0%
       Providers not at location   1,092  35.4%  31.8%   39.3%
   At location, but not participating   1,092  7.6%  5.7%   10.1%
   All Providers by Provider Type 
    Primary care providers   506  45.5%  40.0%   51.1%
 Specialists   586  39.4%  34.4%   44.6%
   All Providers by Area 
    Urban providers   522  43.0%  38.7%   47.5%
    Rural providers  570  43.2%  38.8%   47.7%
   Not Accepting New  Patients Enrolled in Plan  
All Providers   1,092  7.5%  5.6%   10.0%
   All Providers by Provider Type 
    Primary care providers   506  10.2%*  7.3%   14.1%
 Specialists   586  3.5%*  2.0%   6.0%
   All Providers by Area 
    Urban providers   522  7.4%  5.3%   10.3%
    Rural providers  570  8.1%  5.8%   11.0% 
*Indicates that  differences are statistically significant at the 95-percent confidence level. 
 
Source: OIG assessment of provider availability, 2014. 
 
 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                20 
   
   
APPENDIX C (CONTINUED)  
 
Table C-2:  Providers Who Offered Appointments, by Type, 2013  
95-percent confidence limit 
Point 
(%)  
Sample  Estimate 
Data Element  Size  (Percentage)  Lower  Upper 
All Providers   1,092  49.4%  45.5%   53.3%
   All Providers by Provider Type 
    Primary care providers   506  44.3%*  38.9%   49.9%
 Specialists   586  57.1%*  51.8%   62.2%
   Primary Care Providers 
    Pediatricians  122  53.4%*  42.9%   63.7% 
    OB/GYNs  94  41.9%  30.5%   54.2% 
    Family practitioners/general internists   290  40.0%*  32.8%   47.7%
 Specialists  
    Gastroenterologists   55  68.4%  52.4%   81.0%
 Urologists   63  62.7%  47.0%   76.1% 
    Orthopedists   94  56.9%  42.6%   70.2%
    Neurologists  62  56.0%  40.3%   70.6%
    Cardiologists  188  53.7%  44.1%   63.0%
   All Providers by Area 
    Urban providers   522  49.5%  45.1%   54.0%
    Rural providers  570  48.8%  44.3%   53.2% 
*Indicates that  differences are statistically significant at the 95-percent confidence level. 
Source: OIG assessment of provider availability, 2014. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                21 
   
   
APPENDIX C (CONTINUED) 
Table C-3: Provider Wait Times, 2013  
95 percent confidence limit 
(%)  
Sample 
Data Element  Size  Percentage  Lower  Upper 
Provider Wait Times  
All Providers by Timeframe 
    2 weeks or less  502   51.2%  45.4%   56.9% 
       > 2 weeks and  1 month   502   20.5%  16.2%   25.5% 
       > 1 month and  2 months   502   18.4%  14.4%   23.2% 
    > 2 months and  3 months   502   5.3%  3.3%   8.5%
 More than 3 months   502   4.6%  2.6%   7.9% 
Providers With Wait Times Greater Than 1 month  
    All providers greater than 1 month   502   28.4%  23.5%   33.8%
    Primary care providers   199   23.6%  16.9%   32.0%
 Specialists   303   33.7%  27.2%   40.9%
   Primary Care Providers 
    Pediatricians  64   21.8%  11.9%   36.4%
     Family practitioners/general internists   108   26.2%  16.6%   38.7%
   All Providers by Area 
    Urban providers   246   29.2%  23.8%   35.4%
    Rural providers  256   21.8%  17.0%   27.6% 
Providers with  Wait Times Greater Than 2 months  
    All providers greater than 2 months   502   10.0%  7.0%   14.0%
         Primary care providers   199   9.0%  5.0%   15.7%
         Specialists   303   11.1%  7.3%   16.5% 
All Providers by Area  
Urban Providers  246   10.4%  7.1%   15.0% 
Rural Providers  256   6.8%  4.3%   10.7% 
Because of small sample size, point estimates were not calculated for  certain provider types. 
Source: OIG assessment of provider availability, 2014. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                22 
   
