MEDICAID

States Made Multiple 

Program Changes, and 

Beneficiaries 

Generally Reported 

Access Comparable to 

Private Insurance

Report to the Secretary of Health and 

Human Services

November 2012

GAO-13-55

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-55, a report to the 

Secretary of Health and Human Services

November 2012

MEDICAID

States Made Multiple Program Changes, and 

Beneficiaries Generally Reported Access 

Comparable to Private Insurance

Why GAO Did This Study

Medicaid enrollment has grown 

significantly in recent years due to the 

economic downturn. This growth is 

expected to continue as the Patient 

Protection and Affordable Care Act 

potentially extends Medicaid eligibility 

in 2014 to millions of uninsured 

individuals. To better understand 

whether states are providing adequate 

access to medical care for 

beneficiaries, this report examines 

(1) states’ experiences processing 

Medicaid applications, (2) states’ 

changes to beneficiary services and 

provider payment rates, (3) the 

challenges states report to ensure 

sufficient provider participation, and 

(4) the extent to which Medicaid 

beneficiaries reported difficulties 

obtaining medical care. To examine 

the first three objectives, GAO 

administered a nationwide web-based 

survey to Medicaid officials on states’ 

experiences from 2008 through 2011 

and obtained a response rate of 

98 percent. To examine the last 

objective, GAO analyzed data from the 

2008 and 2009 Medical Expenditure 

Panel Survey, the most current 

available at the time of our analysis, to 

assess Medicaid beneficiaries’ 

reported difficulties obtaining care, and 

the 2009 National Health Interview 

Survey to assess their reasons for 

delaying care. To provide context, we 

compared their experiences to those of 

individuals with private insurance or 

who were uninsured.

What GAO Found

From 2008 to 2011, more than half of states reported maintaining or decreasing 

their average Medicaid application processing times—the average number of 

calendar days between the receipt of a new application and the final 

determination of eligibility. The average processing times reported by 39 states 

ranged from 11 to 45 calendar days. For the same time period, however, GAO 

was unable to assess whether states processed applications at a rate that kept 

pace with the number of new applications received each month, because most 

states provided incomplete or inconsistent data.

States reported making numerous changes to provider payments, provider taxes, 

and beneficiary services since 2008. While more states reported provider-rate 

and supplemental payment increases each year from 2008 through 2011, the 

number reporting payment reductions and increased provider taxes also grew. 

More states reported increasing services than limiting them.

Over two-thirds of states reported challenges to ensuring enough Medicaid 

providers to serve beneficiaries—including dental and specialty care providers. 

States cited Medicaid payment rates and a general shortage of providers as 

adding to the challenge. To attract new providers, over half the states reported 

simplifying administrative requirements or increasing payment rates. 

In calendar years 2008 and 2009, less than 4 percent of beneficiaries who had 

Medicaid coverage for a full year reported difficulty obtaining medical care, which 

was similar to individuals with full-year private insurance; however, more 

Medicaid beneficiaries reported difficulty obtaining dental care than those with 

private insurance. Beneficiaries with less than a full year of Medicaid coverage 

were almost twice as likely to report difficulties obtaining medical care as those 

with full-year coverage. Medicaid beneficiaries reported delaying care for reasons 

such as long wait times and lack of transportation.

Percentage of Individuals Who Reported Difficulties Obtaining Necessary Care or Services, by 

Full-Year Insurance Status, Calendar Years 2008-2009

The Department of Health and Human Services reviewed a draft of this report 

and provided technical comments, which GAO incorporated as appropriate.

View GAO-13-55. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov.
Page i GAO-13-55 Medicaid Access

Letter 1 

Background 5

Some States Did Not Report Certain Application Processing Data; 

Most Reported Decreasing or Maintaining Processing Times 9

States Made Numerous Changes to Provider Payments and 

Beneficiary Services 12

States Reported Challenges Ensuring a Sufficient Number of 

Providers 18

Few Full-Year Medicaid Beneficiaries Reported Difficulty 

Obtaining Care, but Experiences Varied 24

Appendix I Scope and Methodology 33

Appendix II States Use of Electronic Medicaid Application Processing and 

Renewal Procedures 42

Appendix III GAO Contact and Staff Acknowledgments 44

Tables

Table 1: Factors States Reported That Affect Provider Participation 

in Medicaid 22

Table 2: State Electronic Processing Procedures for New Medicaid 

Applications 42

Table 3: State Medicaid Renewal Procedures 43

Figures

Figure 1: Number of States Attributing Decreased Application 

Processing Times, since 2008, to Certain Streamlining 

Procedures 11

Figure 2: Number of States Attributing Increased Average 

Application Processing Times, since 2008, to Certain 

Factors 12

Figure 3: Number of States Reporting Increases and Decreases to 

Provider Payment Rates, Calendar Years 2008-2011 14

Contents
Page ii GAO-13-55 Medicaid Access

Figure 4: Number of States Reporting Changes to Supplemental 

Payments, Calendar Years 2008-2011 15

Figure 5: Number of States Reporting Changes to Provider Taxes, 

Calendar Years 2008-2011 16

Figure 6: Number of States Reporting Changes to Benefits or 

Services, Calendar Years 2008-2011 18

Figure 7: Number of States Reporting Challenges to Ensuring 

Enough Participating Medicaid Providers, by Service Type 20

Figure 8: State Reported Efforts to Maintain Existing Pool or 

Attract New Medicaid Providers 23

Figure 9: Percentage of Individuals Who Reported Difficulties 

Obtaining Necessary Care or Services, by Full-Year 

Insurance Status, Calendar Years 2008-2009 25

Figure 10: Percentage of Working-Age Adults and Children with 

Full-Year Coverage Who Reported Difficulties Obtaining 

Necessary Dental Care, by Insurance Status, Calendar 

Years 2008-2009 27

Figure 11: Percentage of Individuals Who Reported Experiencing 

Difficulty Obtaining Necessary Medical Care, by 

Insurance Status, Partial or Full Year, Calendar Years 

2008-2009 29

Figure 12: Percentage of Working-Age Adults (Age 18 to 64) Who 

Reported Difficulty Obtaining Necessary Medical Care, by 

Insurance Status, Partial or Full Year, Calendar Years 

2008-2009 30

Figure 13: Percentage of Individuals Who Cited Specific Reasons 

for Delaying Medical Care in Calendar Year 2009, by 

Insurance Status 31
Page iii GAO-13-55 Medicaid Access

Abbreviations

CHIP State Children’s Health Insurance Program

CHIPRA Children’s Health Insurance Program Reauthorization Act 

 of 2009

CMS Centers for Medicare & Medicaid Services

DSH Disproportionate Share Hospital

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

HCERA Health Care and Education Reconciliation Act

HHS Department of Health and Human Services

ICF/ID Intermediate Care Facilities for Persons with Intellectual 

 Disabilities

MEPS Medical Expenditure Panel Survey

NHIS National Health Interview Survey 

PPACA Patient Protection and Affordable Care Act

UPL Upper Payment Limit

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Page 1 GAO-13-55 Medicaid Access

United States Government Accountability Office

Washington, DC 20548

November 15, 2012

The Honorable Kathleen Sebelius

Secretary of Health and Human Services

Dear Madam Secretary:

Enrollment and expenditures in Medicaid, a federal-state health financing 

program for certain categories of low-income individuals, have grown 

significantly in recent years. During the nation’s recent economic crisis, 

Medicaid enrollment grew 14.2 percent from October 2007 through 

February 2010. During this time, total Medicaid expenditures grew nearly 

21 percent, from $332.2 billion in 2007 to $401.5 billion in 2010.1 Since 

then, enrollment growth has slowed—averaging around 4 percent 

nationally—yet the growth in Medicaid spending continues to be a source 

of concern.2

While recent laws have provided some fiscal relief to states through the 

provision of additional federal funding for Medicaid, they have also limited 

the ability of states to alter their programs. For example, the American 

Recovery and Reinvestment Act of 2009 (Recovery Act) provided a 

temporary increase in the rate at which the federal government matched 

state expenditures, but required states to maintain Medicaid program 

eligibility in order to receive the additional funding.

Economic downturns can create challenges for states 

because tax revenues can decrease, while unemployment—and 

enrollment in Medicaid—can increase. To reduce program spending, 

states generally may make certain changes to their Medicaid programs, 

such as altering payments to providers, limiting eligibility, eliminating 

optional services, or reducing the amount, duration, or scope of services. 

3

 

1

See 2001 Actuarial Report on the Financial Outlook for Medicaid (Office of the Actuary, 

Centers for Medicare & Medicaid Services, Department of Health and Human Services, 

Mar. 16, 2012).

The Patient Protection 

2

See GAO, State and Local Governments’ Fiscal Outlook, April 2012 Update, 

GAO-12-523SP (Washington, D.C.: Apr. 2, 2012).

3

Pub. L. No. 111-5, § 5001,123 Stat.115, 496-502 (2009). The Recovery Act initially 

provided states with an estimated $87 billion in increased federal funds for Medicaid from 

February 2009 through December 2010. In August 2010, Congress extended the 

increased federal matching rate through June 2011, although at a lower level than what 

was provided under the Recovery Act. See Pub. L. No. 111-226, §201, 124 Stat. 2389, 

2393-4 (2010).

 
 

Page 2 GAO-13-55 Medicaid Access

and Affordable Care Act of 2010 (PPACA)4 requires states to expand 

their Medicaid programs to cover additional individuals and provides an 

enhanced federal match for this coverage.5 PPACA also makes other 

changes to Medicaid eligibility and payment, such as requiring states to 

maintain their current levels of eligibility for Medicaid beneficiaries and 

increasing payment rates for Medicaid primary care services in 2013 and 

2014.6

 

4

Pub. L. No. 111-148, 124 Stat. 119 (2010) (PPACA), as amended by the Health Care 

and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (HCERA).

