Medicaid Fee-For-Service: State Resources Vary for Helping Beneficiaries Find Providers
Published: 2016-08-29T00:00:00

Fast Facts:
How are state governments helping Medicaid beneficiaries connect with participating doctors and hospitals?
Millions of Medicaid beneficiaries are in fee-for-service arrangements, in which states pay health care providers per service—if those providers participate in Medicaid. We looked at the resources available to help beneficiaries find participating health care providers. The 23 states we reviewed had four common types of resources:
searchable provider directories
provider lists
helplines
handbooks
These resources had different amounts of information and states differed in how they adapted resources to meet beneficiary needs.

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid is the federal and state health care program for low-income and medically needy individuals including certain children, adults, and aged and disabled individuals. As states transition more Medicaid enrollees and services to managed care, stakeholders have raised questions about populations that remain in FFS arrangements and the resources they can use to find health care providers. GAO was asked to provide information about Medicaid beneficiaries in FFS arrangements.
This report examines (1) the proportion and characteristics of Medicaid beneficiaries served in FFS arrangements, and (2) the federal and state resources available to help Medicaid beneficiaries in FFS arrangements find participating providers and report related challenges. GAO analyzed 2014 CMS data, the most recent available, on the proportion of Medicaid beneficiaries in different service delivery arrangements by state, and a 2015 survey of state Medicaid agencies by the Kaiser Commission on Medicaid and the Uninsured. GAO catalogued online, publicly available information from the 23 states having at least 30 percent of their Medicaid population in FFS arrangements, and confirmed the information via email or interview. GAO interviewed Medicaid officials and advocates in 6 of the 23 states and CMS officials. These states were selected, in part, based on the diversity of delivery system arrangements and resources. GAO also reviewed federal and state resources.
HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.
section_title: What GAO Found
paragraphs: According to the Centers for Medicare & Medicaid Services (CMS), as of July 2014, over 40 percent of nearly 71 million Medicaid beneficiaries were in fee-for-service (FFS) arrangements—traditional FFS and primary care case management—in which participating providers are paid for each delivered service (e.g., an office visit, test, or procedure). The percentage of beneficiaries in FFS arrangements varied widely among states—22 states served between 50 and 100 percent of beneficiaries, almost 16 million people, in FFS arrangements. A recent survey of states suggests that millions remained in FFS arrangements as of July 1, 2015. The survey also suggests that the proportion of beneficiaries in FFS arrangements is declining as states move more populations into risk-based managed care. Aged and disabled beneficiaries and children with special health care needs were the most likely of different Medicaid populations to be served through FFS arrangements instead of managed care.
CMS, the federal agency that oversees Medicaid, and states consider the development of resources to help beneficiaries find a provider to be a state role. CMS supports a federal resource for pediatric dental care and has provided guidance to states related to resources. The 23 states GAO reviewed have 4 common types of resources to help beneficiaries: searchable provider directories; nonsearchable provider lists; beneficiary helplines; and beneficiary handbooks. These resources vary with respect to the scope of information, availability, and states' adaptations to address beneficiary needs. Of the 23 states, GAO found the following:
17 had online, searchable provider directories; 16 of these included provider information on specialty care physicians and 4 indicated whether primary or specialty care providers were accepting new patients.
23 operated a helpline; 6 operated these outside of regular business hours.
9 included a mapping or location feature with their directories or lists.
Helplines are the primary resource that beneficiaries use to report issues finding a provider, according to Medicaid officials in 4 of 6 selected states and half of the advocacy group representatives GAO interviewed. When beneficiaries contact helplines, they can be directed to additional resources—beyond those listed above—to address their complaint.

section_title: Letter
paragraphs: Medicaid, the largest health insurance program by enrollment in the  United States, covered approximately 76 million low-income and  medically needy individuals as of July 2015. This enrollee population is a  diverse group that includes children, low-income adults, aged individuals,  and those who are disabled. However, research has shown that  enrollment in Medicaid does not ensure a beneficiary can obtain needed  services. Access to health care services in Medicaid is affected by a  number of different factors such as physician participation, availability of  appointments, and proximity to participating providers.
