Medicaid finances health care for certain categories of low-income individuals, including pregnant women, children, certain low-income In parents, persons with disabilities, and persons who are elderly.addition, states can expand Medicaid eligibility to other individuals, including children and eligible parents with incomes above the current minimum levels. Under broad federal requirements, states administer the day-to-day operations of their Medicaid programs; activities that include determining whether applicants are eligible for Medicaid, setting the scope of covered services, paying providers, and ensuring access to covered services. The Centers for Medicare & Medicaid Services (CMS), a federal agency within the Department of Health and Human Services (HHS), oversees state Medicaid programs at the federal level. States are required to ensure that all individuals who want to apply for Medicaid coverage have the opportunity to do so and must, with reasonable promptness, provide coverage to applicants who are determined eligible. In general, states are required to determine eligibility for individuals who apply for Medicaid within 45 days from the date of application, and within 90 days for those who apply on the basis of disability. In some states, Medicaid applications are reviewed and eligibility is determined at the county level, while other states have centralized their eligibility determination processes. States' Medicaid programs must cover a set of mandatory services, including those provided by primary and specialty care physicians, as well as services provided in hospitals, clinics, and other settings. States may elect to cover additional optional benefits and services, such as home and community-based services, personal care, and rehabilitative services, under their Medicaid programs. In some cases, not all beneficiaries are eligible for all services. For example, Medicaid requires states to cover necessary dental care for children, but dental coverage for adults is optional. Subject to federal requirements, states may establish the amount, duration, and scope of the mandatory and optional services covered in their Medicaid programs. For example, states may limit the number of visits or the days of care that are provided. States are responsible for setting Medicaid provider payment rates within certain federal requirements. Specifically, federal law requires that state Medicaid payments to providers are consistent with efficiency, economy, and quality of care and are sufficient to enroll enough providers so that services are available to beneficiaries at least to the extent that they are available to the general population in the same geographic area. In addition, states must identify the methodologies for making provider payments in their state plans, and such methodologies must be approved by CMS. In addition to payments made directly to providers for services to beneficiaries, most states also make supplemental payments that are separate from and in addition to regular Medicaid payments. Supplemental payments include Disproportionate Share Hospital (DSH) payments, which states are required by federal law to make to hospitals that treat large numbers of Medicaid and low-income individuals; DSH payments cannot exceed the unreimbursed cost of furnishing inpatient and outpatient services to Medicaid beneficiaries and the uninsured. Many states also make other optional supplemental payments that are above the standard Medicaid payment rates but within the Upper We refer to these payments as non-DSH Payment Limit (UPL). supplemental payments. In fiscal year 2010, states and the federal government made at least $32 billion in supplemental payments-- representing over 8 percent of the Medicaid program's total expenditures--with a federal share of at least $19.8 billion. CMS is responsible for overseeing these payment arrangements, including whether states are appropriately financing their share. States may also use provider taxes and certain other sources of revenue to finance their Medicaid programs. Provider taxes are taxes, fees, assessments, or other mandatory payments that states may impose on the provision of or payment for certain types of health care items or services, such as inpatient hospital and nursing facility services. States may use revenue from provider taxes for their state share of Medicaid expenditures only if the taxes meet certain criteria. Many states use revenue from a provider tax on a certain type of provider to increase Medicaid payment rates for the same type of provider, and a state could effectively increase a payment rate for a provider without using additional state funds to finance the increase if the revenue from the provider tax and the federal share of the payment rates account for the total increase. See Pub. L. No. 111-3, SS 104, 123 Stat. 8, 17-23. States are eligible for these performance bonuses for fiscal years 2009 through 2013. Under continuous eligibility, states allow children to remain eligible for Medicaid or CHIP for a full year before any redetermination of eligibility, regardless of changes in household income. Under the express lane eligibility option, states may rely on findings, including income data, from certain other state agencies for Medicaid or CHIP eligibility determination. For presumptive eligibility, states may allow qualified entities, such as, community-based organizations or schools, to screen for eligibility and immediately enroll eligible individuals for a defined period of time. apply for or renew enrollment in Medicaid using an electronic signature beginning in 2014. Of the 55 states that responded to our survey, 39 states provided specific data on average application