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.