Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

ACCESS TO CARE: 

PROVIDER AVAILABILITY IN 

MEDICAID MANAGED CARE 

Daniel R. Levinson 

Inspector General 

December 2014 

OEI-02-13-00670 
 

EXECUTIVE SUMMARY: ACCESS TO CARE: PROVIDER AVAILABILITY IN 

MEDICAID MANAGED CARE 

OEI-02-13-00670 

WHY WE DID THIS STUDY 

Examining access to care takes on heightened importance as enrollment grows in Medicaid 

managed care programs. Under the Patient Protection and Affordable Care Act, States can 

opt to expand Medicaid eligibility, and even States that have not expanded eligibility have 

seen increases in enrollment. Most States provide some of their Medicaid services—if not 

all of them—through managed care. The Office of Inspector General received a 

congressional request to evaluate the adequacy of access to care for enrollees in managed 

care. This report determines the extent to which providers offer appointments to enrollees 

and the timeliness of these appointments. A companion report issued earlier this year, 

State Standards for Access To Care in Medicaid Managed Care, OEI-02-11-00320, found 

that State standards for access to care vary, and that they are often not specific to certain 

provider types or to areas of the State. Additionally, States have different strategies to 

assess compliance with access standards. 

HOW WE DID THIS STUDY 

We based this study on an assessment of availability of Medicaid managed care providers. 

The assessment included calls to a stratified random sample of 1,800 primary care 

providers and specialists to assess availability and timeliness of appointments for enrollees. 

WHAT WE FOUND 

We found that slightly more than half of providers could not offer appointments to 

enrollees. Notably, 35 percent could not be found at the location listed by the plan, and 

another 8 percent were at the location but said that they were not participating in the plan. 

An additional 8 percent were not accepting new patients. Among the providers who 

offered appointments, the median wait time was 2 weeks. However, over a quarter had 

wait times of more than 1 month, and 10 percent had wait times longer than 2 months. 

Finally, primary care providers were less likely to offer an appointment than specialists; 

however, specialists tended to have longer wait times. 

WHAT WE RECOMMEND 

Together, these findings—along with those from our companion report—call for the 

Centers for Medicare & Medicaid Services (CMS) to work with States to improve the 

oversight of managed care plans. We recommend that CMS work with States to (1) assess 

the number of providers offering appointments and improve the accuracy of plan 

information, (2) ensure that plans’ networks are adequate and meet the needs of their 

Medicaid managed care enrollees, and (3) ensure that plans are complying with existing 

State standards and assess whether additional standards are needed. CMS concurred with 

all three of our recommendations. 
 

 

TABLE OF CONTENTS 

Objectives.................................................................................................... 1 

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

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

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

Half of providers could not offer appointments to 

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

Among the providers who offered appointments, the 

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

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

Primary care providers were less likely to offer an appointment 

than specialists; however, specialists tended to have 

longer wait times ........................................................................... 11
 

Conclusion and Recommendations ........................................................... 13 

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

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

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

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

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

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

Acknowledgments ..................................................................................... 27
 
 

 

 

 

 

OBJECTIVES 

1.	 To determine the extent to which providers could offer appointments 

to Medicaid managed care enrollees. 

2.	 To assess wait times for appointments for Medicaid managed care 

enrollees. 

3.	 To describe any differences in the availability of primary care 

providers and specialists. 

BACKGROUND 

Medicaid is a jointly funded Federal and State health insurance program 

that finances the delivery of medical services to more than 69 million 

people.1

 In fiscal year (FY) 2013, the Federal Government and the States 

combined spent almost $460 billion on the program.2 Each State designs 

and administers its own Medicaid program within broad Federal 

guidelines. Most States provide some or all Medicaid services through 

Medicaid managed care, which covers nearly three-quarters of Medicaid 

enrollees.3 

Examining access to care takes on heightened importance as enrollment 

grows in Medicaid managed care programs. Under the Patient Protection 

and Affordable Care Act, States have the option to expand eligibility for 

their Medicaid programs.4 As a result, Medicaid is expected to provide 

coverage for as many as 18 million more people by 2018.5 In addition, 

____________________________________________________________ 

1 Congressional Budget Office, The Budget and Economic Outlook: 2014 to 2024. 

Accessed at http://www.cbo.gov/publication/45010 on August 26, 2014. 2 The Medicaid and CHIP Payment and Access Commission, Report to the Congress on 

Medicaid and CHIP, March 2014. Accessed at http://www.macpac.gov/reports on 

August 26, 2014.

3

 Centers for Medicare & Medicaid Services (CMS), Medicaid Managed Care 

Enrollment Report: Summary Statistics as of July 1, 2011. Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-andSystems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf on April 1, 2014. 4

 P.L. No. 111-148 § 2001 (March 23, 2010), as amended by the Health Care and 

Education Reconciliation Act of 2010, P.L. No. 111-152 (March 30, 2010), collectively 

referred to as “the ACA.” 

5

 Congressional Budget Office, The Budget and Economic Outlook: 2014 to 2024. 