For purposes of this report, references to PPACA include the amendments made by 

HCERA.

Potential Medicaid expansions under PPACA are estimated to 

result in enrollment of about 7 million additional individuals in 2014 

5

Effective January 1, 2014, states must expand Medicaid eligibility to non-pregnant 

individuals under age 65 who have household incomes that do not exceed 133 percent of 

the federal poverty level for the applicable family size, who are not entitled to or enrolled in 

Medicare, and who are not already required to be covered under Medicaid. States will 

receive an increased federal match for newly eligible adults starting at 100 percent in 2014 

and gradually decreasing to 90 percent in 2020. 42 U.S.C. §§1396a(a)(10)(A)(i)(VIII), 

1396d(y). As initially set forth in PPACA, states that chose not to expand Medicaid 

coverage faced the potential loss of all federal Medicaid funds, including for the population 

already covered under the current program. However, the U.S. Supreme Court has ruled 

that states that choose not to expand Medicaid coverage will forgo only the enhanced 

federal matching funds associated with such expanded coverage. See National 

Federation of Independent Business, et al., vs. Sebelius, Sec. of Health and Human 

Services, et al., 132 S. Ct. 2566, 2012 WL 2427810 (U.S. June 28, 2012).

6

42 U.S.C. §§ 1396a(a)(13)(C), (gg),1396u-2(f). States must maintain Medicaid eligibility 

standards for children from PPACA’s enactment, March 23, 2010, until October 1, 2019, 

and for adults, until the Department of Health and Human Services (HHS) determines an 

exchange in the state is operational. (PPACA requires states to establish exchanges—

marketplaces through which individuals can access private health plans.) Exceptions to 

this maintenance-of-effort requirement may be granted for certain adults with income 

above 133 percent of the federal poverty level for states experiencing or projecting a 

budget deficit. In addition, payment rates for primary care services paid to Medicaid 

providers either by states or Medicaid managed care plans generally must be increased to 

Medicare reimbursement levels for those services; such increases relative to a state’s 

December 2009 rates will be federally funded. On November 6, 2012, CMS published a 

final rule implementing this requirement, in which the agency specifies which services and 

types of providers qualify for the increased payments and the methods for calculating the 

federal share for the increased payment amount. Under this rule, CMS also will require 

states to report data on primary care provider participation before and after the increased 

payments, which CMS will make publicly available. 77 Fed. Reg. 66,670 (November 6, 

2012). 
 

Page 3 GAO-13-55 Medicaid Access

growing to 11 million in 2022.7

In October 2010, we reported on changes states were making to sustain 

their Medicaid programs after certain federal funding increases from the 

Recovery Act lapsed. Some of these changes could affect beneficiaries’ 

access to care.

While it is too early to assess the extent to 

which states will expand Medicaid coverage to this newly eligible 

population, any growth in Medicaid is likely to place additional pressure 

on states to manage their programs, maintain or increase their pool of 

providers, and ensure access to needed health care services for Medicaid 

beneficiaries.

8

To address the first three objectives, we administered a web-based 

survey from February 2012 to May 2012 to Medicaid officials in the 

50 states, the District of Columbia, and the 5 largest U.S. territories, and 

Over half of the states reported making administrative 

changes that could affect Medicaid application processing time, such as 

decreasing the number of staff or staff hours available for processing 

Medicaid applications and increasing furlough days. Additionally, states 

reported changes to certain services and payments to providers that 

could affect beneficiary access. Such changes raise questions about 

whether Medicaid is meeting the health care needs of the current 

beneficiaries and whether the expansion of Medicaid may further 

exacerbate issues of access for beneficiaries. To assess factors that can 

affect access and beneficiaries’ experiences obtaining care, this report 

examines (1) states’ experiences processing Medicaid applications, 

(2) changes that states have made to beneficiary services and provider 

payment rates, (3) the challenges states report with regard to ensuring 

sufficient provider participation, and (4) the extent to which Medicaid 

beneficiaries’ reported difficulties obtaining medical care.

 

7

Enrollment numbers reflect new enrollment in both Medicaid and the Children’s Health 

Insurance Program. See Congressional Budget Office, Estimates for the Insurance 

Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court 

Decision (July 2012). 

8

See GAO, Recovery Act: Increased Medicaid Funds Aided Enrollment Growth, and Most 

States Reported Taking Steps to Sustain Their Programs, GAO-11-58 (Washington, D.C.: 

Oct. 8, 2010). In this report, we described actions states were taking to address program 

sustainability after funding from the Recovery Act was no longer available.
 

Page 4 GAO-13-55 Medicaid Access

obtained a response rate of 98 percent.9 In this survey, we generally 

asked about states’ experiences from 2008 through 2011. For the webbased survey, we relied on the survey response reported by the primary 

contact for the state’s Medicaid program. When we asked states about 

implementing various efforts, such as application processing 

improvements, we generally gave a time frame for implementation, and 

state efforts implemented prior to that time frame are not included in the 

report. We did not independently verify the accuracy of the data reported 

by states, but we reviewed all survey responses for internal consistency. 

In addition, we completed our state survey field work prior to the June 28, 

2012, decision by the Supreme Court on certain aspects of PPACA, 

including the Medicaid expansion provision. Accordingly, state responses 

were provided to us before they had analyzed any potential effect of the 

decision on their own state. To address the fourth objective, we analyzed 

two national surveys, the National Health Interview Survey (NHIS) and 

the Medical Expenditure Panel Survey (MEPS), to examine the extent to 

which Medicaid beneficiaries reported difficulties obtaining care. Our 

MEPS analysis was based on national survey data from 2008 and 2009, 

the most recent data available at the time of our analysis. Our NHIS 

analysis was based on the 2009 survey.10 Both of these national surveys 

rely on information reported by individuals. To provide context for 

difficulties obtaining care reported by Medicaid beneficiaries, we 

examined the extent to which individuals with private insurance or those 

who are uninsured reported such difficulties. We also conducted the 

analysis across different age groups, including children, working-age 

adults,11

 

9

Fifty states, the District of Columbia, and 4 U.S. territories (American Samoa, Guam, 

Puerto Rico and the Commonwealth of the Northern Mariana Islands) responded to the 

survey. The U.S. Virgin Islands did not complete the survey. For the purposes of this 

report, we are referring to all 56 jurisdictions that we surveyed as states. 

and those 65 and older, but small sample sizes limited the 

reliability of some analyses, and therefore we did not report them. For the 

MEPS analysis, children with Medicaid also included those with coverage 

10Data from the 2010 NHIS survey were available, but we chose to analyze the 2009 

survey so the time period would be compatible with the MEPS analysis.

11In this report, the term “working-age adults” refers to those ages 18-64.
 

Page 5 GAO-13-55 Medicaid Access

under the State Children’s Health Insurance Program (CHIP).12 We 

examined differences in reported difficulty obtaining care between 

beneficiaries reporting fair or poor health and those reporting better health 

and between those with full-year coverage and less than full-year 

coverage.13

We conducted this performance audit from December 2011 through 

November 2012 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

For the NHIS and MEPS surveys, we reviewed relevant 

documentation describing how these data are collected and processed, 

and examined other research that has used these data to report on 

potential delays in obtaining health care services to check our results 

against similar analyses. We determined that the data we used in this 

report were sufficiently reliable for the purposes of our engagement. (See 

app. I for additional information on our scope and methodology.)

Medicaid finances health care for certain categories of low-income 

individuals, including pregnant women, children, certain low-income 

parents, persons with disabilities, and persons who are elderly.14

 

12CHIP is a federal-state program that generally provides health care coverage to children 

in low-income families whose incomes exceed the eligibility requirements for Medicaid. 

States have the choice of three design approaches for their CHIP programs: (1) a 

Medicaid expansion program, (2) a separate child health program, or (3) a combination 

program, which has both a Medicaid expansion program and a separate child health 

program.

In 

addition, states can expand Medicaid eligibility to other individuals, 

13Individuals with less than full-year coverage reported having insurance coverage for 

between 1 to 11 months. Individuals may be covered under Medicaid for only part of the 

year for a variety of reasons, including changes in income. In this report, we used a 

95 percent confidence level and compared upper and lower confidence intervals to 

determine whether any differences we found were statistically significant. Statistical 

significance indicates that the difference between observations is unlikely due to chance 

alone.

14Parents are eligible for Medicaid under certain circumstances. For example, states must, 

at a minimum, cover parents who meet the state’s 1996 Aid to Families with Dependent 

Children eligibility criteria, which vary among states and include both financial and 

categorical components.

Background 
 

Page 6 GAO-13-55 Medicaid Access

including children and eligible parents with incomes above the current 

minimum levels. Under broad federal requirements, states administer the 

day-to-day operations of their Medicaid programs; activities that include 

determining whether applicants are eligible for Medicaid, setting the 

scope of covered services, paying providers, and ensuring access to 

covered services. The Centers for Medicare & Medicaid Services (CMS), 

a federal agency within the Department of Health and Human Services 

(HHS), oversees state Medicaid programs at the federal level. States are 

required to ensure that all individuals who want to apply for Medicaid 

coverage have the opportunity to do so and must, with reasonable 

promptness, provide coverage to applicants who are determined 

eligible.15 In general, states are required to determine eligibility for 

individuals who apply for Medicaid within 45 days from the date of 

application, and within 90 days for those who apply on the basis of 

disability.16

States’ Medicaid programs must cover a set of mandatory services, 

including those provided by primary and specialty care physicians, as well 

as services provided in hospitals, clinics, and other settings. States may 

elect to cover additional optional benefits and services, such as home and 

community-based services, personal care, and rehabilitative services, 

under their Medicaid programs. In some cases, not all beneficiaries are 

eligible for all services. For example, Medicaid requires states to cover 

necessary dental care for children, but dental coverage for adults is 

optional.