processing times for new Medicaid applications in 2012, and 43 were able to report generally on whether average application processing time increased, decreased, or remained the same since 2008. The average application processing time is the average number of calendar days between the receipt of a new application and the final determination of eligibility. Among the 39 states that reported data, the current application processing ranged from 11 to 45 calendar days, with a median of 25 calendar days.could not report their average processing times, of which about half noted that they do not track these data or that they track them differently than how they were requested in our survey. For example, 4 states noted that they only tracked whether an application met the mandated time frames for the application--not the specific number of days. Another state reported that its data on application processing times were not reliable because of differences in the way the data were reported by counties. We also asked more generally whether states' application processing times changed since 2008. Of the 55 states that responded, 30 reported decreasing (19 states) or maintaining (11 states) their average processing times for new Medicaid applications, 13 states reported increased processing times, and 12 states reported not knowing whether their processing times had changed. Among the 19 states that reported decreased average processing times for new applications, 15 states attributed the decreases to efforts to streamline application procedures. These 15 states most frequently cited the use of electronic applications and the elimination of face-to-face interviews as streamlining procedures that facilitated decreases in application processing times. (See fig. 1.) Some of these 15 states also cited a decrease in documentation requirements, use of express lane eligibility, revised or shortened applications, or use of presumptive eligibility for helping decrease application processing times. Specifically: Six states reported that the use of express lane eligibility--the reliance on findings from certain other state agencies or state income- tax data to determine eligibility for Medicaid--helped decrease application processing time. Five states reported that their decreased processing times were related to the use of presumptive eligibility procedures, in which authorized entities, including community-based organizations and schools, can screen and immediately enroll eligible individuals into Medicaid for a defined period of time. A few states also attributed decreases in application processing times to other factors not directly related to streamlining application procedures, including additional staff or staff hours (3 states), more intake facilities (2 states) or a reduction in the volume of new applications received (1 state). (See app. II for further information on states' efforts to use electronic application processing and streamlining the renewal application process.) Almost all of the 13 states that reported an increase in average processing times since 2008 attributed these increases to a growth in the volume of new applications received. (See fig. 2.) States could cite more than one factor, and 9 of these states also identified reductions in staff as a result of layoffs, hiring freezes, or furloughs as factors related to increased application processing time. One state that reported an increase in application processing times indicated that, in addition to an increase in the volume of applications received, its staff were learning to use a new computer system to process applications. Because of data limitations, we were unable to assess the extent to which the number of applications states processed kept pace with the number of new applications received each month from January 2008 through December 2011. Most states provided incomplete or inconsistent data on new applications received and processed. For example, 25 states provided incomplete data for 2008 and 15 states provided incomplete information for 2011. States cited various reasons for providing incomplete applications data, including upgrades to their data systems since 2008 and data systems that do not differentiate between applications received and applications processed. For the states that did submit monthly applications data, there were differences among states in the way these data were reported. For example, one state reported totals of Medicaid applications processed that were cumulative over time, rather than just those processed within a month. (For more information, see app. I.) States reported changes--both increases and decreases--to provider payment rates, provider taxes, and beneficiary services since 2008. In a given year, states could make both increases and decreases; for example, states could reduce payment rates to certain types of providers, while increasing payment rates to others. Overall, more states reported payment and service increases than decreases. However, the number of states reporting payment decreases and service limitations grew since 2008. The number of states that reported making at least one payment rate reduction grew from 13 in 2008 to 34 in 2011, while the number of states increasing at least one provider payment rate fell over the same period. Overall, more states reported increasing provider payment rates in 2011 than reducing them. (See fig. 3.) States most frequently reported reducing payment rates for hospitals across all 4 years. For example, in 2011, 19 states reported payment rate reductions for inpatient hospitals and 17 reported reductions for outpatient hospitals. Of the states that increased provider payment rates, more states