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Addressing Provider Access Barriers in Communities of Color Access to Care in Medicaid January 23, 2015

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Access to Care in Medicaid2 Medicaid Public health program for low- income people Jointly funded and regulated by federal and state governments

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Access to Care in Medicaid3 People of Color 59% of Medicaid beneficiaries 37% of U.S. population

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Medicaid enrollment by race / ethnicity - 2013 Access to Care in Medicaid4

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5 Access: Medicaid assistance shall be furnished with reasonable promptness to all eligible individuals

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Access to Care in Medicaid6

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10 Ensuring access to care in Medicaid

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Access to Care in Medicaid11 Who regulates access (federal level): Congress CMS Federal courts

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Access to Care in Medicaid12 Who regulates access (state level): State legislature State Medicaid agency State Insurance agency* Managed care companies* State courts

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Access to Care in Medicaid13

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Access to Care in Medicaid14 Medicaid Reimbursement 15 states will extend ACA pay increase for PCPs through 2015 Dental rate increases in 6 states upped participation by 30-50%

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Access to Care in Medicaid15

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Access to Care in Medicaid16 Essential Community Providers West Virginia requires Medicaid plans to contract with family planning clinics. Ohio Ryan White providers for people with HIV / AIDS to participate in Medicaid.

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Access to Care in Medicaid17

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Access to Care in Medicaid18 Special Rules for Childrens Services Early and Periodic Diagnosis, Screening, and Treatment or EPSDT requirement. In 2014, 3 states expanded services for youth with autism.

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Access to Care in Medicaid19

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Access to Care in Medicaid20 Physician Extenders 10 states + Puerto Rico cover freestanding birth centers. In 2014 Maine began to cover independent dental hygienists and denturists.

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Access to Care in Medicaid21. StateProvider Medicaid Beneficiary

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Access to Care in Medicaid22. State Managed Care Organization ProviderMedicaid Beneficiary

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Access to Care in Medicaid23 Medicaid Managed Care: 70% of Medicaid beneficiaries 38 states + DC use Medicaid managed care

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Access to Care in Medicaid24 Medicaid Managed Care: Access December 2014 OIG Report found that half of listed Medicaid Managed Care providers did not have any appointments available.

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Access to Care in Medicaid25

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Access to Care in Medicaid26 Provider Participation Virginia requires plans to include pediatric subspecialists in their networks. Wisconsin requires plans to meet specific provider-patient ratios.

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Access to Care in Medicaid27

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Access to Care in Medicaid28 Geographic Access Pennsylvania plans must provide specialty care within 30 mins (urban) or 60 mins (rural). Michigan plans must make pharmacy available within 30 minutes or 30 miles.

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Access to Care in Medicaid29

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Access to Care in Medicaid30 Timely Access Minnesota plans must provide preventive care appointments within 45 days. California plans must make mental health appointments available within 10 days.

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Access to Care in Medicaid31

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Access to Care in Medicaid32 Out-of-network Access Maryland plans must provide out-of-network specialty care to children with special health needs.

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Access to Care in Medicaid33

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Access to Care in Medicaid34 Disability Access California plans must complete a facility site review for all contracted providers.

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Access to Care in Medicaid35

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Access to Care in Medicaid36 Linguistic & Cultural Access Virginia plans must provide interpreter services as a separate covered benefit. Illinois plans must ensure that providers complete cultural competency training.

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Access to Care in Medicaid37 Addressing access problems: Managed Care company complaint* Medicaid fair hearing State Insurance Agency process* Federal agency complaint Litigation

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Questions? Abbi Coursolle Staff Attorney, LA Office National Health Law Program T: (310) 204-6010 coursolle@healthlaw.org 38