Accessed at http://www.cbo.gov/publication/45010 on August 26, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 1 
 

 

 

 

 

 

 

many States that have not expanded eligibility have also seen increases in 

enrollment.6 

The Office of Inspector General (OIG) received a congressional request to 

evaluate the adequacy of access to care for enrollees in Medicaid managed 

care. This report determines the extent to which providers offer 

appointments to enrollees and the timeliness of these appointments. A 

companion report found that State standards for access to care vary, and 

that they are often not specific to certain provider types or to areas of the 

State.7 Additionally, States have different strategies to assess compliance 

with access standards. 

Medicaid Managed Care 

States have the option to provide either all or some portion of their 

Medicaid services through Medicaid managed care.8 The goal of managed 

care is to decrease Medicaid costs while providing high-quality care to 

enrollees. Additionally, managed care is intended to reduce the State’s 

financial risk and allow for more predictable Medicaid costs. 

States have different types of managed care arrangements, but the most 

common is full-risk managed care.9 Under this arrangement, managed 

care organizations (MCOs) assume the full financial risk for delivering a 

comprehensive set of services. These services generally include all 

primary, specialty, and acute medical care. States pay MCOs a fixed 

monthly fee per enrollee (often referred to as capitation), and the MCO 

delivers services through a network of participating providers.10 MCOs 

maintain listings—typically in the form of a provider directory—of all 

participating providers in their networks who provide care to enrollees. 

____________________________________________________________ 

6 MACPAC, Report to the Congress on Medicaid and CHIP, March 2014. Accessed at: 

http://www.macpac.gov/reports on September 8, 2014, and Kaiser Family Foundation, 

Medicaid Enrollment: June 2013 Data Snapshot. Accessed at http://kff.org/reportsection/medicaid-enrollment-june-2013-data-snapshot-appendix-a-table-a-1-totalmedicaid-enrollment-by-state/ on September 8, 2014. 7

 OIG, State Standards for Access to Care in Medicaid Managed Care 

(OEI-02-11-00320). 

8

 States may provide Medicaid services through managed care under their State plans for
 

medical assistance in accordance with Social Security Act § 1932(a) or under waivers to
 

their State plans in accordance with Social Security Act §§ 1115, 1915(a), and 1915(b). 9

 Another arrangement is primary care case management, which pays providers a nominal
 

fee for providing case management services to enrollees assigned to them. States may 

also contract with MCOs to provide a limited set of services under managed care, such as
 

dental services. 

10 42 CFR § 438.2. The MCO is responsible for paying for services delivered to enrollees 

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

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

payment from the State. The MCO pays providers on a fee-for-service basis. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 2 
 

 

 

 

 

 

 

 

 

 

 

This report focuses solely on MCOs providing full-risk managed care for a 

comprehensive set of services. 

Federal Regulations Governing Medicaid Managed Care 

Access Standards 

Federal regulations require States to have a written strategy for assessing 

and improving the quality of health care services offered by all MCOs.11 

That strategy must include standards for access to care that all MCOs must 

meet. These standards are intended to ensure that each MCO maintains a 

network of providers that is sufficient to provide adequate access to 

Medicaid services covered under the contract between the State and the 

MCO.12 When establishing and maintaining its provider network, each 

MCO must consider (1) the anticipated Medicaid enrollment, (2) the 

expected utilization of services, (3) the numbers and types of providers 

needed, (4) the numbers of network providers who are not accepting new 

Medicaid patients, and (5) the locations of providers and Medicaid 

enrollees. Regulations also require that each MCO provide timely access 

to care and services.13 

Additionally, regulations require State contracts to ensure that if the MCO 

is unable to provide necessary services to a particular enrollee with 

providers in the managed care network, the MCO must cover these 

services using out-of-network providers at no additional cost to the 

enrollee.14 

CMS Oversight 

According to Federal regulations, CMS must review and approve all 

contracts that States enter into with MCOs, including contract provisions 

that incorporate standards for access to care.15 In addition, each State 

must submit to CMS its quality strategy, which includes these standards, 

and must certify that its MCOs have complied with its requirements for 

availability of services.16 Further, each State must submit to CMS regular 

reports describing the implementation and effectiveness of its quality 

strategy.17

 ____________________________________________________________ 

11 42 CFR § 438.202 (a). 

12 42 CFR § 438.206(b)(1). 

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

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

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

regulatory requirements.
 14 42 CFR § 206(b)(4). 

15 42 CFR § 438.6(a).
 16 42 CFR §§ 438.202 and 438.207(d).
 17 42 CFR § 438.202(e)(2).
 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 3 
 

 

 

Related Work 

In a companion report, OIG found that States that contract with MCOs 

have established at least one of the following three types of standards for 

access to care: (1) standards that limit the distance or amount of time 

enrollees should have to travel to see a provider; (2) standards that require 

appointments be provided within a certain timeframe; and (3) standards 

that require a minimum number of providers in relation to the number of 

enrollees.18 These standards are often not specific to certain types of 

providers or to areas of the State. 

OIG also found that States have different strategies to assess compliance 

with access standards, but they do not commonly use what are called 

“direct tests.” Direct tests seek to reliably measure whether plans comply 

with access standards and commonly include calls to providers. The 

report recommended that CMS strengthen its oversight of State standards 

and ensure that States develop standards for key providers. It also 

recommended that CMS strengthen its oversight of States’ methods to 

assess plan compliance and that it ensure that States conduct direct tests of 

access standards. 