Medicaid was designed as a federal-state partnership that allows states  significant flexibility to design and implement their Medicaid programs.  Medicaid is financed jointly by the federal government and states; the  federal government matches state Medicaid expenditures according to a  statutory formula. The Centers for Medicare & Medicaid Services (CMS),  an agency within the Department of Health and Human Services (HHS),  provides oversight and technical assistance for the Medicaid program, but  states are primarily responsible for administering their respective  Medicaid program’s day-to-day operations, such as setting payment  rates, within broad federal requirements.
The inherent flexibility in the program has resulted in variability across  states in how Medicaid services are delivered, ranging from traditional  fee-for-service (FFS) to comprehensive risk-based managed care. In  traditional fee-for-service, states pay participating providers for each  delivered service (e.g., an office visit, test, or procedure). Primary care  case management (PCCM) is another FFS delivery arrangement in which  providers are reimbursed on a FFS basis for each service delivered.  However, in PCCM a primary care provider also receives a small case  management fee per patient for monitoring, coordinating, and authorizing  patient care, including referrals to specialty care. For the purposes of this  report we generally consider both traditional FFS and PCCM as FFS  arrangements, because the providers serving a beneficiary are  reimbursed on a FFS basis for medical services provided to the patient.  In contrast, under comprehensive, risk-based managed care, states  contract with managed care organizations to provide all or most Medicaid- covered services for beneficiaries and are at financial risk if spending on  services and administration exceeds payments from the state.
States have been transitioning greater numbers of Medicaid enrollees to  managed care in recent years as a way to enhance care and control  costs. For example, according to CMS data, between 2010 and 2014  managed care enrollment grew by over 16 million enrollees. As this  transition continues, stakeholders have raised questions about the  populations that remain in FFS arrangements and the resources, such as  provider directories or hotlines, beneficiaries can use to find health care  providers. We have reported that some Medicaid enrollees may face  challenges accessing needed health care services—for example,  obtaining specialty care (such as mental health care) or dental care.  There are no federal statutory requirements that mandate what resources  states must provide to beneficiaries to assist them in finding available  providers in FFS arrangements.
You asked us to provide information about Medicaid beneficiaries who  are served in FFS arrangements. This report describes  1.  the proportion and characteristics of Medicaid beneficiaries served  in fee-for-service arrangements; and  2.  the federal and state resources available to help Medicaid  beneficiaries in fee-for-service arrangements find participating  providers and report related challenges.
To describe the proportion of Medicaid beneficiaries served through FFS  arrangements at the national and state levels, we analyzed two data sets  that varied in timeliness and completeness. Our primary source was data  collected directly from states by CMS showing the number of Medicaid  beneficiaries in various service delivery arrangements as of July 1, 2014.  We considered beneficiaries served through either PCCM or traditional  FFS to be in a FFS arrangement. Because the CMS data, the most  recent available from the agency, were over 1 year old, we also examined  more recent but less complete data from a second source: the 2015  survey of state Medicaid officials conducted by Health Management  Associates and the Kaiser Commission on Medicaid and the Uninsured in  collaboration with the National Association of Medicaid Directors,  (hereafter called the Medicaid Survey). In the Medicaid Survey, states  reported the percentages of beneficiaries in different service delivery  arrangements as of July 1, 2015, but not the number of beneficiaries. We  were able to use these data to assess whether the reported percentage of  beneficiaries in FFS arrangements had changed in any given state since  2014, but not whether the percentage had changed nationally, as it is not  possible to determine from statewide percentages either the number or  percentage of beneficiaries in FFS arrangements nationwide. We also  reviewed information on selected state Medicaid websites accessed in  March through July 2016 to identify additional changes in service delivery  arrangements that states have planned or made since July 2015. To  describe the characteristics of Medicaid beneficiaries in FFS  arrangements, we analyzed data from two sources: (1) Medicaid Survey  data showing the percentage of beneficiaries in each of four eligibility  groups—children; newly eligible adults in states that opted to expand  Medicaid as authorized by the Patient Protection and Affordable Care Act  (PPACA); other low-income adults; and individuals who were aged or had  disabilities—who were enrolled in managed care as of July 1, 2015; and  (2) CMS data showing whether states enrolled selected populations in  managed care in 2014, from which we were able to determine whether  these populations were served through FFS arrangements instead. We  assessed the reliability of the CMS and Medicaid survey data by  comparing these data to data from other sources and other years and  determined that they were sufficiently reliable for the purposes of our  reporting objectives.
