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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.