METHODOLOGY 

Scope 

We based this study on an assessment of availability of Medicaid managed 

care providers. The assessment included calls to a stratified random 

sample of primary care providers and specialists to assess availability and 

timeliness of appointments for new patients. This study measures the 

availability of specific providers at specific locations in Medicaid 

managed care networks. It does not attempt to measure whether an 

enrollee would have been able to obtain an appointment elsewhere, such 

as with another provider at the same location. Further, it focuses solely on 

Medicaid managed care and does not include an assessment of other types 

of Federal or State health care programs or private insurance. Lastly, this 

study focuses on the earliest routine, non-urgent appointment available for 

new patients. We conducted calls from July through October 2013, which 

preceded States’ expansion of Medicaid under the ACA. 

____________________________________________________________ 

18 OIG, State Standards for Access to Care in Medicaid Managed Care 

(OEI-02-11-00320). 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 4 
 

 

 

 

 

 

 

Identification of Medicaid Managed Care Providers 

We contacted all States to identify those that contracted with Medicaid 

MCOs. We included only MCOs providing full-risk managed care for a 

comprehensive set of services to the general Medicaid population.19 We 

identified 32 States with 221 MCOs that were active from January 2012 

through July 2013. From each of the 32 States, we requested a list of all 

providers participating in Medicaid managed care plans. 

We requested information about each provider, such as the address and 

phone number for each location at which the provider was practicing and 

the name of each Medicaid managed care plan in which the provider was 

participating in as of January 1, 2012.20 We also requested information on 

whether the provider was a primary care provider or specialist, as well as 

the provider’s specialty. 

Using this information, we identified all primary care providers and 

selected specialists participating in Medicaid managed care. For primary 

care providers, we included pediatricians, obstetricians/gynecologists 

(OB/GYN), as well as family practitioners and general internists. We also 

included nonphysician practitioners—such as nurse practitioners and 

midwives—who were primary care providers. For specialists, we selected 

nine types of specialists with whom an enrollee would typically make an 

appointment for a routine consultation in an office setting. These nine 

specialists were: allergists/immunologists; cardiologists; dermatologists; 

endocrinologists; gastroenterologists; neurologists; orthopedists; 

otolaryngologists; and urologists. 

Each provider may practice at multiple locations and may participate in 

multiple plans. A provider may also participate in different plans at 

different locations. In this report, we use the term “provider” to refer to a 

provider at a specific location in a specific plan. In total, we identified 

1.36 million providers who were participating in Medicaid managed care 

as of January 1, 2012. 

From this population of providers, we selected a stratified random sample 

of 1,800 providers, which included 450 providers from each of the 

following four strata: (1) urban primary care providers, (2) rural primary 

____________________________________________________________ 

19 We excluded noncomprehensive plans, as these offer a limited range of services under 

managed care. We also excluded plans that served only specific populations, such as 

foster children, enrollees with long-term-care needs, or enrollees who are eligible for both 

Medicaid and Medicare. 

20 We collected all addresses for each provider but included in our analysis only the 

addresses at which the provider was listed as practicing and offering care to patients. We 

refer to these addresses as the provider’s “location.” 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 5 
 

 

 

 

 

 

 

 

 

 

care providers, (3) urban specialists, and (4) rural specialists. We 

determined whether each provider was in an urban or rural area on the 

basis of the provider’s ZIP Code.21 We determined our sample size on the 

basis of the outcome of a pretest.22 

Assessment of Provider Availability 

To assess provider availability, we called all 1,800 providers in our sample 

and attempted to schedule an appointment. These calls took place from 

July through October 2013. On each call, we confirmed whether the 

provider practiced at the location listed, whether the provider participated 

in the plan, and whether the provider was accepting new patients enrolled 

in the plan. If the provider’s practice had relocated nearby, we considered 

the provider to be at the location and determined whether the provider was 

able to offer an appointment. In contrast, if the provider had retired or left 

the practice, we considered the provider to be not participating at the 

location listed and to be unable to offer an appointment. 

During our calls, we asked for the earliest date available for a routine 

appointment with the provider. We did not provide details about any 

enrollee or schedule appointments. If asked, we said that we were calling 

on behalf of a new enrollee to determine the earliest available 

appointment. For primary care providers, we asked about an appointment 

for a new patient visit and/or checkup; for specialists, we asked about an 

appointment for a consultation.23 

We used several criteria for excluding providers from our sample that 

made our estimate of the percentage of providers who could not offer 

appointments more conservative. For example, when a caller determined 

that a provider was not practicing at a location or participating in a plan, 

we followed up with the plan. If the plan had information indicating that 

the provider was not at the location or not participating in the plan during 

the time of our calls, we excluded this provider from our analysis. We 

also excluded a provider if we determined during the call that the provider 

was a different type than indicated by the State, such as chiropractors 

____________________________________________________________ 

21 We used rural-urban commuting area codes (RUCAs), which classify counties using 

measures of population density, urbanization, and daily commuting distance. Accessed at 

http://depts.washington.edu/uwruca/ on January 15, 2013. We defined an area as urban if 

30 percent or more of its workers commute to or live within an area with 50,000 people 

or more. We considered all other areas to be rural. 