In some states, Medicaid applications are reviewed and 

eligibility is determined at the county level, while other states have 

centralized their eligibility determination processes.

17 Subject to federal requirements,18

 

15See 42 U.S.C.§ 1396a(a)(8).

states may establish the 

amount, duration, and scope of the mandatory and optional services 

covered in their Medicaid programs. For example, states may limit the 

number of visits or the days of care that are provided.

16See 42 CFR § 435.911. These time standards cover the period from the date an 

application is submitted to the date the state mails notice of the decision.

17As part of the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, 

states must provide comprehensive and preventive health care services, including dental 

services, for individuals who are under 21 years of age who are enrolled in Medicaid. 

42 U.S.C. §§ 1936a(a)(43), 1396d(r)(3).

18States must provide Medicaid services sufficient in amount, duration, and scope to 

reasonably achieve their purpose. 42 C.F.R. § 440.230.
 

Page 7 GAO-13-55 Medicaid Access

States are responsible for setting Medicaid provider payment rates within 

certain federal requirements. Specifically, federal law requires that state 

Medicaid payments to providers are consistent with efficiency, economy, 

and quality of care and are sufficient to enroll enough providers so that 

services are available to beneficiaries at least to the extent that they are 

available to the general population in the same geographic area.19

In addition to payments made directly to providers for services to 

beneficiaries, most states also make supplemental payments that are 

separate from and in addition to regular Medicaid payments. 

Supplemental payments include Disproportionate Share Hospital (DSH) 

payments, which states are required by federal law to make to hospitals 

that treat large numbers of Medicaid and low-income individuals; DSH 

payments cannot exceed the unreimbursed cost of furnishing inpatient 

and outpatient services to Medicaid beneficiaries and the uninsured. 

Many states also make other optional supplemental payments that are 

above the standard Medicaid payment rates but within the Upper 

Payment Limit (UPL).

In 

addition, states must identify the methodologies for making provider 

payments in their state plans, and such methodologies must be approved 

by CMS.

20 We refer to these payments as non-DSH 

supplemental payments. In fiscal year 2010, states and the federal 

government made at least $32 billion in supplemental payments—

representing over 8 percent of the Medicaid program’s total 

expenditures—with a federal share of at least $19.8 billion. CMS is 

responsible for overseeing these payment arrangements, including 

whether states are appropriately financing their share.21

 

19See 42 U.S.C. § 1396a(a)(30)(A). On May 6, 2011, the Centers for Medicare & Medicaid 

Services (CMS) issued a proposed rule entitled Medicaid Program: Methods for Assuring 

Access to Covered Medicaid Services, regarding federal guidelines for approaches for 

states to demonstrate compliance with some of these requirements. 76 Fed. Reg. 26342 

(May 6, 2011). As of October 1, 2012, this rule had not been finalized.

20The Upper Payment Limit is the estimated amount that Medicare pays for comparable 

services.

21Over the years, we and others have reported that states were shifting costs 

inappropriately through several financing methods, notably the use of supplemental 

payments. A variety of federal legislative, regulatory, and CMS actions have helped curb 

inappropriate arrangements, but gaps remain. See GAO, High Risk Series: An Update,

GAO-11-278 (Washington, D.C.: February 2011).
 

Page 8 GAO-13-55 Medicaid Access

States may also use provider taxes and certain other sources of revenue 

to finance their Medicaid programs. Provider taxes are taxes, fees, 

assessments, or other mandatory payments that states may impose on 

the provision of or payment for certain types of health care items or 

services, such as inpatient hospital and nursing facility services. States 

may use revenue from provider taxes for their state share of Medicaid 

expenditures only if the taxes meet certain criteria.22 Many states use 

revenue from a provider tax on a certain type of provider to increase 

Medicaid payment rates for the same type of provider, and a state could 

effectively increase a payment rate for a provider without using additional 

state funds to finance the increase if the revenue from the provider tax 

and the federal share of the payment rates account for the total 

increase.23

States also may implement certain options to streamline Medicaid 

eligibility determinations. For example, the Children’s Health Insurance 

Program Reauthorization Act of 2009 (CHIPRA) established new 

performance bonuses for states adopting at least five of eight specified 

policies to simplify Medicaid and CHIP enrollment and retention 

procedures for children. Possible enrollment and retention simplification 

measures include adopting 12-month continuous eligibility, eliminating inperson interviews, adopting express lane eligibility, or implementing 

presumptive eligibility.24

 

22States may receive federal matching funds for provider taxes only if such taxes are 

broad-based, uniformly imposed, and do not result in any taxpayers being held harmless 

(i.e., receiving state funds to reduce the net payment to the state to below the amount of 

the tax). CMS may waive the broad-based and uniform tax requirements if the net effect of 

the tax is generally redistributive and the tax is not directly related to Medicaid payments. 

42 U.S.C. § 1396b(w), 42 C.F.R. §§ 433.68, 72.

PPACA also specified additional policies to 

streamline enrollment and retention in Medicaid and CHIP. For example, 

PPACA requires states to establish a process by which individuals can 

23See also Congressional Research Service, Medicaid Provider Taxes, RS22843 

(Mar. 15, 2012).

24See Pub. L. No. 111-3, § 104, 123 Stat. 8, 17-23. States are eligible for these 

performance bonuses for fiscal years 2009 through 2013. Under continuous eligibility, 

states allow children to remain eligible for Medicaid or CHIP for a full year before any 

redetermination of eligibility, regardless of changes in household income. Under the 

express lane eligibility option, states may rely on findings, including income data, from 

certain other state agencies for Medicaid or CHIP eligibility determination. For 

presumptive eligibility, states may allow qualified entities, such as, community-based 

organizations or schools, to screen for eligibility and immediately enroll eligible individuals

for a defined period of time.
 

Page 9 GAO-13-55 Medicaid Access

apply for or renew enrollment in Medicaid using an electronic signature 

beginning in 2014.25

Of the 55 states that responded to our survey, 39 states provided specific 

data on average application processing times for new Medicaid 

applications in 2012, and 43 were able to report generally on whether 

average application processing time increased, decreased, or remained 

the same since 2008.26 The average application processing time is the 

average number of calendar days between the receipt of a new 

application and the final determination of eligibility. Among the 39 states 

that reported data, the current application processing ranged from 11 to 

45 calendar days, with a median of 25 calendar days.27

We also asked more generally whether states’ application processing 

times changed since 2008. Of the 55 states that responded, 30 reported 

decreasing (19 states) or maintaining (11 states) their average processing 

times for new Medicaid applications, 13 states reported increased 

processing times, and 12 states reported not knowing whether their 

processing times had changed.

Sixteen states 

could not report their average processing times, of which about half noted 

that they do not track these data or that they track them differently than 

how they were requested in our survey. For example, 4 states noted that 

they only tracked whether an application met the mandated time frames 

for the application—not the specific number of days. Another state 

reported that its data on application processing times were not reliable 

because of differences in the way the data were reported by counties.

 

2542 U.S.C. §1396w-3. As a condition of receiving federal Medicaid funds, states must 

establish an Internet website through which individuals can apply for or renew Medicaid 

enrollment and may consent to enrollment or reenrollment through an electronic signature. 

This enrollment website must be linked to the exchange and CHIP websites, ensuring that 

individuals will be considered for eligibility for those programs if they are determined 

ineligible for Medicaid.

26The survey included a question that asked states to report average application 

processing time in calendar days. A separate question asked states generally whether 

application processing time had changed—increased, decreased, or remained the same—

since 2008, but did not ask states to report on the magnitude of the change.

27Data presented here were for 95 percent of the sample of states reporting a current 

average processing time. Data were excluded for one state that reported an average 

processing time of 9 calendar days and for one U.S. territory that reported 120 calendar 

days.

Some States Did Not 

Report Certain 

Application 

Processing Data; Most 

Reported Decreasing 

or Maintaining 

Processing Times
 

Page 10 GAO-13-55 Medicaid Access

Among the 19 states that reported decreased average processing times 

for new applications, 15 states attributed the decreases to efforts to 

streamline application procedures.28 These 15 states most frequently 

cited the use of electronic applications and the elimination of face-to-face 

interviews as streamlining procedures that facilitated decreases in 

application processing times. (See fig. 1.) Some of these 15 states also 

cited a decrease in documentation requirements, use of express lane 

eligibility, revised or shortened applications, or use of presumptive 

eligibility for helping decrease application processing times. Specifically:

• Six states reported that the use of express lane eligibility—the 

reliance on findings from certain other state agencies or state incometax data to determine eligibility for Medicaid—helped decrease 

application processing time.29

• Five states reported that their decreased processing times were 

related to the use of presumptive eligibility procedures, in which 

authorized entities, including community-based organizations and 

schools, can screen and immediately enroll eligible individuals into 

Medicaid for a defined period of time.

• A few states also attributed decreases in application processing times 

to other factors not directly related to streamlining application 

procedures, including additional staff or staff hours (3 states), more 

intake facilities (2 states) or a reduction in the volume of new 

applications received (1 state).

(See app. II for further information on states’ efforts to use electronic 

application processing and streamlining the renewal application process.)