To provide information on the federal and state resources available to  help Medicaid beneficiaries in FFS arrangements find participating  providers and report challenges accessing care, we examined resources  in 23 of the 25 states that use FFS arrangements to deliver care to at  least 30 percent of their Medicaid population as of July 2015, based on  the 2015 Medicaid Survey data. We reviewed and catalogued online,  publicly available resources that assist beneficiaries in finding primary  and specialty care physicians in these 23 states. We confirmed the  resources we identified with all 23 states through either email or phone  interviews. We checked the functionality of the online directories but did  not evaluate the accuracy of the information provided. The information  on state resources that we identified in these 23 states is not  generalizable to other states. From this sample of 23, we interviewed  state Medicaid officials as well as representatives from advocacy groups  that work with Medicaid beneficiaries from 6 states. We chose these  states because of geographic diversity; variation in the proportion of  individuals served through managed care and FFS arrangements; and  variation in types of resources offered to beneficiaries. The selected  states were Alabama, Colorado, Connecticut, Oklahoma, Utah, and  Wisconsin. We used these interviews to better understand the resources  available to beneficiaries, the process for tracking and reporting  beneficiary issues with locating a provider, and any access to care issues  in FFS populations in these states. The experiences of the Medicaid  officials in these 6 states are not generalizable to other states. In addition  to our state interviews, we also interviewed CMS officials and  representatives from a national advocacy group, examined federal  statutes and regulations, and reviewed available federal resources—such  as information on CMS’s website—that are intended to assist either  beneficiaries or states.
We conducted this performance audit from July 2015 to August 2016 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.
subsections: section_title: Background
paragraphs: Historically, Medicaid eligibility has been limited to certain categories of  low-income individuals—such as children, parents, pregnant women,  persons with disabilities, and individuals age 65 and older. In addition to  these traditional eligibility categories, PPACA, which was enacted on  March, 23, 2010, permitted states to expand their Medicaid programs to  cover non-elderly, non-pregnant adults with incomes at or below 138  percent of the federal poverty level, with additional funding available for  this expansion population beginning in January 2014.
subsections: section_title: Health Care Delivery Arrangements
paragraphs: State Medicaid programs are required to offer a minimum, comprehensive  set of services, including services provided by primary care and specialty  care physicians and services provided in hospitals, clinics, and other  settings and are permitted to cover additional services at their option.  Within that framework, states often use a variety of arrangements to  deliver services to their Medicaid populations, including traditional FFS,  PCCM and managed care. The state Medicaid agency is responsible for  administering the program, and the structure of how Medicaid services  are coordinated, administered, and delivered varies by state and  arrangement.
In traditional FFS, beneficiaries can visit any provider that accepts  Medicaid patients. Some states that use both FFS arrangements and  managed care restrict certain populations to traditional FFS to ensure  they have access to all participating Medicaid providers. Certain states  also use PCCM to enhance care coordination and reduce unnecessary  and duplicative costs. PCCM structures vary across the states. While all  PCCM programs feature a primary care case manager that coordinates  beneficiary care, some states have adopted a more enhanced model that  can incorporate provider network management and performance and  quality reporting. To comply with federal regulations, a state’s contract  with a PCCM must include certain provisions, including a requirement to  provide 24-hour availability of information, referral, and treatment for  emergency medical conditions as well as arrangements with, or referrals  to, sufficient numbers of physicians and other practitioners to ensure that  services under the contract can be furnished to enrollees promptly and  without compromise to quality of care. Additionally, federal regulations  require states to give beneficiaries enrolled in PCCM arrangements  contact information for nearby providers.
