Department of Health and Human Services
 

OFFICE OF 

INSPECTOR GENERAL 

STATE STANDARDS FOR 

ACCESS TO CARE IN 

MEDICAID MANAGED CARE 

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 services—if not all of 

them—through 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-andSystems/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 State’s 

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 listings—typically in the form of a provider directory—of 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 §§ 438.310–370.
 

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 

State’s 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 MCO’s 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 

year’s review. 

Violations 

States must have a plan for monitoring MCO compliance and identifying 

violations of access standards.16 If a State finds—through onsite visits, 

reviews of complaints, or any other source—that 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 §§ 438.700–726.
 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 State’s 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 CMS’s role in developing State access standards, in 

monitoring compliance with standards, and in identifying and responding 

to violations of standards. We also asked about CMS’s oversight of the 

external quality reviews. 

Analysis 

To determine each State’s 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 Children’s Health Insurance Program Services, Findings 

from External Quality Review Technical Reports. Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-ofCare/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 State’s 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 CMS’s 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 plan’s 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 

Distance/Time 

Among States 

Longest 

Distance/Time 

Among States 

Distance to 

Primary Care 

Provider 

Urban Areas 6 Miles 30 Miles 

Rural Areas 15 Miles 60 Miles 

Travel Time to 

Primary Care 

Provider 

Urban Areas 30 Minutes 30 Minutes 

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 

Among States 

Longest Wait Times 

Among States 

Primary Care 

Providers 

Routine 

Appointments 10 Days 45 Days 

Urgent 

Appointments 1 Day 2 Days 

Specialists 

Routine 

Appointments 10 Days 60 Days 

Urgent 

Appointments 1 Day 4 Days 

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 plan’s 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 

considerably—from 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 

Numberof States

7 States 

4 States 

1–599 600–1999 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 women’s 

health providers (1 women’s 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 specialists—Nevada 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, Wisconsin’s standards for 

minimum numbers of specialists range from 1 cardiologist per 

1,000 enrollees to 1 urologist per 3,000 enrollees. Tennessee’s 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 provider’s 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 provider’s clinical staff through a tollfree 

telephone number. 

	 Access-related performance measures: Although a number of 

States provide incentive payments based on a plan’s success in 

meeting key performance measures related to access, one State— 

Ohio—has 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 plans—such as provider network 

lists—to 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* 

State 

Number of 

Violations Reported 

for 2008–2013 

Percentage of All 

Violations Reported 

for 2008–2013 

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 State’s 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 States—Ohio, New York, and Georgia—identified 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 plan’s 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 plan’s 

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 violations—in 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 monitors—on an ongoing basis—the State’s 

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 CMS’s 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 

State 

Standards for Distance or Time Between Providers and Enrollees’ Residences 

Primary Care Providers Specialists 

Arizona 

Within 5 miles for 95 percent of enrollees 

residing within boundary of metropolitan 

Phoenix or Tucson 

(There is no standard for enrollees outside of 

these two areas) 

No standard 

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 

Columbia 

Within 30 minutes’ travel time via public 

transportation or within 5 miles No standard 

Florida Within 30 minutes Within 60 minutes 

Georgia Urban: Within 8 miles* 

Rural: Within 15 miles* 

Urban: Within 30 minutes or 30 miles 

Rural: Within 45 minutes or 45 miles 

Hawaii Urban: Within 30 minutes 

Rural: Within 60 minutes 

Urban: Within 30 minutes 

Rural: Within 60 minutes 

Illinois No standard No standard 

Indiana Within 30 miles Within 60 miles for selected specialists*; 

within 90 miles for other specialists 

Kentucky Urban: Within 30 minutes or 30 miles 

Rural: Within 45 minutes or 45 miles No standard 

Maryland Urban: Within 30 minutes or 10 miles 

Rural: Within 30 minutes or 30 miles No standard 

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 

Mississippi Urban: Within 30 minutes or 30 miles * 

Rural: Within 60 minutes or 60 miles* No standard 

Missouri 

Urban: Within 10 miles† 

Basic: Within 20 miles† 

Rural: Within 30 miles† 

Urban: Within 15 miles for general surgeons; 

within 25 miles for other selected specialists 

Basic: Within 30 miles for general surgeons; 

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) 

State 

Standards for Distance or Time Between Providers and Enrollees’ Residences 

Primary Care Providers Specialists 

Nebraska 

Urban: Within 30 miles*† 

Rural: Within 45 miles† 

Frontier: Within 60 miles† 

Within 90 miles for high-demand specialists 

Nevada Within 25 miles No standard 

New Jersey 

Urban: Within 6 miles for 90 percent of 

enrollees*† 

Rural: Within 15 miles for 85 percent of 

enrollees*† 

Within 60 minutes or 45 miles for 90 percent of 

the enrollees in each county or approved 

subcounty service area 

New Mexico 

Urban: Within 30 miles for 90 percent of 

enrollees 

Rural: Within 45 miles for 90 percent of 

enrollees 

Frontier: Within 60 miles for 90 percent of 

enrollees 

No standard 

New York Urban: Within 30 minutes 

Rural: Within 30 minutes or 30 miles Within 30 minutes or 30 miles 

Ohio If medically necessary care is not within 

30 miles, MCO must provide transportation 

If medically necessary care is not within 

30 miles, MCO must provide transportation 

Pennsylvania Urban: Within 30 minutes* 

Rural: Within 60 minutes* 

Urban: Within 30 minutes for selected 

specialists* 

Rural: Within 60 minutes for selected 

specialists* 

Rhode Island Standard varies by plan* Standard varies by plan* 

South Carolina Within 30 miles No standard 

Tennessee Urban: Within 30 minutes or 20 miles 

Rural: Within 30 minutes or 30 miles 

Within 60 miles for 75 percent of enrollees; 

within 90 miles for all enrollees 

Texas Within 30 miles Within 75 miles 

Utah Within 40 minutes or 40 miles* No standard 

Virginia Urban: Within 30 minutes or 15 miles*† 

Rural: Within 60 minutes or 30 miles*† 

Urban: Within 30 miles 

Rural: Within 60 miles 

Washington 

Urban: Within 10 miles for 90 percent of 

enrollees in the service area* 

Rural: Within 25 miles for 90 percent of 

enrollees in the service area 

No standard 

West Virginia Within 30 minutes* Within 30 minutes for high-demand specialists*; 

within 60 minutes for other specialists 

Wisconsin 

Urban: Within 10 miles for enrollees residing 

in Milwaukee, Racine, or Kenosha 

Rural: Within 20 miles for enrollees residing in 

the remainder of the service areas 

No standard 

* 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 

State 

Maximum Appointment Wait Times (Days) 

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 

Pennsylvania 10* 1 

15* for selected 

specialists; 

10* for others 

1 

*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) 

State 

Appointment Wait Times (Days) 

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 

State Number of Enrollees per

 Primary Care Provider Number of Enrollees per Specialist 

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 

Maryland 2,000 adult enrollees 

1,500 enrollees under 21 No standard** 

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) 

State Number of Enrollees per

 Primary Care Provider Number of Enrollees per Specialist 

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""""'.., ~ DEPARTMENT 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 of health 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 of potential 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 OIG’s 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.