 

28Survey results do not indicate the number of states that use a particular application 

procedure—only the extent to which a state considered this a factor that affected its 

application processing time. States could cite more than one type of effort to streamline 

application procedures. 

29These agencies may include those administering programs including Supplemental 

Nutrition Assistance, National School Lunch Program, Temporary Assistance for Needy 

Families, and Head Start.
 

Page 11 GAO-13-55 Medicaid Access

Figure 1: Number of States Attributing Decreased Application Processing Times, since 2008, to Certain Streamlining 

Procedures

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifteen states attributed decreased application time to one or 

more application streamlining procedures, as described in the figure above. Survey results do not 

indicate the number of states that use a particular application procedure—only the extent to which a 

state considered this a factor that affected its application processing time.

a

Express lane eligibility allows states to rely on findings from certain other state agencies or state 

income tax data to determine eligibility for Medicaid.

b

Under presumptive eligibility, states allow authorized entities, such as community-based 

organizations or schools, to screen for eligibility and immediately enroll eligible individuals for a 

defined time period.

Almost all of the 13 states that reported an increase in average 

processing times since 2008 attributed these increases to a growth in the 

volume of new applications received. (See fig. 2.) States could cite more 

than one factor, and 9 of these states also identified reductions in staff as 

a result of layoffs, hiring freezes, or furloughs as factors related to 

increased application processing time. One state that reported an 

increase in application processing times indicated that, in addition to an 

increase in the volume of applications received, its staff were learning to 

use a new computer system to process applications.
 

Page 12 GAO-13-55 Medicaid Access

Figure 2: Number of States Attributing Increased Average Application Processing Times, since 2008, to Certain Factors

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Thirteen states attributed their increased application processing 

time to one or more factors.

Because of data limitations, we were unable to assess the extent to which 

the number of applications states processed kept pace with the number of 

new applications received each month from January 2008 through 

December 2011. Most states provided incomplete or inconsistent data on

new applications received and processed. For example, 25 states 

provided incomplete data for 2008 and 15 states provided incomplete 

information for 2011. States cited various reasons for providing 

incomplete applications data, including upgrades to their data systems 

since 2008 and data systems that do not differentiate between 

applications received and applications processed. For the states that did 

submit monthly applications data, there were differences among states in 

the way these data were reported. For example, one state reported totals 

of Medicaid applications processed that were cumulative over time, rather 

than just those processed within a month. (For more information, see 

app. I.)

States reported changes—both increases and decreases—to provider 

payment rates, provider taxes, and beneficiary services since 2008. In a 

given year, states could make both increases and decreases; for 

example, states could reduce payment rates to certain types of providers, 

while increasing payment rates to others. Overall, more states reported 

payment and service increases than decreases. However, the number of 

states reporting payment decreases and service limitations grew since 

2008.

States Made 

Numerous Changes to 

Provider Payments 

and Beneficiary 

Services 
 

Page 13 GAO-13-55 Medicaid Access

The number of states that reported making at least one payment rate 

reduction grew from 13 in 2008 to 34 in 2011, while the number of states 

increasing at least one provider payment rate fell over the same period. 

Overall, more states reported increasing provider payment rates in 2011 

than reducing them.30 (See fig. 3.) States most frequently reported 

reducing payment rates for hospitals across all 4 years. For example, in 

2011, 19 states reported payment rate reductions for inpatient hospitals 

and 17 reported reductions for outpatient hospitals. Of the states that 

increased provider payment rates, more states generally reported 

increasing payment rates for nursing facilities than any other provider 

type across all 4 years. For example, in 2011, 19 states reported an 

increase in rates for nursing facilities, 18 states reported increased 

payment rates for Intermediate Care Facilities for Persons with 

Intellectual Disabilities (ICF/ID), and 14 states reported increased 

payment rates for clinics.

 

30The survey asked states to report whether a certain type of change was made for a 

provider type in a year, but did not ask for a detailed description of the change, including 

the magnitude of the change. A state may have made more than one type of change for a 

provider type in a year.

The Number of States 

Reducing Providers’ 

Payments or Implementing 

Supplemental Payments 

Grew
 

Page 14 GAO-13-55 Medicaid Access

Figure 3: Number of States Reporting Increases and Decreases to Provider 

Payment Rates, Calendar Years 2008-2011

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to questions on changes to payment 

rates for 13 provider types. States could report multiple increases and decreases in payment rates in 

a year to different provider types. States that reported more than one increase or decrease in 

payment rates in a year were counted for one increase or one decrease, respectively, or both, for that 

year.

From 2008 through 2011, 20 or more states reported increasing their use 

of supplemental payments, which are payments separate from and in 

addition to regular Medicaid payments.31

 

31Supplemental payments include DSH and non-DSH supplemental payments.

This included both states that 

added new supplemental payments or increased existing ones. The 

number of states that reduced supplemental payments was greater in 

2011 (10 states) than 2008 (4 states). (See fig. 4.) States most often cited 

inpatient hospitals, outpatient hospitals, and nursing facilities as recipients 

of new or increased supplemental payments across all years. These 
 

Page 15 GAO-13-55 Medicaid Access

increases in additional supplemental payments coincided with states 

reporting more payment rate increases for nursing facilities and more rate 

decreases for inpatient and outpatient hospitals.

Figure 4: Number of States Reporting Changes to Supplemental Payments, 

Calendar Years 2008-2011

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty five states responded to this question. States could report 

both implementing a new or increasing an existing supplemental payment and decreasing a 

supplemental payment in a year. States that reported more than one increase or decrease in 

supplemental payments in a year were counted for one increase or one decrease, respectively, or 

both, for that year.

The number of states implementing new or increasing existing provider 

taxes more than doubled from 12 states in 2008 to 26 states in 2011. In 

contrast, the number of states that reported decreasing or eliminating 

provider taxes fell during the same time period—from 13 states in 2008 to 

4 states in 2011. (See fig. 5.) Almost all of the provider taxes that states 

reported implementing or increasing were for institutional providers—

inpatient hospitals, outpatient hospitals, nursing facilities, inpatient mental 

health providers, and ICF/ID. States most frequently reported that the 

The Number of States 

Implementing New or 

Increased Provider Taxes 

Grew
 

Page 16 GAO-13-55 Medicaid Access

purpose was to avoid cuts in services or payment rates, rather than 

expanding services or increasing provider payment rates.

Figure 5: Number of States Reporting Changes to Provider Taxes, Calendar Years 

2008-2011

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report 

both implementing a new or increased provider tax and implementing a decrease in provider taxes. 

States that reported more than one increase or decrease in provider taxes in a year were counted as 

one increase or one decrease, respectively, or both, for that year.
 

Page 17 GAO-13-55 Medicaid Access

The number of states reporting service increases was relatively stable—

ranging from 26 to 31 states—while the number of states reporting 

service limitations generally grew from 2008 through 2011.32

 

32States were asked about changes to a variety of specific Medicaid services by provider 

and benefit type. Changes to benefit types included changes to managed care plan 

benefits, prescription drug formularies, and beneficiary copays and premiums. For the 

purposes of this report, services include provider-type services and these Medicaid 

benefits.

(See fig. 6.)

From 2008 through 2011, states reported making more changes to 

coverage for dental, primary, and specialty care services and prescription 

drug benefits than for other services. For example, in 2011, six states 

reported increasing coverage for dental services, and nine states reported 

decreases. Similarly, eight states reported that they increased 

prescription drug formularies, and seven states reported that they limited 

them in 2011. From 2008 through 2011, states reported the fewest 

changes to coverage for ICF/ID and nursing facility services.

The Number of States 

Implementing Beneficiary 

Service Limitations Grew
 

Page 18 GAO-13-55 Medicaid Access

Figure 6: Number of States Reporting Changes to Benefits or Services, Calendar 

Years 2008-2011

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report 

both an increase and limitation in benefits and services in a year. States that reported more than one 

increase or limitation on a benefit or service in a year were counted as one increase or one decrease, 

respectively, or both, for that year.

Thirty-eight states reported that they experienced challenges ensuring 

enough participating Medicaid providers.33

 

33The state responses described here reflect their experiences ensuring a sufficient 

number of Medicaid providers in fee-for-service Medicaid, primary care case 

management, and with managed care organizations. 

In general, states attributed 

these challenges to a shortage of providers and Medicaid payment rates, 

but also cited other issues, such as missed appointments and 

administrative burden, as factors that influenced provider participation. 

States reported efforts to simplify administrative processes to retain and 

States Reported 

Challenges Ensuring a 

Sufficient Number of 

Providers 
 

Page 19 GAO-13-55 Medicaid Access

attract Medicaid providers and, to a lesser extent, reported efforts to 

increase payment rates or other financial incentives.

Of the 55 states responding to our survey, 38 states reported 

experiencing challenges to ensuring enough participating providers for 

Medicaid beneficiaries.34

 

34One recent study found that physicians’ acceptance rate of new Medicaid patients 

varied across the states, ranging from about 40 to 99 percent of physicians accepting new 

Medicaid patients in 2011. Overall, physicians were less likely to take new Medicaid 

patients than they were to take patients with Medicare, private insurance, or who self-pay. 

See S. Decker, “In 2011 Nearly One-third of Physicians Said They Would Not Accept New 

Medicaid Patients, but Rising Fees May Help, Health Affairs,” vol. 31, no. 8 (August 2012). 