Medicaid managed care has become more prevalent over the past  decade as states look to provide health care services in a cost-effective  manner. Under managed care, state agencies typically contract with  organizations to provide a specific set of Medicaid-covered services to  beneficiaries, paying those organizations a set amount per beneficiary,  per month to provide services. States vary in terms of the populations and  services included in managed care. For example, states may have  mandatory enrollment in managed care for some populations, voluntary  enrollment for others, and may also exclude certain populations from  managed care. States or their managed care contractors are required to  provide information to enrolled beneficiaries about primary care providers,  specialists, and hospitals included in their provider network, including  names, locations, telephone numbers, languages spoken, and whether  the provider is accepting new patients.
section_title: Federal Access to Care Requirements
paragraphs: Federal law establishes that state Medicaid payments to providers must  be sufficient to enlist enough providers so that care and services are  available to beneficiaries to at least the extent that they are available to  the general population in the same geographic area. This part of the  Medicaid statute, which is sometimes referred to as the “equal access  provision,” has been previously used by providers and beneficiaries to  challenge state reimbursement rates to providers on the grounds that the  rates are insufficient to attract enough providers and are, therefore, not in  compliance with the law. In March 2015, however, the U.S. Supreme  Court ruled in Armstrong v. Exceptional Child Center, Inc., that the equal  access provision does not provide a cause of action for providers to  challenge a state’s reimbursement rates.
Subsequent to the Armstrong decision, CMS published a final rule on  Medicaid access to care, Medicaid Program: Methods for Assuring  Access to Covered Medicaid Services. One purpose of the rule is to  provide CMS with the necessary information to ensure that state  reimbursement rates meet the requirements of the equal access  provision. The rule outlines a process for states to document their  approach to monitoring access, especially when proposed rate reductions  or other changes that may reduce beneficiaries’ abilities to access care.  Under the rule, states are required to develop access monitoring review  plans—which must contain specific data sources to support a finding of  sufficient access—that cover at a minimum primary care and physician  specialist services, behavioral health services, pre- and post-natal  obstetric care, including labor and delivery, home health services, and  any services for which the state or CMS has received a higher than usual  volume of complaints. The data collected for these services through the  access monitoring review plan must be analyzed every 3 years by states.  States proposing to reduce or restructure provider payments that could  result in diminished access to care must also submit an access review  with the state plan amendment proposing such changes. In addition,  states must monitor access to care after the implementation of the rate  reduction or payment restructuring, at a minimum, annually over a 3-year  period.  States must submit their initial access monitoring review plans to  CMS by October 1, 2016. Additionally, the rule requires that states have  ongoing mechanisms for beneficiaries and providers to comment on  access to care (through hotlines, surveys, ombudsman, review of  grievance and appeals data, or another equivalent mechanism). States  are required to maintain a record of the input they receive and how they  responded. States must also provide this information to CMS upon  request.
section_title: Medicaid Access to Care
paragraphs: We have previously reported on Medicaid access to care issues that  different Medicaid populations have faced. By some measures, access  to care for Medicaid enrollees is comparable to that of privately insured  individuals and better than that of uninsured individuals. In a national  survey, for example, 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. At  the same time, however, Medicaid beneficiaries may have greater health  care needs; for example, higher rates of obesity and other health  conditions, and greater difficulty accessing specialty and dental care.  Certain groups of Medicaid enrollees have reported difficulty obtaining  necessary care relative to others. For example, in 2012, about 7.8  percent of working-age adults with full-year Medicaid reported difficulty  obtaining care compared with 3.3 percent of similar adults with private  insurance—a statistically significant difference. Medicaid enrollees also  were more likely than individuals with private insurance to report factors  such as lack of transportation and long wait times as reasons for delaying  medical care.
