Medicaid enrollees may have better options in their provider network than enrollees with a Marketplace health insurance plan, a new study from the Robert Wood Johnson Foundation found. The researchers looked at the network standards for Medicaid providers compared to standards for Affordable Care Act Marketplace providers and found that standards vary dramatically state by state, and some states lack any standards for cultural competency for providers.
“Having health insurance should give people the peace of mind that they can get the care they need,” said Andrea Ducas, senior program officer at the Robert Wood Johnson Foundation. “One important dimension of that is having enough providers that accept your insurance. Policymakers can bring greater peace of mind to more people by ensuring that provider networks are adequate in size and scope of coverage.”
The Affordable Care Act for the first time established a national standard for network adequacy in the commercial insurance market, but this only applies to providers sold through the Marketplaces. State insurance departments primarily establish and enforce network adequacy standards. As a result, network adequacy standards and oversight can vary considerably from state to state, according to the study published March 31.
“Medicaid enrollees on paper have stronger network adequacy protections than QHP enrollees,” the study authors concluded. “At the state level, however, there can be dramatic differences in standards across and within states.” [QHPs are Qualified Health Plans that refer to insurance policies that fulfill the protections and requirements of the Affordable Care Act and meant for people not covered by Medicare]
The study selected six states for analysis: Florida, Georgia, Kansas, New Mexico, Pennsylvania, and Washington, reviewing federal laws, regulations, and sub-regulatory guidance governing network adequacy standards for Marketplace and Medicaid plans in each state.
Consumers in the same state may experience different network access depending on the program in which they are enrolled. For example, in Georgia and Kansas, Medicaid Managed Care Organizations, or MCOs must meet time and distance standards for primary care providers, mental health providers, and OB/GYNs. Meanwhile, Marketplace qualified health plans, or QHPs, in those states are not required to meet such standards. “Without measurable standards, access to crucial healthcare services is dictated by how the insurer decides to interpret subjective terms,” the authors wrote.
For example, in George the standard distance for a primary care provider covered by Medicaid is divided into two categories, rural and urban. For rural, the standard is to list two providers within 8 miles, and for urban, it’s to list two providers within 15 miles. But for marketplace enrollees, they don’t have any standards for distance. It’s the same for Kansas, where urban and semi-urban providers must be within a 40 minute drive, but for Marketplace enrollees there’s no standard.
The researchers also analyzed cultural competency requirements. Language and cultural barriers impact enrollees with Medicaid or with a Marketplace plan, but according to the study, those with Medicaid may have more luck finding a provider who meets their cultural needs. That’s because most state MCO standards include some cultural competency requirements. Such requirements are far less common for QHPs. Federally there are no specific requirements that enrollees access care from a culturally diverse provider network that meets their language or cultural needs.
“As policymakers take incremental steps to reduce the numbers of uninsured, they need to pay equal attention to the adequacy of the coverage being provided,” the authors wrote.
For example, Florida’s MCO standards require plans to offer Medicaid enrolled access to a primary care provider who “is or has office staff who are linguistically and culturally competent to communicate with the enrollee.” Georgia’s standards are less specific, and require MCO networks to “adequately represent cultural diversity of membership.”
As a result of their findings, the study authors came up with a list of recommendations to improve network provider options for enrollees in Marketplace plans.
The group says Marketplace plans need more oversight, more attention to health equity, more access to essential community providers, more consumer protections, more transparency, more support for consumer decision-making, and more enforcement.
To improve Medicaid enrollees’ provider options, the group recommends implementing current federal regulations and creating new federal access regulations. They also recommend periodically reviewing data on patient experience through surveys and focus groups, and monitor complaints received.
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