Ensuring sufficient dental providers was 

particularly challenging—but states also reported that ensuring sufficient 

provider participation in specialty care was problematic. Specifically, 

states most frequently reported having difficulty ensuring sufficient 

Medicaid providers for psychiatry, obstetrics and gynecology, surgical 

specialties, and pediatric services. To a lesser extent, states also cited 

challenges ensuring enough dermatology and orthopedic service 

providers. In contrast, fewer states indicated challenges to ensuring 

adequate nursing facility and community long-term care providers. (See 

fig. 7.)

Over Two-Thirds of States 

Reported Challenges 

Ensuring Sufficient 

Providers, Including 

Dental and Specialty 

Providers
 

Page 20 GAO-13-55 Medicaid Access

Figure 7: Number of States Reporting Challenges to Ensuring Enough Participating 

Medicaid Providers, by Service Type

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to this question. States could select 

more than one service for which they considered it challenging to ensure enough participating 

providers.

To monitor provider participation, states reported using provider 

enrollment data, utilization or claims data, and datasets such as the 

Healthcare Effectiveness Data and Information Set.35 For example, 

34 states reported that they analyze provider enrollment data and 

24 states reported that they analyze utilization or claims data to monitor 

provider participation in primary or specialty care, or both.36

 

35The Healthcare Effectiveness Data and Information Set, which is managed by the 

National Committee for Quality Assurance, is a tool used by health plans across the 

country to measure the plans’ performance on certain dimensions of care and service.

Additionally, 

18 states indicated that they have identified data sources that they plan to 

36These data reflect states’ fee-for-service Medicaid programs. 
 

Page 21 GAO-13-55 Medicaid Access

use to meet future requirements to measure beneficiary access to 

services under CMS’s proposed regulation, which if finalized, would 

require states to conduct access reviews for a subset of services each 

calendar year and release the results to the public.37

When asked about factors affecting provider participation, states cited an 

overall shortage of providers, low payment rates, and other factors—such 

as missed appointments, and physicians’ difficulties referring Medicaid 

patients to specialists.

Most states reported 

that they will analyze claims data or provider enrollment data to meet this 

requirement. To a lesser extent, states noted that they will assess other 

sources such as provider and beneficiary surveys as a means to measure 

access to services in the state. States that use managed care 

organizations also cited oversight of contract requirements as a way to 

ensure access.

38 (See table 1.) The factors cited by states are 

similar to those found in published research. For example, some studies 

have shown that Medicaid payment rates strongly influence provider 

willingness to participate in the program,39 while other studies have 

indicated that the level of payment was not the sole driver of the decision 

to participate. For example, a study that examined the willingness of 

primary care providers to accept new Medicaid patients found that while 

higher Medicaid payment rates were associated with a greater probability 

of primary care providers accepting all or most new Medicaid patients, the 

effects were relatively modest—suggesting that other factors affect the 

decision to accept Medicaid patients.40

 

37See 76 Fed. 26342 (May 6, 2011). 

According to this study, other 

38Our prior work also found that physicians reported difficulties referring Medicaid children 

to specialists. See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children 

but Have Difficulty Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.: 

June 30, 2011). 

39One study that analyzed data the years before and after Maryland increased Medicaid 

payment rates to physicians found that physician participation had increased in the state 

following the rate increases. See S. H. Fakhraei, “Payments for Physician Services: An 

Analysis of Maryland Medicaid Reimbursement Rates,” International Journal of Healthcare 

Technology and Management, vol. 7, numbers 1 / 2 (2006). Also, another study found a 

positive relationship between state Medicaid payment levels and pediatrician participation. 

See S. Berman, J. Dolins, S. Tang, and B. Yudkowsky, “Factors That Influence the 

Willingness of Private Primary Care Pediatricians to Accept More Medicaid Patients,” 

Pediatrics, vol. 110, no. 2 (2002).

40P. Cunningham, State Variation in Primary Care Physician Supply: Implications for 

Health Reform Medicaid Expansions, Research Brief, no. 19 (Center for Studying Health 

System Change, March 2011).
 

Page 22 GAO-13-55 Medicaid Access

factors, such as the structure of the practice and Medicaid administrative 

requirements can affect the decision to participate as well.

Table 1: Factors States Reported That Affect Provider Participation in Medicaid 

Factors affecting provider participation

Number of 

states

Shortage of providers serving all insurance groups 33

Low Medicaid payment rates 33

Missed appointments 31

Administrative burden of enrolling as a Medicaid provider 17

Administrative burden relating to submitting claims and claims 

processing 15

Difficulty referring to specialists 14

Source: GAO analysis of states’ survey responses.

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report 

more than one factor.

Another study of physicians found that, in light of the multiple factors that 

may influence willingness to serve Medicaid beneficiaries, an increase in 

Medicaid payment rates must be accompanied by other program 

simplifications in order to influence physician participation.41 Similarly, in a 

study on dental care, states reported particular challenges ensuring 

enough participating dental providers. While this study found that dental 

provider participation increased following rate increases in the states 

examined, the rate increases were not sufficient on their own to improve 

Medicaid beneficiaries’ access to dental care. The study also noted that 

streamlining administrative processes and changing dentists’ perception 

of Medicaid could improve participation among them as well.42

 

41See P. Cunningham and A. O’Malley, “Do Reimbursement Delays Discourage Medicaid 

Participation by Physicians?” Health Affairs, Web Exclusive, (November 2008), doi: 

10.1377/hlthaff.28.1.w17.

42See A. Borchgrevink, A. Snyder, S. Gehshan, The Effects of Medicaid Reimbursement 

Rates on Access to Dental Care (National Academy for State Health Policy, March 2008).
 

Page 23 GAO-13-55 Medicaid Access

Thirty-eight states reported making at least one administrative or payment 

rate change to encourage provider participation. These efforts included 

streamlining enrollment, increasing payments, increasing the speed of 

claims processing, and reducing administrative burdens. (See fig. 8.) 

Other efforts cited by states included direct recruitment of providers, 

improved prior authorization of services, and assistance to providers 

through training, education efforts, and improved claims resolution.

Figure 8: State Reported Efforts to Maintain Existing Pool or Attract New Medicaid 

Providers

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that 

responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report 

more than one type of effort to maintain existing or attract new Medicaid providers. Survey results do 

not indicate the overall number of states that use a particular application procedure—only the extent 

to which a state considered this an effort to maintain existing or to attract new Medicaid providers.

States Implemented 

Administrative and 

Payment Changes to 

Encourage Provider 

Participation
 

Page 24 GAO-13-55 Medicaid Access

PPACA provided an increase in Medicaid payments for primary care 

services in 2013 and 2014, and we asked states the extent to which these 

payments will assist in increasing primary care participation. Of the 

55 states that responded to this question, 24 indicated that they were 

uncertain whether such an increase would assist the state in boosting 

participation of Medicaid primary care providers. Seventeen states 

reported that the increase will help to some extent, while 3 reported it will 

help a great extent. Nine states reported that the increase will not help 

with participation. Various states reported a number of possible reasons 

that the increase may not help with provider participation, including its 

temporary nature, because provider payment with the increase will still fall 

below commercial rates, and because of a provider shortage in the state, 

among other reasons.

In calendar years 2008 and 2009, less than 4 percent of all Medicaid 

beneficiaries enrolled for a full year reported difficulty obtaining necessary 

medical care or prescription medicines, a percentage similar to individuals 

with full-year private insurance. The extent to which Medicaid 

beneficiaries reported difficulties obtaining medical care varied by age 

and whether they were enrolled for a full or partial year. Medicaid 

beneficiaries also reported delaying care for a variety of reasons, most 

commonly due to not having transportation, a long wait once at the 

doctor’s office, and being unable to get an appointment soon enough.

Beneficiaries covered by Medicaid for a full year reported low rates of 

difficulty obtaining necessary medical care and prescription medicine, 

similar to those with private insurance for a full year.43

 

43We added together those individuals who reported being unable to obtain or had delays 

in obtaining needed medical care to report on those who had difficulty obtaining care. 

In calendar years 

2008 and 2009, approximately 3.7 percent of Medicaid beneficiaries 

enrolled for a full year and 3 percent of individuals enrolled in private 

insurance for a full year reported difficulties obtaining needed medical 

care; the difference between these two groups was not statistically 

significant. In addition, 2.7 percent of full-year Medicaid beneficiaries 

reported difficulty obtaining needed prescription medicines and about 

2.4 percent of individuals with full-year private insurance reported the 

same issue—also not statistically significant. Full-year Medicaid 

Few Full-Year 

Medicaid 

Beneficiaries 

Reported Difficulty 

Obtaining Care, but 

Experiences Varied

Full-Year Medicaid 

Beneficiaries Reported 

Similar Difficulty 

Obtaining Needed Medical 

Care as Privately Insured 

Individuals 
 

Page 25 GAO-13-55 Medicaid Access

beneficiaries did however, report experiencing greater difficulty obtaining 

necessary dental care than those with full-year private insurance. (See 

fig. 9.) Individuals who were uninsured for a full year reported the greatest 

difficulty obtaining medical care, prescription drugs, and dental services—

at least twice the reported rate of full-year Medicaid beneficiaries.

Figure 9: Percentage of Individuals Who Reported Difficulties Obtaining Necessary 

Care or Services, by Full-Year Insurance Status, Calendar Years 2008-2009

Note: This figure includes only those individuals who reported insurance coverage or lack of coverage 

for the entire year (2008 or 2009, or both). The difference between the percentage of individuals with 

Medicaid and the percentage of individuals with private insurance who reported difficulty obtaining 

necessary dental care is statistically significant at the 95 percent confidence level. The difference 

between the percentage of individuals with Medicaid and the percentage of the uninsured who 

reported difficulty obtaining dental care is also statistically significant at the 95 percent confidence 

level. The differences between the percentage of individuals who were uninsured who reported 

difficulty obtaining medical care and the percentages of individuals with Medicaid or private insurance 

were statistically significant at the 95 percent confidence level. Other differences—such as 

comparisons between Medicaid and private insurance for medical care and prescription medicine—

were not statistically significant. The 95 percent confidence intervals for estimates in this figure are 

within +/- 1.5 percent of the estimates themselves. Medicaid data include children enrolled in the 

Children’s Health Insurance Program.
 