We also have found that both Medicaid-covered adults and children may  face challenges obtaining mental health and other specialty services.  For example, while Medicaid expansion under PPACA has increased the  availability of mental health treatment for newly eligible adults, states  have reported access concerns for new beneficiaries due to shortages of  Medicaid-participating psychiatrists and psychiatric drug prescribers.  Even though Medicaid beneficiaries’ use of dental services has  increased, states have found it particularly challenging to ensure a  sufficient number of dental providers for Medicaid enrollees, and Medicaid  and other low-income beneficiaries, particularly children, visit the dentist  less often than those with private insurance.
section_title: Over 40 Percent of Medicaid Beneficiaries, Including Many with Disabilities, Were in Fee-for-Service Arrangements in 2014
paragraphs: CMS data show 41 percent of Medicaid beneficiaries nationwide were in  FFS arrangements in 2014, with wide variation among states; more  recent 2015 Medicaid Survey data suggest that millions remain in these  arrangements. Disabled beneficiaries were among the most likely to be  served through FFS arrangements.
subsections: section_title: 2014 Federal Data Show 41 Percent of Beneficiaries in Fee-for- Service, with Wide Variation among States; 2015 Medicaid Survey Data Suggest Millions Remain in These Arrangements
paragraphs: The most recent CMS data available show that 41 percent of about 71  million beneficiaries nationwide were served through FFS arrangements  as of July 1, 2014. About 21 million of the almost 29 million beneficiaries  in these arrangements were served through traditional FFS, while another  7 million were enrolled in PCCM.
Among states, the percentage of beneficiaries in FFS arrangements  varied widely, ranging from 0 to 100 percent (fig.1). In 22 states, the  majority of Medicaid beneficiaries were served through FFS  arrangements. Together, these states accounted for 55 percent, or almost  16 million, of all beneficiaries in FFS nationwide. The 22 states were  evenly divided between those in which all or nearly all beneficiaries were  in some type of FFS arrangement and those in which some beneficiaries  were enrolled in managed care. For a few of the latter states, enrollment  of beneficiaries in managed care was relatively recent. For example, both  Iowa and Louisiana began enrolling beneficiaries in managed care in  2012, and North Dakota began doing so in January 2014.
In the remaining 29 states, the majority of Medicaid beneficiaries were  enrolled in managed care. But in many of these states, the percentage of  beneficiaries in FFS or PCCM was still sizeable—more than 20 percent in  19 states and more than 30 percent in 9. Beneficiaries not enrolled in  managed care in these states were primarily in traditional FFS, rather  than PCCM.
The Medicaid Survey data suggest that millions of beneficiaries were still  in FFS arrangements as of July 1, 2015. Although exact enrollment is  unknown, all 11 states that reported serving all or nearly all beneficiaries  through FFS arrangements in 2014—and which together accounted for  5.9 million beneficiaries at that time—reported the same in 2015. In  addition, 27 other states reported that at least 20 percent of beneficiaries  were receiving services through some type of FFS arrangement in  2015.
However, the Medicaid Survey data also suggest that the proportion of  beneficiaries in FFS arrangements is declining, as states continue to  move populations from a FFS delivery model into managed care. These  data show 15 states with FFS as the predominant service delivery  arrangement, compared with the 22 states reported in the 2014 CMS  data. A few states reported significantly lower percentages of  beneficiaries in FFS arrangements than previously. For example,  Louisiana, which eliminated PCCM in early 2015, reported 29 percent of  beneficiaries in FFS arrangements as of July 1, 2015, compared with 68  percent a year earlier. At least 5 states, including Iowa and North  Carolina, have expanded or begun managed care enrollment since the  Medicaid Survey was conducted in 2015 or planned to do so within the  next few years.
section_title: Beneficiaries with Disabilities Were among Those Most Likely to Be Served Through FFS Arrangements
paragraphs: The 2015 Medicaid Survey data indicate that individuals with disabilities  and aged individuals, who were reported together as one group, were the  most likely to be served through FFS arrangements. While the vast  majority of aged beneficiaries likely had both Medicare and Medicaid  coverage, beneficiaries with disabilities were much more likely to rely  solely on Medicaid for coverage of acute care services. Historically,  many states have served beneficiaries with disabilities through FFS  arrangements rather than managed care, in part to ensure that these  vulnerable beneficiaries have access to a range of providers (some of  whom might not have participated in managed care). While this trend is  changing and states are increasingly enrolling individuals with disabilities  in managed care, along with those whose complex health care needs  require long-term services and supports, some states with managed care  still serve all or most individuals with disabilities through FFS  arrangements. According to Medicaid Survey data, of the 39 states with  managed care as of July 1, 2015, 6 had enrolled no aged or disabled  beneficiaries in managed care, and another 7 had enrolled fewer than  one-third of these beneficiaries.