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Resources: Medicaid Managed Care: NHeLPs Medicaid Managed Care Model Provisions on Network Adequacy: http://www.healthlaw.org/publications/browse-all-publications/medicaid-managed-Care-model-provisions- issue-3 http://www.healthlaw.org/publications/browse-all-publications/medicaid-managed-Care-model-provisions- issue-3 NHeLPs Recommendations for Advocates on Network Adequacy Provisions in Medicaid Managed Care: http://www.healthlaw.org/publications/network-adequacy-in-medicaid-managed-care http://www.healthlaw.org/publications/network-adequacy-in-medicaid-managed-care OIG Report on State Access Standards for Medicaid Managed Care: http://oig.hhs.gov/oei/reports/oei-02-11- 00320.pdfhttp://oig.hhs.gov/oei/reports/oei-02-11- 00320.pdf General Network Adequacy: Families USA Report on Network Adequacy and Health Equity: http://familiesusa.org/sites/default/files/product_documents/ACT_Network%20Adequacy%20Brief_final_082 214_web.pdf http://familiesusa.org/sites/default/files/product_documents/ACT_Network%20Adequacy%20Brief_final_082 214_web.pdf Families USA Example Standards for Health Insurance Provider Networks: http://familiesusa.org/sites/default/files/product_documents/ACT_Network%20Adequacy%20Brief_final_web. pdf http://familiesusa.org/sites/default/files/product_documents/ACT_Network%20Adequacy%20Brief_final_web. pdf NHeLP Factsheet on Network Adequacy Laws in Covered California Plans: http://healthconsumer.org/081214-ManagedCareinCaliforniaSeries-2-networkadequacy-coveredca.pdf http://healthconsumer.org/081214-ManagedCareinCaliforniaSeries-2-networkadequacy-coveredca.pdf Access to Childrens Services in Medicaid: CMS Guide: Coverage in the Medicaid Benefit for Children and Adolescents: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Benefits/Downloads/EPSDT_Coverage_Guide.pdf http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Benefits/Downloads/EPSDT_Coverage_Guide.pdf NHeLP Paper on EPSDT Services for Children with Autism: http://www.healthlaw.org/publications/cms- guidance-on-epsdt-services-for-children-with-asdhttp://www.healthlaw.org/publications/cms- guidance-on-epsdt-services-for-children-with-asd NHeLP Paper on Hearing Services for Children on Medicaid: http://www.healthlaw.org/publications/Issue- brief-hearing-services-for-children-on-medicaidhttp://www.healthlaw.org/publications/Issue- brief-hearing-services-for-children-on-medicaid Access to Care in Medicaid39

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Resources (contd): Language Access in Medicaid: CMS Letter on Funds for Language Services in Medicaid: http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/cmsletteronincreasefunds. pdf http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/cmsletteronincreasefunds. pdf NHeLP Report on Medicaid Reimbursement Mechanisms for Language Services: http://www.healthlaw.org/publications/how-can-states-get-medicaid-and-chip-for-language-services http://www.healthlaw.org/publications/how-can-states-get-medicaid-and-chip-for-language-services NHeLPs Language Servcies Resource Guide: http://www.healthlaw.org/publications/language-services- resource-guide-for-health-care-providershttp://www.healthlaw.org/publications/language-services- resource-guide-for-health-care-providers Disability Access in Medicaid: NHeLPs Medicaid Managed Care Model Provisions on Language and Disability Access: http://www.healthlaw.org/publications/medicaid-managed-care-model-provisions-issue-4 http://www.healthlaw.org/publications/medicaid-managed-care-model-provisions-issue-4 NHeLP Q&A on Medicaid Managed Care and Disability Protections: http://www.healthlaw.org/publications/qa-medicaid-managed-care-and-disability-protections http://www.healthlaw.org/publications/qa-medicaid-managed-care-and-disability-protections DREDF Legal Position Paper on Medicaid Healthcare Accessibility for People with Disabilities: http://dredf.org/healthcare/DREDF_Legal_Position.html http://dredf.org/healthcare/DREDF_Legal_Position.html Access to Reproductive Health Services in Medicaid: NHeLP Q&A on Medicaid Coverage of Reproductive Health Services: http://www.healthlaw.org/issues/reproductive-health/qa-medicaid-coverage-of-reproductive-health-services http://www.healthlaw.org/issues/reproductive-health/qa-medicaid-coverage-of-reproductive-health-services NHeLP Paper on Sexuality Education in Health Care Delivery for Medicaid: http://www.healthlaw.org/publications/Sexuality-Education-Health-Care-Delivery http://www.healthlaw.org/publications/Sexuality-Education-Health-Care-Delivery Kaiser Family Foundation Report on State Medicaid Coverage of Perinatal Services: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8014.pdf http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8014.pdf Access to Care in Medicaid40

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