Page 26 GAO-13-55 Medicaid Access

The percentage of individuals experiencing difficulty accessing needed 

care was higher for those who reported fair or poor health status, with 

little difference in the rates between those with Medicaid or private health 

insurance. Approximately 9.9 percent of full-year Medicaid beneficiaries 

and 8.4 percent of individuals with full-year private insurance reporting fair 

or poor health indicated difficulty obtaining necessary medical care; 

again, the difference between these two groups was not statistically 

significant. The percentage of individuals who were uninsured for an 

entire year, reported being in fair or poor health, and indicated difficulty 

obtaining medical care was significantly higher—approximately 

29.3 percent.

When looking specifically at the experience of working-age adults, 

individuals aged 18 through 64,44 we found differences between those 

with Medicaid and those with private health insurance. Working-age 

adults with full-year Medicaid coverage reported greater difficulty 

obtaining needed medical care than similar adults with private health 

insurance. Specifically, about 7.8 percent of working-age adults with fullyear Medicaid reported difficulty obtaining care compared with 

3.3 percent of similar adults with private insurance—a statistically 

significant difference.45 With respect to dental care, working-age adults 

with full-year Medicaid were nearly three times more likely to report 

difficulty obtaining services than similar adults with private insurance, and 

about six times more likely than children with Medicaid. Children with fullyear Medicaid were reported to have no greater difficulties obtaining 

dental care than children with full-year private insurance.46

 

44This includes all working-age adults, including those with disabilities.

(See fig. 10.)

45We also explored reported difficulties obtaining medical care for children but the sample 

sizes were too small to provide reliable results and so we are not presenting them here.

46We reported in more detail on difficulties children enrolled in Medicaid have in obtaining 

dental care in GAO, Medicaid: Extent of Dental Disease in Children Has Not Decreased, 

and Millions Are Estimated to Have Untreated Tooth Decay, GAO-08-1121 (Washington, 

D.C.: Sept. 23, 2008). The MEPS analysis in that report examined children who were 

enrolled in Medicaid for any part of the year, and thus included both full-year and part-year 

beneficiaries.

Working-Age Adult 

Medicaid Beneficiaries 

Reported Greater 

Difficulties Obtaining Care 

Than Those with Private 

Insurance 
 

Page 27 GAO-13-55 Medicaid Access

Figure 10: Percentage of Working-Age Adults and Children with Full-Year Coverage 

Who Reported Difficulties Obtaining Necessary Dental Care, by Insurance Status, 

Calendar Years 2008-2009

Note: Working-age adults include individuals aged 18 through 64, including those with disabilities. 

This figure includes only those individuals who reported insurance coverage for the entire year (2008 

or 2009, or both). Sample sizes for uninsured children and for adults age 65 and older were below 

100, limiting confidence in their results. As such, the results for the uninsured and for beneficiaries 65 

and older are not included in the figure. The difference between the percentage of adults with 

Medicaid and private insurance who reported difficulty obtaining necessary dental care is statistically 

significant at the 95 percent confidence level. The difference between children with Medicaid and 

private insurance was not statistically significant. The 95 percent confidence intervals for estimates in 

this figure are within +/- 1.8 percent of the estimates themselves. Medicaid data include children 

enrolled in the Children’s Health Insurance Program.
 

Page 28 GAO-13-55 Medicaid Access

Individuals with partial year health insurance—coverage for between 1 

and 11 months—were more likely to report difficulties obtaining needed 

care, whether covered by Medicaid or private health insurance. In 

calendar years 2008 and 2009, the percentage of Medicaid beneficiaries 

enrolled for a partial year who reported difficulties obtaining needed 

medical care was almost double that of full-year Medicaid beneficiaries.47

 

47Partial year insurance groups overlap. For example, some individuals had both Medicaid 

and private insurance for part of the year, or had Medicaid and were uninsured for part of 

the year.

Similarly, individuals with private insurance for a partial year also reported 

difficulties at more than double the rate of those with full year coverage. 

Finally, individuals who were uninsured for a partial year reported less 

difficulty obtaining care than those uninsured for a full year—likely 

because they had some type of insurance for part of the year. There were 

no statistically significant differences across all groups with partial year 

coverage. (See fig. 1.)

Individuals with PartialYear Coverage Reported 

Almost Double the Rate of 

Difficulty Obtaining 

Medical Care
 

Page 29 GAO-13-55 Medicaid Access

Figure 11: Percentage of Individuals Who Reported Experiencing Difficulty 

Obtaining Necessary Medical Care, by Insurance Status, Partial or Full Year, 

Calendar Years 2008-2009

Note: The differences between individuals who had insurance (Medicaid or private) or were uninsured 

for a full year versus those with the same insurance status for a partial year were statistically 

significant at the 95 percent confidence level. Among those who had insurance or were uninsured for 

a partial year, there were no statistically significant differences. The 95 percent confidence intervals 

for estimates in this figure are within +/- 1.2 percent of the estimates themselves. Medicaid data 

include children enrolled in the Children’s Health Insurance Program.

Among working-age adults with Medicaid, 7.8 percent with full-year 

coverage and 11.9 percent with partial-year coverage reported difficulty 

obtaining necessary medical care. Those with partial year Medicaid were 

more likely to report difficulty obtaining medical care than those with 

partial year private insurance or who were uninsured for part of the year. 

(See fig. 12).
 

Page 30 GAO-13-55 Medicaid Access

Figure 12: Percentage of Working-Age Adults (Age 18 to 64) Who Reported 

Difficulty Obtaining Necessary Medical Care, by Insurance Status, Partial or Full 

Year, Calendar Years 2008-2009

Note: The differences between adults who had insurance (Medicaid or private) for a full year versus 

those with the same insurance status for a partial year were statistically significant at the 95 percent 

confidence level. Similarly, differences between those who were uninsured for a full year versus a 

partial year were statistically significant at the 95 percent confidence level. Those with partial-year 

Medicaid were more likely to report difficulty obtaining Medical care than those with partial-year 

private insurance or who were uninsured for part of the year. The 95 percent confidence intervals for 

estimates in this figure are within +/- 1.7 percent of the estimates themselves.

Medicaid beneficiaries were more likely than individuals with private 

insurance to report factors such as lack of transportation and long wait 

time as reasons for delaying medical care. In 2009, approximately 

9.6 percent of Medicaid beneficiaries reported delaying medical care 

because they had no transportation, compared with less than 1 percent of 

individuals with private insurance. Similarly, about 9.4 percent of Medicaid 

beneficiaries indicated that they delayed medical care because they could

not get an appointment soon enough, or once they arrived for the 

appointment, the wait was too long. In contrast, 4.2 percent of individuals 

Medicaid Beneficiaries 

Most Frequently Reported 

Delaying Care Due to Lack 

of Transportation and Long 

Wait Times
 

Page 31 GAO-13-55 Medicaid Access

with private insurance reported delaying care because, once they arrived 

for the appointment, the wait was too long. Individuals who were 

uninsured were the most likely to cite cost as a reason for delaying care. 

(See fig. 13.)

Figure 13: Percentage of Individuals Who Cited Specific Reasons for Delaying Medical Care in Calendar Year 2009, by 

Insurance Status

Note: This figure reflects individuals who reported their insurance status at the time the survey was 

administered. The responses related to delays in care for cost reasons are from the Person file of the 

National Health Interview Survey (NHIS) and include all age groups. The remaining reasons for 

delayed responses were from the Sample Adult component of NHIS and include only adults over 

18 years old. The differences between Medicaid beneficiaries and individuals with private insurance 

reporting delaying medical care to due to a lack of transportation, too long of a wait time once at an 

appointment, not being able to get an appointment soon enough, and being unable to get through on 

the phone were all statistically significant at the 95 percent confidence level. While there was not a 

statistically significant difference between individuals with Medicaid and private insurance citing cost 

as a reason for delayed medical care, the uninsured were significantly more likely than both to report 

delaying care due to cost. Among individuals reporting that a provider was not open when he or she 

could get there, there were no statistically significant differences across insurance statuses. The 

95 percent confidence intervals for estimates in this figure are within +/- 1.4 percent of the estimates 

themselves.
 

Page 32 GAO-13-55 Medicaid Access

We provided a draft of this report to HHS for its review and comment. 

HHS provided technical comments, which we incorporated as 

appropriate. This report is intended for use by HHS management. We are 

sending copies of this report to interested congressional committees and 

members, and other interested parties. The report is also available at no 

charge on the GAO website at http://www.gao.gov. If you or your staff 

have any questions about this report, please contact me at (202) 512-

7114 or yocomc@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Key contributors to this report are listed in appendix III.

Sincerely yours,

Carolyn L. Yocom

Director, Health Care
Appendix I: Scope and Methodology

Page 33 GAO-13-55 Medicaid Access

To examine states’ experiences processing Medicaid applications, 

changes states made to provider payment rates and beneficiary services, 

and challenges, if any, states face ensuring sufficient provider 

participation, in February 2012 we surveyed Medicaid officials in all 

50 states, the District of Columbia, and the 5 largest territories.1 The 

survey was e-mailed to the Medicaid officials on February 22, 2012. 