22 We selected a stratified random sample of 120 providers to conduct a pretest. From the 

results of the pretest, we included additional providers in each strata in our study sample 

to ensure that we could project the results of our analysis at the 95-percent confidence 

level. 

23 For obstetricians, we asked about an appointment for a first prenatal visit at the eighth 

week of pregnancy. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 6 
 

 

 

 

incorrectly identified as orthopedists. Finally, we excluded providers if 

they practiced at a location at which appointments could not be made, 

such as a hospital where a provider had admitting privileges. 

In total, we excluded 692 of the 1,800 providers from our sample. We also 

excluded 16 additional nonrespondents for a total sample population of 

1,092 providers.24 See Appendix A for the number of providers excluded 

from our analysis by reason. 

Analysis 

We first determined the percentage of providers who could not offer 

appointments. We defined this measure to include providers who could 

not be found at the location listed by the plan as well as providers at the 

listed location who said that they were not participating in the plan. In all 

of these cases, the plans confirmed that these providers were supposed to 

have been participating in the plan at the location at the time of our calls. 

We also included providers who were not accepting new patients. 

Next, we determined the length of wait times for appointments. For 

providers who offered appointments, we determined the number of days 

between the date of the call and the earliest available appointment date. 

For providers who offered an approximate appointment or a range of 

possible appointment dates, we chose the earliest appointment date 

possible (e.g., if the earliest appointment with a provider was “sometime 

in October,” we considered the earliest appointment date to be October 1). 

Lastly, we determined whether there were any differences in availability 

and wait times between primary care providers and specialists.25 We did 

the same for urban and rural providers but did not find any differences in 

availability and wait times that were statistically significant. 

We projected the results of our analysis to the population of 778,475 Medicaid 

managed care providers. See Appendix B for the projected population by 

strata. See Appendix C for the point estimates and confidence intervals. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

____________________________________________________________ 

24 We had a 98-percent response rate overall; we did not adjust our results for 

nonresponse. 

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

interval unless otherwise specified.
 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 7 
 

 

FINDINGS 

Half of providers could not offer appointments to 

enrollees 

Fifty-one percent of providers could not offer appointments because they 

were not participating at the listed location (i.e., not practicing at the 

location listed or were practicing there but not participating in the plan), or 

were not accepting new patients enrolled in the plan. This means that 

Medicaid managed care enrollees may not be able to make appointments 

with as many as half of the providers listed by their plans. See Figure 1. 

Figure 1: Availability of Providers, 2013 

Source: OIG assessment of provider availability, 2014. 

When providers listed as participating in a plan cannot offer appointments, 

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

Moreover, it raises questions about the adequacy of provider networks—it 

suggests that the actual size of provider networks may be considerably 

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

raises questions about whether these plans are complying with their States’ 

standards for access to care.
 

Forty-three percent of providers were not participating in the 

plan at the listed location 

Forty-three percent of providers were not participating in the Medicaid 

managed care plan at the listed location and could not offer appointments. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 8 
 

 

 

 

Notably, 35 percent of providers could not be found at the location listed 

and were therefore not participating at the location listed by the plan. In 

these cases, callers were sometimes told that the practice had never heard 

of the provider or that the provider had practiced at the location in the past 

but had retired or left the practice. Some providers had left months or 

even years before the time of the call. 

Another 8 percent of providers were at the location listed but said that they 

were not participating in the plan. In some cases, these providers had 

participated in the plan in the past; in other cases, the providers had never 

participated in the Medicaid managed care plan. 

In all of these cases, the plans confirmed that these providers were 

supposed to have been participating in the plan at the location at the time 

of our calls. Plans typically provide lists of participating providers and 

their locations to enrollees in Medicaid managed care plans, and enrollees 

often refer to these lists when seeking care from primary care providers 

and specialists. Potential enrollees also refer to these lists when selecting 

a plan. By continuing to inaccurately list these providers as participating, 

plans limit an enrollee’s ability to find a participating provider at a nearby 

location. 

Additionally, many States rely on information from plans to determine 

plan compliance with State standards for access to care.26 For example, all 

but one of the States we reviewed have standards that establish a 

maximum distance enrollees should have to travel to see a provider, and 

these States often use provider location information from plans to 

determine compliance with their distance standards. If 43 percent of 

providers are not participating in plans at the locations specified, these 

States may be incorrectly determining plans’ compliance with their access 

standards. 

Another 8 percent of providers were not accepting new 

patients 

Additionally, 8 percent of providers were participating in the Medicaid 

managed care plan but were not accepting new patients enrolled in the 

plan. As a result, these providers could not offer appointments to 

enrollees. Providers were often not accepting new patients because they 

were leaving the practice, or because they already had too many patients. 

One provider was not accepting new patients with the plan because of 

frequent no-shows. Having a large number of providers who are not 

accepting new patients can also affect enrollees’ access to care. 