Children with special health care needs and certain other populations also  were more likely to be served through FFS arrangements, because states  were less likely to require or permit these populations to enroll in  managed care. For instance, 9 of the 41 states with managed care in  2014 did not require or permit children with special health care needs to  enroll in managed care, and another 9 states made enrollment voluntary  for this group, according to CMS data. Other populations that some states  served through FFS arrangements rather than managed care included  children in foster care or adoption assistance, Native Americans and  Alaska Natives, and individuals who were eligible for only partial benefits,  such as family planning services.
In contrast, the 2015 Medicaid Survey data indicate that adults newly  eligible under the Medicaid expansion made possible by PPACA were  among the least likely to be in FFS arrangements. Twenty-nine states had  exercised the option to expand Medicaid eligibility as of July 1, 2015. In  23 of those expansion states, fewer than 25 percent of adults newly  eligible under the expansion were in FFS arrangements. In states with  managed care, the only beneficiaries as unlikely to be in FFS  arrangements as expansion adults were non-disabled children.
section_title: A Few Federal Resources Exist to Help Fee-For-Service Beneficiaries Find Providers; Selected States’ Resources Vary
paragraphs: Although CMS and states consider the provision of resources to help  beneficiaries locate a provider to be primarily a state role, CMS has  provided a few resources to help beneficiaries. While most states  generally have developed common resources, the scope of information  that these resources provide, and the availability of resources among  states, varies. Telephone helplines are the primary resource that  beneficiaries use to report challenges in finding a provider.
subsections: section_title: Although States Play a Primary Role in Helping Fee-For-Service Beneficiaries Find Providers, CMS Has Provided a Few Resources
paragraphs: The development of resources to help Medicaid beneficiaries find a  provider is primarily a state role, according to federal and state officials.  CMS officials told us that states have the flexibility to operationalize  resources as they see fit to meet state-specific needs and that resources  are likely to vary among states as a result of this flexibility. Medicaid  officials we interviewed from the six selected states agreed with CMS’s  view and noted that none of their states had requested assistance from  CMS around developing resources for beneficiaries to help them find a  provider.
The Dentist Locator on the Insure Kids Now website is the only federal  resource that aims to directly assist Medicaid beneficiaries in locating a  provider. CMS developed the Dentist Locator in partnership with the  Health Resources and Services Administration to meet a requirement of  the Children’s Health Insurance Program Reauthorization Act of 2009.  The web-based tool allows beneficiaries to locate nearby dentists that  treat children in Medicaid and the State Children’s Health Insurance  Program and to identify which providers are accepting new patients,  speak languages other than English, and are able to provide support for  patients with special health care needs.
In addition to the Dentist Locator, CMS also provides state Medicaid  agencies with a few suggested outreach messages through its “Helping  Connect Enrollees to Care” initiative. The initiative does not give  detailed information on developing resources to help beneficiaries find a  provider; instead, it provides general messaging for use on state Medicaid  websites or in materials given to new enrollees to (1) help new enrollees  establish a regular source of health care and (2) promote use of  preventive health care services. Specifically, CMS’s suggested outreach  messages instruct beneficiaries to ask their provider if they accept  Medicaid, visit their state’s Medicaid website, or call their state Medicaid  agency for information on finding a doctor. The initiative also directs  beneficiaries looking for a pediatric dentist to visit the Insure Kids Now  Dentist Locator.