Respondents were initially given 3 weeks to respond, and extensions 

were granted to encourage survey participation. The survey was available 

online through May 22, 2012. Fifty states, the District of Columbia, and 

4 U.S. territories completed the survey, for a response rate of 98 percent. 

The U.S. Virgin Islands did not complete the survey.

To examine states’ experiences processing Medicaid applications, states 

were asked to report their current average processing time for new 

regular Medicaid applications—those not based on disability—and how 

those times changed since 2008.2

The survey also asked states about changes to benefits, provider 

payment rates, provider taxes, and supplemental payments in each year 

from 2008 through 2011. The questions in this section asked about 

changes by provider and benefit type, including both those benefits that 

are mandatory and optional.

The survey also included questions 

about the factors states attributed to any reported changes in the average 

processing time for Medicaid applications. In addition, to assess the 

extent to which states were keeping pace with processing new 

applications, the survey asked for monthly data on the number of new 

regular applications received and processed from January 2008 through 

December 2011.

3

 

1

The U.S. territories included in our sample are American Samoa, Guam, the 

Commonwealth of the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. 

For the purposes of this report, we are referring to all 56 jurisdictions we surveyed as 

states.

The survey asked, generally, about any 

2

Average processing time is the average number of calendar days between the day that a 

new application is received and the day that a final eligibility determination is made.

3

States were asked to report on a number of provider and service types, including 

inpatient hospitals, outpatient hospitals, nursing facilities, intermediate care facilities for 

the intellectually disabled, primary care, specialty care, dental, home health services, 

clinics, targeted case management, rehabilitative and therapeutic services, managed care 

plans, beneficiary copayments or premiums, and prescription drug formularies.

Appendix I: Scope and Methodology

Development and 

Analysis of GAO 

Survey of States
Appendix I: Scope and Methodology

Page 34 GAO-13-55 Medicaid Access

changes by provider type (i.e., increased, decreased, eliminated, etc.) 

and did not ask states to report the details of these changes. States could 

report more than one type of change for a provider type in a year. For 

example, a state could report both an increase and a decrease in a 

provider payment rate for a given provider type in a year. The survey 

asked whether the state made a particular change for a provider type in a 

year and did not ask for the actual number of those changes it made in a 

year or the magnitude of those changes. The survey also asked about the 

purpose of any new or increased provider taxes, including avoiding cuts 

in benefits, expanding benefits, avoiding cuts in payment rates, increasing 

payment rates, or other purposes. Finally, states were asked to report any 

changes to supplemental payments by provider type and the role of 

provider taxes or county and local government funds in any changes to 

the supplemental payments.4

To examine any challenges to ensuring sufficient provider participation, 

the survey included questions asking how states monitor whether they 

have sufficient providers, which provider types are challenging for states 

to ensure sufficient participation, and any steps the states have taken 

since January 2008 to maintain their existing pools of providers. The 

survey asked how the states monitor the sufficiency of providers across 

three service delivery arrangements—fee-for-service, primary care case 

management, and risk-based managed care organizations. The survey 

included questions about any planned efforts to meet potential increases 

in demand for primary care providers due to the Medicaid expansion 

under the Patient Protection and Affordable Care Act as amended by the 

Health Care and Education Reconciliation Act of 2010 (PPACA), and 

whether the increase in payment rates for primary care providers under 

PPACA would likely assist in increasing provider participation in Medicaid. 

The survey also asked states about plans to measure access to care for 

Medicaid beneficiaries in response to recently proposed federal 

regulations that, if finalized, would provide a framework under which 

 

4

Supplemental payments are payments separate from and in addition to those made at a 

state’s standard Medicaid payment rate, including Disproportionate Share Hospital 

payments and Upper Payment Limit payments. Disproportionate Share Hospital payments 

are payments required under federal law that are made to hospitals that treat large 

numbers of Medicaid and uninsured individuals. Upper Payment Limit payments are 

payments to certain providers above the standard Medicaid payment rates but within the 

Upper Payment Limit, the estimated amount that Medicare pays for comparable services.
Appendix I: Scope and Methodology

Page 35 GAO-13-55 Medicaid Access

states can demonstrate Medicaid payments are adequate for access to 

providers.5

We took steps in developing the survey and collecting and analyzing the 

data to minimize nonsampling errors.6

It is important to note that while the data that we reported were sufficiently 

reliable for the purposes of this report, we did not use the data on monthly 

application processing submitted by states for 2008 through 2011, 

because much of the data were either incomplete or inconsistently 

reported. In particular, we noted that for some states, data provided to us 

in a 2010 survey did not match the data provided for our current survey.

However, any survey may 

introduce nonsampling errors, such as difficulties in interpreting a 

particular question or limited sources of information available to 

respondents. We pretested the draft survey with Medicaid officials in 

three states in January 2012 to ensure that the questions were relevant, 

clearly stated, and easy to understand. The states selected for a pretest 

were diverse with respect to the population size, geography, and total 

Medicaid spending in 2009. We modified the survey as appropriate as a 

result of the pretests. Finally, since this was a web-based survey, 

respondents entered their answers directly into the electronic survey, 

eliminating the need to key data into a database, which helps to minimize 

error. We did not independently verify the data reported by states in the 

survey; however, we reviewed published data submitted by state 

Medicaid programs to us for another engagement and to outside 

researchers to assess the reasonableness of the data reported. We also 

assessed the internal consistency of answers to certain questions. We 

determined that the data from the survey included in this report were 

sufficiently reliable for the purposes of this report.

7

 

5

76 Fed. Reg. 26342.

We contacted four states to inquire about the inconsistencies in the data 

about which the states provided differing responses. For example:

6

The survey was not a sample survey and so sampling errors were not a concern.

7

We used data provided in response to our 2010 survey of Medicaid directors to 

determine any changes in states’ application processing volumes and rates between 

October 2007 and February 2010. See GAO, Recovery Act: Increased Medicaid Funds 

Aided Enrollment Growth, and Most States Reported Taking Steps to Sustain Their 

Programs, GAO-11-58 (Washington, D.C.: Oct. 8, 2010).
Appendix I: Scope and Methodology

Page 36 GAO-13-55 Medicaid Access

• One state official was not certain why the data would be reported 

differently in the prior survey and suggested that it could be related to 

interpretation of the prior survey question because the state does not 

collect information in the way we requested it.

• Officials from two states noted that there were changes in the staff 

that responded to the survey and could not be certain why the data 

reported were different.

• An official from a third state indicated that the data provided to us in 

2010 appeared to have included a broader array of applications (such 

as those for disability, long-term care, and food stamps), noting that 

the same application process is used for multiple programs in the 

state.

To examine the extent to which Medicaid beneficiaries reported difficulties 

obtaining care, we analyzed data from the Medical Expenditure Panel 

Survey (MEPS) and the National Health Interview Survey (NHIS).8 MEPS 

is administered by the Department of Health and Human Services’ (HHS) 

Agency for Healthcare Research and Quality and collects data on the use 

of specific health services; NHIS is conducted by the National Center for 

Health Statistics, Centers for Disease Control and Prevention. We 

analyzed results from the MEPS household component, which collects 

data from a sample of families and individuals in selected communities 

across the United States. These families and individuals are drawn from a 

nationally representative subsample of households that participated in the 

prior year’s NHIS.

Our MEPS analysis was based on data from surveys conducted in 2008 

and 2009, the most recent data available at the time of our analysis. 

MEPS includes insurance status for respondents for each month of the 

year and NHIS includes respondent information on insurance status at a 

point in time. Analyzing MEPS allowed us to use information on insurance 

status for each month to create variables for full-year and partial-year 

 

8

We considered using data from other federal surveys, such as the Consumer 

Assessment of Healthcare Providers and Systems Health Plan Survey, but determined 

that the questions in the MEPS and NHIS made them better surveys to use to determine 

the extent to which Medicaid beneficiaries had difficulty accessing medical care and the 

reasons for any difficulties.

Analysis of Other 

Federal Health Care 

Consumer Survey 

Data

MEPS
Appendix I: Scope and Methodology

Page 37 GAO-13-55 Medicaid Access

coverage.9 As a result, we determined that the MEPS insurance status 

data provided more options to report on the extent to which Medicaid 

beneficiaries reported difficulties obtaining medical care. In addition to 

determining the extent to which full-year Medicaid beneficiaries had 

difficulty accessing care, we also compared Medicaid beneficiaries’ 

reported experiences to the experience of respondents with private 

insurance and respondents who were uninsured, in order to provide 

context.10

The MEPS household interviews feature several rounds of interviewing 

covering 2 full calendar years. MEPS is continuously fielded; each year a 

new sample of households is introduced into the study. MEPS collects 

information for each person in the household based on information 

provided by one adult member of the household. This information 

includes demographic characteristics, use of medical services, reasons 

for medical visits, and health insurance coverage. We analyzed 

responses to MEPS questions about individuals’ reported delays and 

inability to obtain necessary medical care, dental care, and prescription 

medicine, the reasons for those delays, and the perceived health status of 

those individuals who delay or are unable to obtain care.

Further, we examined whether working-age adults 18 to 64 in 

Medicaid for a full year reported greater difficulty accessing medical care 

than children in Medicaid or full-year Medicaid beneficiaries 65 and older. 

We also compared full-year and partial-year Medicaid beneficiaries, to 

determine if the extent of reported difficulties obtaining care varied by 

length of coverage. Finally, we compared responses from full-year and 

partial-year privately insured individuals, and full-year and partial-year 

uninsured individuals to provide additional context for the Medicaid 

beneficiaries’ reported difficulties.

