Medicaid participants may have better options in their provider network than participants with Marketplace health insurance plans, new research Discovered from the Robert Wood Johnson Foundation. The researchers compared network standards for Medicaid providers to those of ACA marketplace providers and found that standards varied widely across states, with some states lacking any standards for provider cultural competency.
“Having health insurance should give people peace of mind that they can get the care they need,” said Andrea Ducasse, senior program officer at the Robert Wood Johnson Foundation. “One of the important aspects is having enough providers to accept your coverage. Policy makers can put more people at ease by ensuring that provider networks are sufficiently large and covered.”
For the first time, the Affordable Care Act established a national standard for network adequacy in the commercial insurance market, but this only applies to providers who sell through the marketplace. The national insurance sector primarily establishes and enforces network adequacy standards. As a result, cyber adequacy standards and oversight may vary from state to state, according to research released March 31.
“Medicaid enrollees on paper had stronger network adequacy protections than QHP enrollees,” the study authors concluded. “However, at the state level, there can be substantial differences in within-state and within-state standards.” [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, examining federal laws, regulations, and subsections that govern each state’s market and Medicaid network adequacy standards Regulatory Guidelines.
Consumers in the same state may experience different web access depending on which plan they sign up for. 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. At the same time, market-qualified health plans or QHPs in these states are not required to meet such criteria. “In the absence of measurable criteria, access to critical health care services depends on how insurers decide to interpret subjective terms,” the authors wrote.
In George, for example, standard distances for primary care providers covered by Medicaid fall into two categories, rural and urban. For rural, the standard is to list two providers within 8 miles, and for urban, the standard is to list two providers within 15 miles. But for market participants, they don’t have any distance criteria. The same goes for Kansas, where urban and semi-urban vendors must be within a 40-minute drive, but for Marketplace registrants, there is no standard.
The researchers also analyzed cultural competency requirements. Language and cultural barriers can affect enrollees in Medicaid or Marketplace plans, but according to this study, those with Medicaid may be more fortunate to find providers that meet their cultural needs. This is because most state MCO standards include some cultural competency requirements. For QHP, such requirements are much less. There are no specific federal requirements that enrollees receive care from a network of multicultural providers who meet their language or cultural needs.
“As policymakers take incremental steps to reduce the uninsured, they need to be equally concerned about the adequacy of coverage provided,” the authors wrote.
For example, Florida’s MCO standards require plans to provide Medicaid enrollment visits to primary care providers who “are or have office staff who are linguistically and culturally capable of communicating with enrollees.” Georgia’s standards are less specific and require the MCO network to “adequately represent the cultural diversity of its members.”
Based on their findings, the study authors made a series of recommendations to improve the choice of network providers for participants in the marketplace program.
The group said market programs need more oversight, more focus on health equity, more access to essential community providers, more consumer protection, greater transparency, more support for consumer decision-making, and More enforcement.
To improve provider choice for Medicaid participants, the panel recommends implementing current federal regulations and developing new federal access regulations. They also recommend regular review of patient experience data through surveys and focus groups, and monitoring of complaints received.
Photo: zimmytws, Getty Images