____________________________________________________________ 

26 For more detailed information, see OIG, State Standards for Access to Care in 

Medicaid Managed Care (OEI-02-11-00320). 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 9 
 

 

51% 

21% 18% 

5% 5% 

0% 

10% 

20% 

30% 

40% 

50% 

60% 

2 weeks or > 2 weeks > 1 month > 2 months More than 

less and ≤ 1 and ≤ 2 and ≤ 3 3 months 

month months months

Percentage of providers who could offer appointments 

 

Among the providers who offered appointments, the 

median wait time was 2 weeks; however, over a 

quarter had wait times of more than 1 month 

Forty-nine percent of providers offered appointments for new patients 

enrolled in a Medicaid managed care plan with a median wait time of 

2 weeks.27 Wait times for these appointments varied widely, ranging from 

same-day appointments to an appointment in 9 months. For 28 percent of 

providers who offered appointments, enrollees had to wait more than a 

month for an appointment. Ten percent of providers had wait times longer 

than 2 months. See Figure 2. 

All but two of the States we reviewed have access standards that require 

appointments be provided within a certain timeframe. For the majority of 

these States, the required timeframe is 1 month or less.28 That more than a 

quarter of providers were unable to offer appointments within a month 

raises further questions about enrollees’ ability to obtain timely access to 

care. 

Figure 2: Wait Times for Routine Appointments for Enrollees 

Source: OIG assessment of provider availability, 2014. 

____________________________________________________________ 

27 Five percent of providers were accepting new patients enrolled in the plan, but did not 

offer a specific appointment date without more information about the enrollee (e.g., 

Medicaid identification number). Although these providers are counted as offering 

appointments, they are excluded from the wait-time analysis because we could not obtain 

an appointment date. 

28 In most cases, these States’ standards require the plan to ensure that an enrollee can get 

an appointment within the given timeframe. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 10 
 

 

In some circumstances, long wait times can have a significant impact on 

patient care. For example, a number of obstetricians had wait times of 

more than 1 month, and one had wait times of more than 2 months for an 

enrollee who was 8 weeks pregnant. Such lengthy wait times could result 

in a pregnant enrollee receiving no prenatal care in the first trimester of 

pregnancy.29 

A small number of providers required patients to submit 

medical records prior to scheduling an appointment or would 

not accept patients with certain medical conditions 

Enrollees’ ability to obtain timely access to care may also be affected by 

providers who offer appointments only under certain circumstances. A 

small number of primary care providers required medical records prior to 

scheduling appointments. These providers first review the medical 

records and then accept patients on a case-by-case basis. A few providers 

would not accept patients with certain medical conditions, such as chronic 

pain. In one example, a specialist would offer an appointment only if the 

patient had a body mass index (BMI) under 40. By requiring enrollees to 

submit medical records or meet certain criteria, providers may be further 

limiting enrollees’ ability to access care. 

Primary care providers were less likely to offer an 

appointment than specialists; however, specialists 

tended to have longer wait times 

Primary care providers were less likely to offer appointments than 

specialists. Only 44 percent of primary care providers offered 

appointments, compared to 57 percent of specialists. See Figure 3. 

Among primary care providers, family practitioners and general internists 

were less likely to offer appointments than pediatricians: 40 percent of 

family practitioners and general internists offered appointments compared 

to 53 percent of pediatricians. Among the different types of specialists, 

the ability to offer appointments ranged from 68 percent of 

gastroenterologists to 54 percent of cardiologists; however, the differences 

among specialists were not statistically significant.30

 ____________________________________________________________ 

29 The Agency for Healthcare Research and Quality recommends at least one prenatal 

visit in the first trimester. Accessed at http://www.guideline.gov/content.aspx?id=38256 

on September 18, 2014.

30 Except for cardiologists, the 95-percent confidence intervals for these estimates exceed 

plus or minus 10 percent because of small sample sizes. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 11 
 

 

 

60% 57%

44% 

Primary Care Providers Specialists 

50% 

40% 

30% 

20% 

10% 

0% 

Figure 3: Percentage of Providers Who Could Offer a New Patient 

Appointment, by Provider Type 

Source: OIG assessment of provider availability, 2014. 

The median wait time for specialists was twice as long as that 

for primary care providers 

Although primary care providers were less likely to offer appointments, 

specialists had longer wait times. Specialists offered appointments with 

wait times that were twice as long as those offered by primary care 

providers. The median wait time for an appointment with a specialist was 

20 days, compared to just 10 days for a primary care provider. 

Moreover, 34 percent of specialists who offered appointments had wait 

times longer than 1 month, and 11 percent had wait times longer than 

2 months. Specialists gave a variety of reasons for long wait times. For 

example, in some cases callers were told that the providers practiced only 

one day a week or once a month at their offices. One provider practiced 

even less often, and his first opening was almost 3 months away; another 

provider closed his office entirely during the winter. In other cases, 

providers were highly sought after for their specialization, which could 

explain the longer wait times. For example, one neurologist who 

specialized in Tourette’s and tic disorders had a wait time of 9 months. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 12 
 

 

 

CONCLUSION AND RECOMMENDATIONS 

Our findings demonstrate significant vulnerabilities in provider 

availability, which is a key indicator for access to care. These findings 

also raise serious questions about the abilities of plans, States, and CMS to 

ensure that access-to-care standards are met. Without adequate access, 

enrollees cannot receive the preventive care and treatment necessary to 

achieve positive health outcomes and improved quality of life. 