generally reported increasing payment rates for nursing facilities than any other provider type across all 4 years. For example, in 2011, 19 states reported an increase in rates for nursing facilities, 18 states reported increased payment rates for Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/ID), and 14 states reported increased payment rates for clinics. From 2008 through 2011, 20 or more states reported increasing their use of supplemental payments, which are payments separate from and in addition to regular Medicaid payments. This included both states that added new supplemental payments or increased existing ones. The number of states that reduced supplemental payments was greater in 2011 (10 states) than 2008 (4 states). (See fig. 4.) States most often cited inpatient hospitals, outpatient hospitals, and nursing facilities as recipients of new or increased supplemental payments across all years. These increases in additional supplemental payments coincided with states reporting more payment rate increases for nursing facilities and more rate decreases for inpatient and outpatient hospitals. The number of states implementing new or increasing existing provider taxes more than doubled from 12 states in 2008 to 26 states in 2011. In contrast, the number of states that reported decreasing or eliminating provider taxes fell during the same time period--from 13 states in 2008 to 4 states in 2011. (See fig. 5.) Almost all of the provider taxes that states reported implementing or increasing were for institutional providers-- inpatient hospitals, outpatient hospitals, nursing facilities, inpatient mental health providers, and ICF/ID. States most frequently reported that the purpose was to avoid cuts in services or payment rates, rather than expanding services or increasing provider payment rates. The number of states reporting service increases was relatively stable-- ranging from 26 to 31 states--while the number of states reporting service limitations generally grew from 2008 through 2011. (See fig. 6.) From 2008 through 2011, states reported making more changes to coverage for dental, primary, and specialty care services and prescription drug benefits than for other services. For example, in 2011, six states reported increasing coverage for dental services, and nine states reported decreases. Similarly, eight states reported that they increased prescription drug formularies, and seven states reported that they limited them in 2011. From 2008 through 2011, states reported the fewest changes to coverage for ICF/ID and nursing facility services. Thirty-eight states reported that they experienced challenges ensuring In general, states attributed enough participating Medicaid providers.these challenges to a shortage of providers and Medicaid payment rates, but also cited other issues, such as missed appointments and administrative burden, as factors that influenced provider participation. States reported efforts to simplify administrative processes to retain and attract Medicaid providers and, to a lesser extent, reported efforts to increase payment rates or other financial incentives. Of the 55 states responding to our survey, 38 states reported experiencing challenges to ensuring enough participating providers for Medicaid beneficiaries. Ensuring sufficient dental providers was particularly challenging--but states also reported that ensuring sufficient provider participation in specialty care was problematic. Specifically, states most frequently reported having difficulty ensuring sufficient Medicaid providers for psychiatry, obstetrics and gynecology, surgical specialties, and pediatric services. To a lesser extent, states also cited challenges ensuring enough dermatology and orthopedic service providers. In contrast, fewer states indicated challenges to ensuring adequate nursing facility and community long-term care providers. (See fig. 7.) To monitor provider participation, states reported using provider enrollment data, utilization or claims data, and datasets such as the Healthcare Effectiveness Data and Information Set. For example, 34 states reported that they analyze provider enrollment data and 24 states reported that they analyze utilization or claims data to monitor provider participation in primary or specialty care, or both.18 states indicated that they have identified data sources that they plan to Additionally, use to meet future requirements to measure beneficiary access to services under CMS's proposed regulation, which if finalized, would require states to conduct access reviews for a subset of services each calendar year and release the results to the public. Most states reported that they will analyze claims data or provider enrollment data to meet this requirement. To a lesser extent, states noted that they will assess other sources such as provider and beneficiary surveys as a means to measure access to services in the state. States that use managed care organizations also cited oversight of contract requirements as a way to ensure access. Our prior work also found that physicians reported difficulties referring Medicaid children to specialists. See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.: June 30, 2011). factors, such as the structure of the practice and Medicaid administrative requirements can affect the decision to participate as well. Another study of physicians found that, in light of the multiple factors that may influence willingness to serve Medicaid beneficiaries, an increase in Medicaid payment rates must be accompanied by other program simplifications in order to influence physician participation. Similarly, in a study on dental care, states reported particular challenges ensuring enough