   
APPENDIX C (CONTINUED)  
 
Table C-4: Median Wait Times, 2013  
95-percent confidence limit 
(Days) 
Sample 
Data Element  Size  Days  Lower  Upper 
Median Wait Times  
All Providers   502   13.6   11.3   16.0  
   All Providers by Provider Type 
    Primary care providers   199   9.9*   6.4   13.3 
 Specialists   303   19.5*   15.3   23.7 
   All Providers by Area 
    Urban providers   246   13.9   10.5   17.3 
    Rural providers  256   11.8   9.5   14.1  
*Indicates that  differences are statistically significant at the 95-percent confidence level. 
Source: OIG assessment of provider availability, 2014. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                23 
  APPENDIX D 
Agency Comments 
/,..vw.,'<r, 
(,..__f. 	
DEPARJ'MENT OF HEALTII & HUMAN SERV_r_c_E_s_______ee_nr_er__ro_rM-ed-lc-are_&_M_ct_lc_al_d_se_rv_ice_s 
s~ 	
Admi11istrator 
Washington, DC 20201 
DATE:  OC I"  Z8  ZOl~ 
TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Matil):n Tavel\ner 

Adminktratl)r 

SUB.JECT: 	 Office oflnspeclOr General (OIG) Draft Report: "Access to Care: Provider 
Availability in Medicaid Managed Care" (OEI-02-13-00670) 
Thank you for the opportunity to review and comment on the above-referenced 010 draft report. 
The Centers for Medicare & Medicaid Services (CMS) appreciates the OIG's interest in 
Medicaid beneficiaries' access to care under state managed care arrangements. 
CMS is strongly committed to assuring access to care and is implementing a number of 
initiatives to ensure all Medicaid beneficiaries, including those in managed care, have timely 
access to high-quality, low-cost care. 
Recent CMS efforts to ensure access to care in Medicaid managed care include: 
 	 Benchmarking wait times for Medicaid beneficiaries against other data, including data for 
privately insured populations whenever possible. For example, data from the Consumer 
Assessment of Healthcare Providers and Systems {CAHPS) from the Agency for 
Healthcare Research and Quality shows that Medicaid enrollees' experiences are 
generally close to those ofother insured populations. These additional efforts will 
provide a more comprehensive assessment of access than could be determined through 
the use of "cold calls" that was used in this report. 
. :e  Working With states to implement best practices for updating provider directories, using 
electronic communication methods for sharing provider information, and analyzing 
managed care organization provider's capacity to offer timely appointments. 
  Strengthening our internal processes for reviewing state oversight ofnetwork adequacy 
as part ofreviewing State Plan amendments, reviewing and approving Managed Care 
Organization contracts, implementing and renewing waivers, and reviewing quarterly 
waiver status reports. 
 	 Ensuring that states monitor managed care organizations' compliance with state 
established access and network adequacy standards, and develop additional guidance 
where it is needed to establish and assess network adequacy under Medicaid managed 
care. 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)  24   
   
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                25 
   
   
 
   
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                26 
   
   
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 team leader for this study.  Other staff from the 
New York regional office who conducted the study include Marissa Baron, 
Judy Bartlett, and Hailey Davis. New York regional office staff who 
provided support include Miriam  Anderson, Marisa Beatley,  
Rachel Bryan, Lucia Fort, Jen Karr, Judy Kellis, Jason Kwong, and 
Michael Rubin.  Additional Office of Evaluation and Inspections staff who 
provided support include Deborah Cosimo from the Dallas regional office 
and Janna Sayer from the Atlanta regional office.  Central office staff who 
provided support include Kevin Farber, Kevin Manley, Christine Moritz, 
and Julie Taitsman.  
 
Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670)                                27 
   
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 
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enforcement authorities.