Notably, 51 percent of providers were either not participating in the plan at 

the location listed or not accepting new patients enrolled in the plan. 

When providers listed as participating in a plan cannot offer appointments, 

it creates a significant obstacle for an enrollee seeking care. Moreover, it 

suggests that the actual size of provider networks may be considerably 

smaller than what is presented by Medicaid managed care plans. 

Among the providers who offered appointments, the median wait time was 

2 weeks. However, over a quarter had wait times of more than 1 month, 

and 10 percent had wait times longer than 2 months. Long wait times can 

have a significant impact on patient care. It also raises questions about 

whether these plans are complying with their States’ standards for access 

to care, as most States have access standards that require appointments be 

provided within 1 month or less. That so many providers could not offer 

appointments within a month raises concerns about enrollees’ ability to 

obtain timely access to care. 

Together, these findings—along with those from our companion report— 

call for CMS to work with States to improve the oversight of managed 

care plans. In our companion report, we recommended that CMS 

strengthen its oversight of State standards and States’ methods to assess 

plan compliance. This report expands on these recommendations and 

provides additional recommendations about how CMS should further 

ensure access to care for Medicaid managed care enrollees. 

We recommend that CMS: 

Work with States to assess the number of network providers 

who can offer timely appointments and to improve the 

accuracy of plan information 

CMS should work with States to ensure that they routinely test the 

availability of network providers. These tests could include calls to 

providers or other methods to determine whether providers are able to 

offer care in a timely manner. In addition, tracking the availability of 

network providers over time will help ensure that enrollees have access to 

care as coverage expansions under the ACA take effect. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 13 
 

 

 

CMS should also work with States to develop strategies for improving the 

accuracy of plan data. These strategies should ensure that plans are 

effectively identifying providers who are no longer actively participating. 

CMS should work with States to ensure that plans have detailed steps for 

how they verify providers’ participation. This could be achieved through 

such means as using claims data to identify those who have not submitted 

claims for enrollees for a significant amount of time or by contacting 

providers directly by phone or by mail. As part of its approval of MCO 

contracts with States, CMS should ensure that plans have controls to 

ensure that provider information is accurate and up to date. 

Work with States to ensure that plans’ networks are adequate 

and meet the needs of their Medicaid managed care enrollees 

CMS should work with States to use the data from their testing to assess 

the robustness of their networks. CMS should ensure that States and plans 

continually monitor their networks to identify any barriers that are 

impeding access to care. For example, States should monitor whether 

there are shortages of specific provider types, such as 

obstetricians. Similarly, States should monitor whether there are shortages 

in specific geographic areas. States should also monitor their networks for 

other barriers to care, such as providers who require patients to submit 

medical records prior to scheduling appointments or providers who do not 

accept patients with certain medical conditions. If such barriers are 

identified, CMS should work with States to address them and increase 

plans’ networks as needed to ensure timely access to care for enrollees. 

Work with States to ensure that plans are complying with 

existing State standards and to assess whether additional 

standards are needed 

CMS should work with States to use the data from their testing to reassess 

whether plans are—in fact—complying with State standards for access to 

care. If plans are found to not be in compliance, CMS should work with 

States to take actions to ensure that any instances of noncompliance are 

addressed. 

CMS should also work with States to determine whether each State needs 

to modify its existing standards or develop additional standards to address 

gaps in provider availability. For example, if a State discovers that 

specialists have particularly long wait times for appointments, and the 

State does not have any wait-time standards that are specific to specialists, 

the State should consider revising its standards. Similarly, if States are 

uncovering access issues among key provider types, such as obstetricians, 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 14 
 

 

 

the State should consider developing additional standards that apply 

specifically to those providers. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 15 
 

 

 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with all three of our recommendations. 

CMS concurred with our first recommendation to work with States to 

assess the number of network providers who can offer timely 

appointments and improve the accuracy of plan information. CMS stated 

that it will continue to work with States to reinforce their regulatory 

obligations to provide timely care and to identify proven best practices. 

CMS is considering how best to strengthen its and States’ oversight of 

provider networks and ensure that enrollees have access to up-to-date 

information on the network. It is also considering establishing 

expectations of States regarding assessing network access under managed 

care, the frequency with which an MCO’s provider directory should be 

updated, and the increased use of electronic communication methods to 

improve data timeliness and accuracy. Finally, CMS will collaborate with 

States and MCOs to consider best practices for the various mechanisms 

designed to connect enrollees with providers in a timely fashion. 

CMS noted that although the provider directory is one resource used by 

enrollees, there are many other supports that plans provide, such as 

managed care call centers, care coordinators, ombudsman offices, and 

community health centers. Additionally, CMS noted that managed care 

enrollees would not need to make a "cold call" to set up an appointment. 

Although we recognize that many enrollees may receive additional 

support from plans in finding a provider, the vast majority of States 

reported to OIG that they provide a plan directory to enrollees upon 

enrollment so that they may select a primary care provider. As a result, we 

continue to stress the importance of accurate provider information. 