participating dental providers. While this study found that dental provider participation increased following rate increases in the states examined, the rate increases were not sufficient on their own to improve Medicaid beneficiaries' access to dental care. The study also noted that streamlining administrative processes and changing dentists' perception of Medicaid could improve participation among them as well. Thirty-eight states reported making at least one administrative or payment rate change to encourage provider participation. These efforts included streamlining enrollment, increasing payments, increasing the speed of claims processing, and reducing administrative burdens. (See fig. 8.) Other efforts cited by states included direct recruitment of providers, improved prior authorization of services, and assistance to providers through training, education efforts, and improved claims resolution. PPACA provided an increase in Medicaid payments for primary care services in 2013 and 2014, and we asked states the extent to which these payments will assist in increasing primary care participation. Of the 55 states that responded to this question, 24 indicated that they were uncertain whether such an increase would assist the state in boosting participation of Medicaid primary care providers. Seventeen states reported that the increase will help to some extent, while 3 reported it will help a great extent. Nine states reported that the increase will not help with participation. Various states reported a number of possible reasons that the increase may not help with provider participation, including its temporary nature, because provider payment with the increase will still fall below commercial rates, and because of a provider shortage in the state, among other reasons. In calendar years 2008 and 2009, less than 4 percent of all Medicaid beneficiaries enrolled for a full year reported difficulty obtaining necessary medical care or prescription medicines, a percentage similar to individuals with full-year private insurance. The extent to which Medicaid beneficiaries reported difficulties obtaining medical care varied by age and whether they were enrolled for a full or partial year. Medicaid beneficiaries also reported delaying care for a variety of reasons, most commonly due to not having transportation, a long wait once at the doctor's office, and being unable to get an appointment soon enough. Beneficiaries covered by Medicaid for a full year reported low rates of difficulty obtaining necessary medical care and prescription medicine, similar to those with private insurance for a full year.2008 and 2009, approximately 3.7 percent of Medicaid beneficiaries enrolled for a full year and 3 percent of individuals enrolled in private insurance for a full year reported difficulties obtaining needed medical care; the difference between these two groups was not statistically significant. In addition, 2.7 percent of full-year Medicaid beneficiaries reported difficulty obtaining needed prescription medicines and about 2.4 percent of individuals with full-year private insurance reported the same issue--also not statistically significant. Full-year Medicaid In calendar years beneficiaries did however, report experiencing greater difficulty obtaining necessary dental care than those with full-year private insurance. (See fig. 9.) Individuals who were uninsured for a full year reported the greatest difficulty obtaining medical care, prescription drugs, and dental services-- at least twice the reported rate of full-year Medicaid beneficiaries. The percentage of individuals experiencing difficulty accessing needed care was higher for those who reported fair or poor health status, with little difference in the rates between those with Medicaid or private health insurance. Approximately 9.9 percent of full-year Medicaid beneficiaries and 8.4 percent of individuals with full-year private insurance reporting fair or poor health indicated difficulty obtaining necessary medical care; again, the difference between these two groups was not statistically significant. The percentage of individuals who were uninsured for an entire year, reported being in fair or poor health, and indicated difficulty obtaining medical care was significantly higher--approximately 29.3 percent. When looking specifically at the experience of working-age adults, individuals aged 18 through 64, we found differences between those with Medicaid and those with private health insurance. Working-age adults with full-year Medicaid coverage reported greater difficulty obtaining needed medical care than similar adults with private health insurance. Specifically, about 7.8 percent of working-age adults with full- year Medicaid reported difficulty obtaining care compared with 3.3 percent of similar adults with private insurance--a statistically significant difference. With respect to dental care, working-age adults with full-year Medicaid were nearly three times more likely to report difficulty obtaining services than similar adults with private insurance, and about six times more likely than children with Medicaid. Children with full- year Medicaid were reported to have no greater difficulties obtaining dental care than children with full-year private insurance. (See fig. 10.) Individuals with partial year health insurance--coverage for between 1 and 11 months--were more likely to report difficulties obtaining needed care, whether covered by Medicaid or private health insurance. In calendar years 2008 and 2009, the percentage of Medicaid beneficiaries enrolled for a partial year who reported difficulties obtaining needed medical care was almost double that of full-year Medicaid beneficiaries.Similarly, individuals