section_title: States Generally Have Resources to Help Beneficiaries Find a Provider, but Scope of Information and Availability of the Resources Varies
paragraphs: The 23 states we reviewed generally offered four common types of  resources—searchable provider directories, nonsearchable provider lists,  handbooks, and telephone helplines—to help beneficiaries in FFS  arrangements find a provider, with variation across states in the scope of  information they provided and how they addressed the needs of specific  Medicaid populations through their resources. Twenty-one of the 23  states provided searchable provider directories or nonsearchable provider  lists that contain contact information for providers who see Medicaid  beneficiaries (see fig. 2). All of the 23 selected states had a publicly  available beneficiary handbook or brochure containing information about  the Medicaid program and operated a statewide telephone helpline that  allows beneficiaries to contact a Medicaid representative by telephone— either at the state Medicaid office or through a contractor—who can  answer questions and provide information on a variety of topics.  Officials from all 6 state Medicaid agencies we interviewed told us they  generally developed resources as a way to help beneficiaries access  covered Medicaid services.
The scope of information offered and the functionality of these common  resources varied:
Searchable provider directories: Seventeen of the 23 selected  states had online, searchable provider directories, and 16 of these  included provider information on specialty care physicians. Four of the  23 selected states’ searchable directories indicated whether providers  (primary or specialty care) were accepting new patients. Additionally,  of the 15 states with PCCM, 10 offered provider information (primary  and specialty care) to beneficiaries through searchable provider  directories. Although we did not evaluate the accuracy of the provider  information itself, we identified errors in 8 of the 16 provider  directories from our 23 selected states. These errors included  duplication errors where identical provider information appeared more  than once in a page of search results, functionality errors where the  search tool did not work as indicated in the instructions, and missing  data errors where multiple provider listings had more than two fields of  data missing.
Nonsearchable provider lists: Six of the 23 selected states had  nonsearchable lists containing provider contact information, and 2 of  these included contact information for participating specialty care  physicians. Provider lists from 2 of these states indicated whether a  provider was accepting new Medicaid patients. Additionally, of the  15 states with PCCM, 5 offered primary care information to  beneficiaries through nonsearchable provider lists and 1 of these lists  also provided information on specialty care providers. Beneficiaries in  PCCM gain access to specialty care physicians through referrals from  their primary care physician.
Beneficiary telephone helplines: All states operated a helpline and  six operated outside of regular business hours. Seventeen of the 23  states explicitly stated that the helplines could assist beneficiaries in  finding or changing providers on the state’s Medicaid website or in the  beneficiary handbook. For example, the Connecticut handbook notes  that beneficiaries can call member services for help with finding a  provider, making appointments, and choosing or changing a primary  care provider. Without such an explicit statement from the states,  beneficiaries may not know they can use the helpline to get  assistance in finding a provider.
States may face challenges maintaining accurate provider information  within the resources developed. Medicaid officials in four states, along  with three beneficiary advocacy groups, told us that resources—mainly  directories and lists—are not useful if the provider information in them is  not accurate. Officials from one state commented that provider  information is only a “snapshot in time” and that maintaining accuracy is  challenging because, in their directory, providers are responsible for  updating their own information. An official from another state attributed  that state’s decision not to create a provider list for FFS beneficiaries to  the challenging process of determining if a provider will accept new  Medicaid patients.
Mobile application   In Colorado, the state Medicaid agency  developed a mobile application for Medicaid  beneficiaries that contains the same  searchable provider directory as the Medicaid  website as well as additional information  about Medicaid benefits. State Medicaid  officials told us they developed the application  as a communication tool to reach young  adults, the beneficiary population that grew  the most following Colorado’s decision to  After-Hours locator  In Oklahoma, the state Medicaid agency  developed an after-hours provider locator to  help beneficiaries locate Medicaid providers in  their area who are available outside of  business hours. Oklahoma Medicaid officials  told us all providers listed on the site have  agreed to see Medicaid patients after hours.  They noted that providers receive a higher  reimbursement for services provided after- hours.
Quick Guide  In Connecticut, the state Medicaid agency  developed a Covered Services Quick Guide, a  one page resource that provides specific  information on Medicaid coverage and contact  information for the state Medicaid office and  their four administrative services  organizations.  The administrative services  organizations provide support around medical,  behavioral health, dental, and transportation  services, and beneficiaries can contact the  appropriate call center for assistance finding  that type of provider. Connecticut Medicaid  officials said the Quick Guide was developed  to offer a brief, yet comprehensive, resource  list to help beneficiaries access services and  supports.