CMS concurred with our second recommendation to work with States to 

ensure that plans’ networks are adequate and meet the needs of their 

Medicaid managed care enrollees. CMS added that it would engage 

collaboratively with States and MCOs to identify and share best practices 

for ongoing, effective network analysis as well as support services that 

States and MCOs can provide. Further, CMS will remind States of the 

availability of technical assistance that can support States’ efforts. Finally, 

CMS will identify issues associated with network adequacy during its 

waiver implementation, monitoring efforts, and renewals reviews, and 

bring them to each State’s attention when warranted. 

CMS concurred with our third recommendation to work with States to 

ensure that plans are complying with existing State standards and to assess 

whether additional standards are needed. Finally, CMS will encourage 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 16 
 

 

States to use its technical assistance resources when researching or 

developing standards. 

We support CMS’s efforts to provide increased oversight of Medicaid 

managed care, and encourage it to continue to work with States to ensure 

access to care for managed care enrollees. 

For the full text of CMS’s comments, see Appendix D. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 17 
 

 

 

APPENDIX A 

Providers Excluded from Analysis 

Table A-1: Providers Excluded from Analysis, by Reason 

Reason 

Number of 

Providers 

Plan had information indicating that the provider was not at the location or not participating 

in the plan during the time of our calls. 348 

Provider practiced at a location at which appointments could not be made, such as a 

hospital where the provider had admitting privileges. 166 

Provider was associated with a plan that was not providing Medicaid managed care during 

the time of our calls.1 75 

Provider was not one of our provider types 75 

Provider did not have a valid address 28

 Total 692 

1 One plan became inactive, and another plan was mistakenly identified as serving Medicaid enrollees. 

Source: OIG analysis of State Medicaid data, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 18 
 

 

 

 

APPENDIX B 

Projected Population 

Table B: Projected Population 

Area 

Primary Care 

Providers Specialists Total 

Urban 398,392 283,079 681,471 

Rural 68,154 28,850 97,004

 Total 466,546 311,929 778,475 

Source: OIG analysis of State Medicaid data, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 19 
 

 

 

 

APPENDIX C 

Point Estimates and Confidence Intervals 

Table C-1: Providers Who Could Not Offer Appointments, by Type, 2013 

Data Element 

Sample 

Size 

Point 

Estimate 

(Percentage) 

95-percent confidence limit 

(%) 

Lower Upper 

Could Not Offer Appointment 

All Providers 1,092 50.6% 46.7% 54.5% 

Not Participating in Plan

 All Providers 1,092 43.0% 39.2% 47.0%

 Providers not at location 1,092 35.4% 31.8% 39.3%

 At location, but not participating 1,092 7.6% 5.7% 10.1%

 All Providers by Provider Type

 Primary care providers 506 45.5% 40.0% 51.1%

 Specialists 586 39.4% 34.4% 44.6%

 All Providers by Area

 Urban providers 522 43.0% 38.7% 47.5%

 Rural providers 570 43.2% 38.8% 47.7%

 Not Accepting New Patients Enrolled in Plan 

All Providers 1,092 7.5% 5.6% 10.0%

 All Providers by Provider Type

 Primary care providers 506 10.2%* 7.3% 14.1%

 Specialists 586 3.5%* 2.0% 6.0%

 All Providers by Area

 Urban providers 522 7.4% 5.3% 10.3%

 Rural providers 570 8.1% 5.8% 11.0% 

*Indicates that differences are statistically significant at the 95-percent confidence level. 

Source: OIG assessment of provider availability, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 20 
 

 

 

 

 

 

APPENDIX C (CONTINUED) 

Table C-2: Providers Who Offered Appointments, by Type, 2013 

Data Element 

Sample 

Size 

Point 

Estimate 

(Percentage) 

95-percent confidence limit 

(%) 

Lower Upper 

All Providers 1,092 49.4% 45.5% 53.3%

 All Providers by Provider Type

 Primary care providers 506 44.3%* 38.9% 49.9%

 Specialists 586 57.1%* 51.8% 62.2%

 Primary Care Providers

 Pediatricians 122 53.4%* 42.9% 63.7% 

OB/GYNs 94 41.9% 30.5% 54.2% 

Family practitioners/general internists 290 40.0%* 32.8% 47.7%

 Specialists 

Gastroenterologists 55 68.4% 52.4% 81.0%

 Urologists 63 62.7% 47.0% 76.1% 

Orthopedists 94 56.9% 42.6% 70.2%

 Neurologists 62 56.0% 40.3% 70.6%

 Cardiologists 188 53.7% 44.1% 63.0%

 All Providers by Area

 Urban providers 522 49.5% 45.1% 54.0%

 Rural providers 570 48.8% 44.3% 53.2% 

*Indicates that differences are statistically significant at the 95-percent confidence level. 