with private insurance for a partial year also reported difficulties at more than double the rate of those with full year coverage. Finally, individuals who were uninsured for a partial year reported less difficulty obtaining care than those uninsured for a full year--likely because they had some type of insurance for part of the year. There were no statistically significant differences across all groups with partial year coverage. (See fig. 1.) Among working-age adults with Medicaid, 7.8 percent with full-year coverage and 11.9 percent with partial-year coverage reported difficulty obtaining necessary medical care. Those with partial year Medicaid were more likely to report difficulty obtaining medical care than those with partial year private insurance or who were uninsured for part of the year. (See fig. 12). Medicaid beneficiaries were more likely than individuals with private insurance to report factors such as lack of transportation and long wait time as reasons for delaying medical care. In 2009, approximately 9.6 percent of Medicaid beneficiaries reported delaying medical care because they had no transportation, compared with less than 1 percent of individuals with private insurance. Similarly, about 9.4 percent of Medicaid beneficiaries indicated that they delayed medical care because they could not get an appointment soon enough, or once they arrived for the appointment, the wait was too long. In contrast, 4.2 percent of individuals with private insurance reported delaying care because, once they arrived for the appointment, the wait was too long. Individuals who were uninsured were the most likely to cite cost as a reason for delaying care. (See fig. 13.) We provided a draft of this report to HHS for its review and comment. HHS provided technical comments, which we incorporated as appropriate. This report is intended for use by HHS management. We are sending copies of this report to interested congressional committees and members, and other interested parties. The report is also available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512- 7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Key contributors to this report are listed in appendix III. To examine states' experiences processing Medicaid applications, changes states made to provider payment rates and beneficiary services, and challenges, if any, states face ensuring sufficient provider participation, in February 2012 we surveyed Medicaid officials in all The 50 states, the District of Columbia, and the 5 largest territories.survey was e-mailed to the Medicaid officials on February 22, 2012. Respondents were initially given 3 weeks to respond, and extensions were granted to encourage survey participation. The survey was available online through May 22, 2012. Fifty states, the District of Columbia, and 4 U.S. territories completed the survey, for a response rate of 98 percent. The U.S. Virgin Islands did not complete the survey. To examine states' experiences processing Medicaid applications, states were asked to report their current average processing time for new regular Medicaid applications--those not based on disability--and how those times changed since 2008.about the factors states attributed to any reported changes in the average processing time for Medicaid applications. In addition, to assess the extent to which states were keeping pace with processing new applications, the survey asked for monthly data on the number of new regular applications received and processed from January 2008 through December 2011. The survey also included questions The survey also asked states about changes to benefits, provider payment rates, provider taxes, and supplemental payments in each year from 2008 through 2011. The questions in this section asked about changes by provider and benefit type, including both those benefits that are mandatory and optional. The survey asked, generally, about any changes by provider type (i.e., increased, decreased, eliminated, etc.) and did not ask states to report the details of these changes. States could report more than one type of change for a provider type in a year. For example, a state could report both an increase and a decrease in a provider payment rate for a given provider type in a year. The survey asked whether the state made a particular change for a provider type in a year and did not ask for the actual number of those changes it made in a year or the magnitude of those changes. The survey also asked about the purpose of any new or increased provider taxes, including avoiding cuts in benefits, expanding benefits, avoiding cuts in payment rates, increasing payment rates, or other purposes. Finally, states were asked to report any changes to supplemental payments by provider type and the role of provider taxes or county and local government funds in any changes to the supplemental payments. To examine any challenges to ensuring sufficient provider participation, the survey included questions asking how states monitor whether they have sufficient providers, which provider types are challenging for states to ensure sufficient participation, and any steps the states have taken since January 2008 to maintain their existing pools of providers. The survey asked how the states monitor the sufficiency of providers across three service delivery arrangements--fee-for-service, primary care case management, and risk-based managed care organizations. The survey included questions about any planned efforts to meet potential increases in demand for primary care providers due to the Medicaid expansion under the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010 (PPACA), and whether the increase in payment rates for primary