Medicaid officials we interviewed in four of the six states and  representatives from advocacy groups in three of the six states noted that  helplines are the primary resource beneficiaries use to report issues  finding a provider. When beneficiaries contact helplines, they can be  directed to additional resources—beyond those listed in the above  sections—to address their complaint. Other resources and approaches to  address beneficiary complaints about finding a provider vary by state.  These resources include using on-staff providers (nurses, psychiatrists,  and dentists) to make referral requests to their peers in the medical  community and escalating complaints to an ombudsman for one-on-one- service.
States used different approaches to document and track the beneficiary  complaints they received about finding a provider and access challenges  more broadly. While state approaches varied, all state Medicaid officials  in the six states where we conducted interviews told us they track  beneficiary complaint data in some way. In one state, officials told us the  data were tracked in a spreadsheet and that one administrative employee  typically handles calls about access challenges. Another state collected  trend data from a statewide helpline and several more specialized call  centers. Medicaid officials in all six states told us they had not  established a number, or threshold, of complaints that triggered state  action (state actions could include providing incentives to recruit  providers, creating an ombudsman service, developing a telemedicine  program, etc.) on specific access issues. An official from one state told us  that the process of identifying a widespread access issue (e.g., a  shortage of dental providers) can be subjective due to the variety of ways  complaints are classified. Under CMS’s rule, states must have ongoing  mechanisms for beneficiary and provider input on access to care (through  hotlines, surveys, ombudsman, review of grievance and appeals data, or  other equivalent mechanism). States are required to maintain a record of  the input they receive and how they responded. They must also provide  this information to CMS upon request. Medicaid officials in the six states  told us that they were still determining how they will adjust their  approaches to identifying and responding to access to care challenges— such as issues locating a provider—to comply with CMS’s rule.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment. The department  provided technical comments, which we incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents of  the report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or iritanik@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of the report. GAO staff who made key contributions to this report  are listed in appendix II.
section_title: Appendix I: Additional State Actions to Address Access Challenges
paragraphs: Consistent with our prior work, which noted that over two-thirds of states  reported challenges to ensuring enough Medicaid providers to serve  beneficiaries, state Medicaid officials and beneficiary advocacy groups we  interviewed identified specific state actions that attempt to address certain  access challenges. Several state Medicaid officials and advocacy groups  noted that provider shortages, proximity to participating providers, and  transportation, among other things, were more directly related to access  challenges than resources for finding a provider. Several states have  initiated efforts to address these challenges, including the following  examples:  In Oklahoma, Medicaid officials have started using telemedicine to  help address the shortage of child and adolescent psychiatrists in the  state.
In Connecticut, Medicaid officials require the administrative service  organizations to perform and present annual geo-access analyses. A  geo-access analysis is a visual mapping of provider locations to help  identify potential access issues due to remoteness of beneficiaries.
Utah’s state legislature passed a law in 2016 to create state income  tax credits for psychiatrists and psychiatric mental health nurse  practitioners, under certain circumstances, to help recruit those  providers to the state.
While some states are addressing access challenges with statewide  efforts, several state Medicaid officials and advocates in the 6 states we  interviewed commented that challenges locating a provider can be  community-specific at the county or city level and noted that federally  qualified health centers, local health departments, or community health  workers are points for both disseminating information about resources  and for identifying and mitigating local access challenges. Additionally,  some communities are developing resources to tackle specific access  challenges in their area. For example, an alliance of health care  stakeholder organizations in Denver is preparing to pilot the use of a  specialty care referral network to address the difficulties underserved  residents in the area face in finding specialty care physicians. The  proposed network will help streamline referrals from primary care  physicians to specialists and will allow for electronic consultation between  the two about a patient’s treatment.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Leslie V. Gordon, Assistant  Director; Dan Klabunde, Analyst-in-Charge; Summar Corley; Christine  Davis; Nancy Fasciano; Laurie Pachter; and Emily Wilson made key  contributions to this report.