For the delays and inability to obtain care measures we used responses 

to the following questions:

• In the last 12 months, was anyone in the family delayed in getting 

medical care, tests, or treatments they or a doctor believed 

necessary?

 

9

In contrast, the variable “any Medicaid” includes individuals with coverage that could 

range from 1 to 12 months for a given year.

10The Medicaid category in MEPS includes children enrolled in the Children’s Health 

Insurance Program.
Appendix I: Scope and Methodology

Page 38 GAO-13-55 Medicaid Access

• Which of these best describes the main reason (PERSON) 

(were/was) delayed in getting medical care, tests, or treatments 

(he/she) or a doctor believed necessary?11

• In the last 12 months, was anyone in the family unable to obtain in 

getting medical care, tests, or treatments they or a doctor believed 

necessary?

• Which of these best describes the main reason (PERSON) 

(were/was) unable to obtain medical care, tests, or treatments 

(he/she) or a doctor believed necessary?

We also analyzed responses to similar questions related to delays or the 

inability to obtain needed dental care and prescription medicines. To 

address sample size concerns and obtain frequencies above 100 

responses, we combined data from 2008 and 2009 and the responses 

from the questions on both the delays and inability to obtain needed 

health care.

We examined the insurance status of respondents who answered that 

they delayed or were unable to obtain needed health care.12

 

11Possible answers to this question were: could not afford care, insurance company would 

not approve/cover/pay, doctor refused family insurance plan, problems getting to doctor’s 

office, different language, could not get time off work, could not get child care, did not 

have time or took too long, don’t know where to go to get care, was refused services, and 

other.

To 

understand the differences in responses by insurance status we identified 

the percentage of respondents who delayed or were unable to obtain care 

with a variety of insurance statuses as well as those who were uninsured.

We looked at those respondents who indicated they had Medicaid and 

private insurance for each month of the year, as well as looking at the 

responses for those with Medicaid or private insurance for a partial year 

(1-11 months). We also examined the percentage of respondents who 

were uninsured for a full and partial year as well as those with mixed 

insurance statuses, such as Medicaid part year and uninsured for part of 

the year. In addition, we examined demographic variables—such as age, 

12MEPS respondents were asked whether they needed medical care, and if they 

responded that they did, they were then asked if they were able or unable to receive care. 

If they responded they were unable to receive care, they were then asked about the main 

reason they were unable to receive care. A similar pattern of questions asked about 

whether a respondent had delayed care. 
Appendix I: Scope and Methodology

Page 39 GAO-13-55 Medicaid Access

sex, education, and perceived health status—for those respondents who 

indicated they delayed or were unable to obtain care as well as those that 

did not delay care. We also looked at responses to the questions by age 

group and insurance status to identify potential differences. Small sample 

sizes for some analyses limited the reliability of the results, and in those 

cases, we did not report the analyses. In this report, we used a 

95 percent confidence level and compared upper and lower confidence 

intervals to determine whether any differences we found were statistically 

significant. Statistical significance indicates that the difference between 

observations is unlikely due to chance alone.

We supplemented our MEPS analysis with analysis of data from the 2009 

NHIS survey. NHIS data are collected continuously throughout the year 

for the National Center for Health Statistics, Centers for Disease Control 

and Prevention, by interviewers from the U.S. Bureau of the Census. 

NHIS collects information about the health and health care of the civilian, 

noninstitutionalized U.S. population. Interviews are conducted in 

respondents’ homes, but follow-ups to complete interviews may be 

conducted over the telephone. We analyzed NHIS data to obtain 

information on reasons Medicaid beneficiaries reported delays obtaining 

needed medical care, and compared those to privately insured individuals 

and the uninsured, for context. We analyzed NHIS data for these 

questions because the sample size for those questions in NHIS was 

larger than for similar questions on delays or the inability to obtain care in 

MEPS. Because NHIS asks about insurance coverage at a point in time, 

individuals identified as Medicaid beneficiaries would include those with 

full-year and partial-year coverage. Data from the 2010 NHIS survey were 

available, but we chose to analyze the 2009 survey so the time period 

would be compatible with the MEPS analysis.

NHIS collects information from the civilian, noninstitutionalized population 

about demographic characteristics, use of medical services, and health 

insurance coverage and organizes the data into several data files. NHIS 

collects information on each family member. More information is collected 

on a randomly selected adult (the Sample Adult component) and a 

randomly selected child (the Sample Child component) within each family 

if a child is present. More information is collected on a sample of adults 

and children within each family and household. To match the insurance 

status variables with the answers to the selected questions, we merged 

NHIS
Appendix I: Scope and Methodology

Page 40 GAO-13-55 Medicaid Access

data from the Person file, which has information on each family member, 

with the Sample Adult file, which has more information on sampled 

adults.

13

From the Sample Adult component of the survey, we looked at the 

following questions:

We analyzed responses to the following NHIS question from the 

Person file of the survey: During the past 12 months, [have you delayed 

seeking medical care/has medical care been delayed for anyone in the 

family] because of worry about the cost?

• Have you delayed getting care for any of the following reasons in the 

past 12 months?14

• You couldn’t get through on the telephone

• You couldn’t get an appointment soon enough

• Once you get there, you have to wait too long to see the doctor

• The (clinic/doctor’s) office wasn’t open when you could get there

• You didn’t have transportation.

We examined the insurance status of respondents to those questions 

using the suggested variables for Medicaid, private insurance, and 

uninsurance.

For all estimated percentages for both MEPS and NHIS, we calculated a 

lower and upper bound at the 95 percent confidence level using the 

appropriate sampling weights and survey design variables provided for 

each survey.

 

13Information from the Sample Child file was not used for the purposes of our analysis.

14Each of these questions is asked separately. Possible answers included: Yes, No, 

Refused, Don’t Know.
Appendix I: Scope and Methodology

Page 41 GAO-13-55 Medicaid Access

To determine the reliability of the MEPS and NHIS data, we reviewed 

related documentation, and identified other studies that used MEPS to 

address similar research questions to compare the published data with 

our findings. We determined that the MEPS and NHIS data were 

sufficiently reliable for the purposes of our report.

Data Reliability for MEPS 

and NHIS
Appendix II: States Use of Electronic Medicaid 

Application Processing and Renewal 

Procedures

Page 42 GAO-13-55 Medicaid Access

Given the potential of electronic application processing to reduce 

processing time and related provisions of the Patient Protection and 

Affordable Care Act of 2010 (PPACA), we asked all of the states about 

their use of electronic application processing. PPACA required states to 

begin to accept electronic signatures by 2014, as part of a coordinated 

enrollment process that includes using a federally defined uniform 

application and verifying income electronically through a federally 

managed data hub.

We found states varied in the extent to which new Medicaid applications 

were currently available and processed electronically. (See table 2.) For 

example, fewer states reported that the application is submitted 

electronically with an electronic signature than those reporting that the 

application is available electronically. Twenty-six states reported the 

percentage of their new Medicaid applications that were accessed, 

signed, and submitted electronically. In these 26 states, the median 

proportion of applications accessed, signed, and submitted electronically 

was 25 percent. Only 11 states reported that the applications were 

approved or denied electronically.

Table 2: State Electronic Processing Procedures for New Medicaid Applications

Procedure Number of states

Medicaid applications available electronically 35

Medicaid applications can be submitted electronically 31

Processed at least some Medicaid applications electronically, with 

electronic signature

26

Medicaid applications approved or denied electronically 11

Source: GAO analysis of state-reported survey data.

Note: States could report more than one procedure.

We also asked all states about their efforts to streamline processing 

through improved renewal procedures, and a number of states reported 

implementing procedures to streamline the renewal application process 

for adults and children since 2008. (See table 3.) Such efforts can help 

limit interruptions in Medicaid coverage for beneficiaries. For children, the 

streamlined procedures states most frequently reported using were 

12-month renewal periods, as opposed to shorter renewal periods; 

telephone or electronic renewals, or both, instead of in-person interviews; 

Appendix II: States Use of Electronic 

Medicaid Application Processing and 

Renewal Procedures
Appendix II: States Use of Electronic Medicaid 

Application Processing and Renewal 

Procedures

Page 43 GAO-13-55 Medicaid Access

and prepopulated renewal forms.1

Table 3: State Medicaid Renewal Procedures 

For adult Medicaid beneficiaries, the 

most commonly reported efforts were 12-month renewal periods and 

telephone or electronic renewal, or both, instead of in-person interviews.

Number of states

Procedure For children For adults

Twelve-month renewal periods 26 24

Telephone or electronic renewals, or both, instead of 

in-person interviews 24 24

Prepopulated renewal forms 22 15

Continuous eligibility 18 n/a

Source: GAO analysis of state-reported survey data.

a

Notes: n/a = not applicable. The term “states” includes the 50 states, the District of Columbia, and 4 

U.S. territories that responded to the 2012 GAO survey. Fifty-four states responded to this question. 

States could report more than one procedure.

a

States may use continuous eligibility to allow children to remain eligible for Medicaid or the Children’s 

Health Insurance Program for up to a full year before any redetermination of eligibility.

 

1

Some states send families renewal forms pre-populated with the families’ information. If a 

family’s circumstances, as reflected on the form, have not changed, the family simply 

returns the signed form to renew their eligibility.
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 44 GAO-13-55 Medicaid Access

Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov

In addition to the contact named above, Sheila K. Avruch, Assistant 

Director; Carolyn Fitzgerald; Sandra George; Mollie Hertel; Joanne Jee; 

Eagan Kemp; Drew Long; JoAnn Martinez-Shriver; Janet Sparks; and 

Hemi Tewarson made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(290993)
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