care providers under PPACA would likely assist in increasing provider participation in Medicaid. The survey also asked states about plans to measure access to care for Medicaid beneficiaries in response to recently proposed federal regulations that, if finalized, would provide a framework under which states can demonstrate Medicaid payments are adequate for access to providers. We took steps in developing the survey and collecting and analyzing the data to minimize nonsampling errors. However, any survey may introduce nonsampling errors, such as difficulties in interpreting a particular question or limited sources of information available to respondents. We pretested the draft survey with Medicaid officials in three states in January 2012 to ensure that the questions were relevant, clearly stated, and easy to understand. The states selected for a pretest were diverse with respect to the population size, geography, and total Medicaid spending in 2009. We modified the survey as appropriate as a result of the pretests. Finally, since this was a web-based survey, respondents entered their answers directly into the electronic survey, eliminating the need to key data into a database, which helps to minimize error. We did not independently verify the data reported by states in the survey; however, we reviewed published data submitted by state Medicaid programs to us for another engagement and to outside researchers to assess the reasonableness of the data reported. We also assessed the internal consistency of answers to certain questions. We determined that the data from the survey included in this report were sufficiently reliable for the purposes of this report. We used data provided in response to our 2010 survey of Medicaid directors to determine any changes in states' application processing volumes and rates between October 2007 and February 2010. See GAO, Recovery Act: Increased Medicaid Funds Aided Enrollment Growth, and Most States Reported Taking Steps to Sustain Their Programs, GAO-11-58 (Washington, D.C.: Oct. 8, 2010). One state official was not certain why the data would be reported differently in the prior survey and suggested that it could be related to interpretation of the prior survey question because the state does not collect information in the way we requested it. Officials from two states noted that there were changes in the staff that responded to the survey and could not be certain why the data reported were different. An official from a third state indicated that the data provided to us in 2010 appeared to have included a broader array of applications (such as those for disability, long-term care, and food stamps), noting that the same application process is used for multiple programs in the state. To examine the extent to which Medicaid beneficiaries reported difficulties obtaining care, we analyzed data from the Medical Expenditure Panel Survey (MEPS) and the National Health Interview Survey (NHIS). MEPS is administered by the Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality and collects data on the use of specific health services; NHIS is conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention. We analyzed results from the MEPS household component, which collects data from a sample of families and individuals in selected communities across the United States. These families and individuals are drawn from a nationally representative subsample of households that participated in the prior year's NHIS. Our MEPS analysis was based on data from surveys conducted in 2008 and 2009, the most recent data available at the time of our analysis. MEPS includes insurance status for respondents for each month of the year and NHIS includes respondent information on insurance status at a point in time. Analyzing MEPS allowed us to use information on insurance status for each month to create variables for full-year and partial-year coverage. As a result, we determined that the MEPS insurance status data provided more options to report on the extent to which Medicaid beneficiaries reported difficulties obtaining medical care. In addition to determining the extent to which full-year Medicaid beneficiaries had difficulty accessing care, we also compared Medicaid beneficiaries' reported experiences to the experience of respondents with private insurance and respondents who were uninsured, in order to provide context.Medicaid for a full year reported greater difficulty accessing medical care than children in Medicaid or full-year Medicaid beneficiaries 65 and older. We also compared full-year and partial-year Medicaid beneficiaries, to determine if the extent of reported difficulties obtaining care varied by length of coverage. Finally, we compared responses from full-year and partial-year privately insured individuals, and full-year and partial-year uninsured individuals to provide additional context for the Medicaid beneficiaries' reported difficulties. Further, we examined whether working-age adults 18 to 64 in The MEPS household interviews feature several rounds of interviewing covering 2 full calendar years. MEPS is continuously fielded; each year a new sample of households is introduced into the study. MEPS collects information for each person in the household based on information provided by one adult member of the household. This information includes demographic characteristics, use of medical services, reasons for medical visits, and health insurance coverage. We analyzed responses to MEPS questions about individuals' reported delays and inability to obtain necessary medical care, dental care, and prescription medicine, the reasons for those delays, and the perceived health status of those individuals who delay or are