Source: OIG assessment of provider availability, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 21 
 

 

 

 

 

 

 

 

APPENDIX C (CONTINUED) 

Table C-3: Provider Wait Times, 2013 

Data Element 

Sample 

Size Percentage 

95 percent confidence limit 

(%) 

Lower Upper 

Provider Wait Times 

All Providers by Timeframe 

 2 weeks or less 502 51.2% 45.4% 56.9% 

> 2 weeks and ≤ 1 month 502 20.5% 16.2% 25.5% 

> 1 month and ≤ 2 months 502 18.4% 14.4% 23.2% 

> 2 months and ≤ 3 months 502 5.3% 3.3% 8.5%

 More than 3 months 502 4.6% 2.6% 7.9% 

Providers With Wait Times Greater Than 1 month 

 All providers greater than 1 month 502 28.4% 23.5% 33.8%

 Primary care providers 199 23.6% 16.9% 32.0%

 Specialists 303 33.7% 27.2% 40.9%

 Primary Care Providers

 Pediatricians 64 21.8% 11.9% 36.4%

 Family practitioners/general internists 108 26.2% 16.6% 38.7%

 All Providers by Area

 Urban providers 246 29.2% 23.8% 35.4%

 Rural providers 256 21.8% 17.0% 27.6% 

Providers with Wait Times Greater Than 2 months

 All providers greater than 2 months 502 10.0% 7.0% 14.0%

 Primary care providers 199 9.0% 5.0% 15.7%

 Specialists 303 11.1% 7.3% 16.5% 

All Providers by Area 

Urban Providers 246 10.4% 7.1% 15.0% 

Rural Providers 256 6.8% 4.3% 10.7% 

Because of small sample size, point estimates were not calculated for certain provider types. 

Source: OIG assessment of provider availability, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 22 
 

 

 

APPENDIX C (CONTINUED) 

Table C-4: Median Wait Times, 2013 

Data Element 

Sample 

Size Days 

95-percent confidence limit 

(Days) 

Lower Upper 

Median Wait Times 

All Providers 502 13.6 11.3 16.0 

All Providers by Provider Type

 Primary care providers 199 9.9* 6.4 13.3

 Specialists 303 19.5* 15.3 23.7

 All Providers by Area

 Urban providers 246 13.9 10.5 17.3

 Rural providers 256 11.8 9.5 14.1 

*Indicates that differences are statistically significant at the 95-percent confidence level. 

Source: OIG assessment of provider availability, 2014. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 23 
APPENDIX D 

Agency Comments 

/,..vw.,'<r, 

(,..__f. 	DEPARJ'MENT OF HEALTII & HUMAN SERV_r_c_E_s_______ee_nr_er_•_ro_rM-ed-lc-are_&_M_•ct_lc_al_d_se_rv_ice_s 

s~ Admi11istrator 

Washington, DC 20201 

DATE: OC I" Z 8 ZOl~ 

TO: 	 Daniel R. Levinson 


Inspector General 


FROM: 	 Matil):n Tavel\ner 


Adminktratl)r 


SUB.JECT: 	 Office oflnspeclOr General (OIG) Draft Report: "Access to Care: Provider 

Availability in Medicaid Managed Care" (OEI-02-13-00670) 

Thank you for the opportunity to review and comment on the above-referenced 010 draft report. 

The Centers for Medicare & Medicaid Services (CMS) appreciates the OIG's interest in 

Medicaid beneficiaries' access to care under state managed care arrangements. 

CMS is strongly committed to assuring access to care and is implementing a number of 

initiatives to ensure all Medicaid beneficiaries, including those in managed care, have timely 

access to high-quality, low-cost care. 

Recent CMS efforts to ensure access to care in Medicaid managed care include: 

• 	 Benchmarking wait times for Medicaid beneficiaries against other data, including data for 

privately insured populations whenever possible. For example, data from the Consumer 

Assessment of Healthcare Providers and Systems {CAHPS®) from the Agency for 

Healthcare Research and Quality shows that Medicaid enrollees' experiences are 

generally close to those ofother insured populations. These additional efforts will 

provide a more comprehensive assessment of access than could be determined through 

the use of "cold calls" that was used in this report. 

. :e Working With states to implement best practices for updating provider directories, using 

electronic communication methods for sharing provider information, and analyzing 

managed care organization provider's capacity to offer timely appointments. 

Strengthening our internal processes for reviewing state oversight of network adequacy • as part ofreviewing State Plan amendments, reviewing and approving Managed Care 

Organization contracts, implementing and renewing waivers, and reviewing quarterly 

waiver status reports. 

• 	 Ensuring that states monitor managed care organizations' compliance with state· 

established access and network adequacy standards, and develop additional guidance 

where it is needed to establish and assess network adequacy under Medicaid managed 

care. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 24 
 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 25 
 

 

 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 26 
 

 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New York regional 

office, and Nancy Harrison and Meridith Seife, Deputy Regional 

Inspectors General. 

Vincent Greiber served as team leader for this study. Other staff from the 

New York regional office who conducted the study include Marissa Baron, 

Judy Bartlett, and Hailey Davis. New York regional office staff who 

provided support include Miriam Anderson, Marisa Beatley, 

Rachel Bryan, Lucia Fort, Jen Karr, Judy Kellis, Jason Kwong, and 

Michael Rubin. Additional Office of Evaluation and Inspections staff who 

provided support include Deborah Cosimo from the Dallas regional office 

and Janna Sayer from the Atlanta regional office. Central office staff who 

provided support include Kevin Farber, Kevin Manley, Christine Moritz, 

and Julie Taitsman. 

Access to Care: Provider Availability in Medicaid Managed Care (OEI-02-13-00670) 27 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.