unable to obtain care. For the delays and inability to obtain care measures we used responses to the following questions: In the last 12 months, was anyone in the family delayed in getting medical care, tests, or treatments they or a doctor believed necessary? Which of these best describes the main reason (PERSON) (were/was) delayed in getting medical care, tests, or treatments (he/she) or a doctor believed necessary? In the last 12 months, was anyone in the family unable to obtain in getting medical care, tests, or treatments they or a doctor believed necessary? Which of these best describes the main reason (PERSON) (were/was) unable to obtain medical care, tests, or treatments (he/she) or a doctor believed necessary? We also analyzed responses to similar questions related to delays or the inability to obtain needed dental care and prescription medicines. To address sample size concerns and obtain frequencies above 100 responses, we combined data from 2008 and 2009 and the responses from the questions on both the delays and inability to obtain needed health care. We examined the insurance status of respondents who answered that they delayed or were unable to obtain needed health care. To understand the differences in responses by insurance status we identified the percentage of respondents who delayed or were unable to obtain care with a variety of insurance statuses as well as those who were uninsured. We looked at those respondents who indicated they had Medicaid and private insurance for each month of the year, as well as looking at the responses for those with Medicaid or private insurance for a partial year (1-11 months). We also examined the percentage of respondents who were uninsured for a full and partial year as well as those with mixed insurance statuses, such as Medicaid part year and uninsured for part of the year. In addition, we examined demographic variables--such as age, sex, education, and perceived health status--for those respondents who indicated they delayed or were unable to obtain care as well as those that did not delay care. We also looked at responses to the questions by age group and insurance status to identify potential differences. Small sample sizes for some analyses limited the reliability of the results, and in those cases, we did not report the analyses. In this report, we used a 95 percent confidence level and compared upper and lower confidence intervals to determine whether any differences we found were statistically significant. Statistical significance indicates that the difference between observations is unlikely due to chance alone. We supplemented our MEPS analysis with analysis of data from the 2009 NHIS survey. NHIS data are collected continuously throughout the year for the National Center for Health Statistics, Centers for Disease Control and Prevention, by interviewers from the U.S. Bureau of the Census. NHIS collects information about the health and health care of the civilian, noninstitutionalized U.S. population. Interviews are conducted in respondents' homes, but follow-ups to complete interviews may be conducted over the telephone. We analyzed NHIS data to obtain information on reasons Medicaid beneficiaries reported delays obtaining needed medical care, and compared those to privately insured individuals and the uninsured, for context. We analyzed NHIS data for these questions because the sample size for those questions in NHIS was larger than for similar questions on delays or the inability to obtain care in MEPS. Because NHIS asks about insurance coverage at a point in time, individuals identified as Medicaid beneficiaries would include those with full-year and partial-year coverage. Data from the 2010 NHIS survey were available, but we chose to analyze the 2009 survey so the time period would be compatible with the MEPS analysis. NHIS collects information from the civilian, noninstitutionalized population about demographic characteristics, use of medical services, and health insurance coverage and organizes the data into several data files. NHIS collects information on each family member. More information is collected on a randomly selected adult (the Sample Adult component) and a randomly selected child (the Sample Child component) within each family if a child is present. More information is collected on a sample of adults and children within each family and household. To match the insurance status variables with the answers to the selected questions, we merged data from the Person file, which has information on each family member, with the Sample Adult file, which has more information on sampled adults. We analyzed responses to the following NHIS question from the Person file of the survey: During the past 12 months, [have you delayed seeking medical care/has medical care been delayed for anyone in the family] because of worry about the cost? From the Sample Adult component of the survey, we looked at the following questions: Have you delayed getting care for any of the following reasons in the past 12 months? You couldn't get through on the telephone You couldn't get an appointment soon enough Once you get there, you have to wait too long to see the doctor The (clinic/doctor's) office wasn't open when you could get there You didn't have transportation. We examined the insurance status of respondents to those questions using the suggested variables for Medicaid, private insurance, and uninsurance. For all estimated percentages for both MEPS and NHIS, we calculated a lower and upper bound at the 95 percent confidence level using the appropriate sampling weights and survey design variables provided for each survey. To determine the reliability of the MEPS and NHIS data, we reviewed related documentation, and identified other studies that used MEPS to address similar research questions to compare the published data with our findings. We determined that the MEPS and NHIS data were sufficiently reliable for the purposes of our report. Given the potential of electronic application processing to reduce processing time and related provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA), we asked all of the states about their use of electronic application processing. PPACA required states to begin to accept electronic signatures by 2014, as part of a coordinated enrollment process that includes using a federally defined uniform application and verifying income electronically through a federally managed data hub. We found states varied in the extent to which new Medicaid applications were currently available and processed electronically. (See table 2.) For example, fewer states reported that the application is submitted electronically with an electronic signature than those reporting that the application is available electronically. Twenty-six states reported the percentage of their new Medicaid applications that were accessed, signed, and submitted electronically. In these 26 states, the median proportion of applications accessed, signed, and submitted electronically was 25 percent. Only 11 states reported that the applications were approved or denied electronically. We also asked all states about their efforts to streamline processing through improved renewal procedures, and a number of states reported implementing procedures to streamline the renewal application process for adults and children since 2008. (See table 3.) Such efforts can help limit interruptions in Medicaid coverage for beneficiaries. For children, the streamlined procedures states most frequently reported using were 12-month renewal periods, as opposed to shorter renewal periods; telephone or electronic renewals, or both, instead of in-person interviews; and prepopulated renewal forms.most commonly reported efforts were 12-month renewal periods and telephone or electronic renewal, or both, instead of in-person interviews. In addition to the contact named above, Sheila K. Avruch, Assistant Director; Carolyn Fitzgerald; Sandra George; Mollie Hertel; Joanne Jee; Eagan Kemp; Drew Long; JoAnn Martinez-Shriver; Janet Sparks; and Hemi Tewarson made key contributions to this report.

Summary:
Medicaid enrollment has grown significantly in recent years due to the economic downturn. This growth is expected to continue as the Patient Protection and Affordable Care Act potentially extends Medicaid eligibility in 2014 to millions of uninsured individuals. To better understand whether states are providing adequate access to medical care for beneficiaries, this report examines (1) states' experiences processing Medicaid applications, (2) states' changes to beneficiary services and provider payment rates, (3) the challenges states report to ensure sufficient provider participation, and (4) the extent to which Medicaid beneficiaries reported difficulties obtaining medical care. To examine the first three objectives, GAO administered a nationwide web-based survey to Medicaid officials on states' experiences from 2008 through 2011 and obtained a response rate of 98 percent. To examine the last objective, GAO analyzed data from the 2008 and 2009 Medical Expenditure Panel Survey, the most current available at the time of our analysis, to assess Medicaid beneficiaries' reported difficulties obtaining care, and the 2009 National Health Interview Survey to assess their reasons for delaying care. To provide context, we compared their experiences to those of individuals with private insurance or who were uninsured. From 2008 to 2011, more than half of states reported maintaining or decreasing their average Medicaid application processing times--the average number of calendar days between the receipt of a new application and the final determination of eligibility. The average processing times reported by 39 states ranged from 11 to 45 calendar days. For the same time period, however, GAO was unable to assess whether states processed applications at a rate that kept pace with the number of new applications received each month, because most states provided incomplete or inconsistent data. States reported making numerous changes to provider payments, provider taxes, and beneficiary services since 2008. While more states reported provider-rate and supplemental payment increases each year from 2008 through 2011, the number reporting payment reductions and increased provider taxes also grew. More states reported increasing services than limiting them. Over two-thirds of states reported challenges to ensuring enough Medicaid providers to serve beneficiaries--including dental and specialty care providers. States cited Medicaid payment rates and a general shortage of providers as adding to the challenge. To attract new providers, over half the states reported simplifying administrative requirements or increasing payment rates. In calendar years 2008 and 2009, less than 4 percent of beneficiaries who had Medicaid coverage for a full year reported difficulty obtaining medical care, which was similar to individuals with full-year private insurance; however, more Medicaid beneficiaries reported difficulty obtaining dental care than those with private insurance. Beneficiaries with less than a full year of Medicaid coverage were almost twice as likely to report difficulties obtaining medical care as those with full-year coverage. Medicaid beneficiaries reported delaying care for reasons such as long wait times and lack of transportation. The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.