At the beginning of July, North Carolina became the fortieth state to make the switch from fee-for-service (FFS) to Medicaid managed care. With the new system barely off the ground, a recent news report highlighted the stories of providers facing denied prior authorizations, delayed payments, and excessive paperwork. One provider stressed that she hadn’t received any payments from two of the five managed care organizations (MCOs) and several providers were considering putting their patients on hold while they waited for compensation. While it is still too early to judge North Carolina’s transition in a systematic way, these providers’ stories raise an important question: how will advocates and other stakeholders be able to tell which MCOs are holding up their end of the contract by paying providers and making sure children and other patients get the services to which they are entitled? Indeed, in the other 39 states (and the District of Columbia), is there enough publicly-available information for advocates to judge the performance of their MCOs (282 total) providing services to children?
As Andy Schneider points out in his recent guide to managed care advocacy, advocates and other stakeholders can use publicly available information to work with the state both holding poor-performing MCOs to account and rewarding high-performing MCOs. But, first the information has to be available. In our newest brief on managed care, “Transparency in Medicaid Managed Care: Findings from a 13-State Scan,” we take a deep-dive into what performance information was and was not available for 56 MCOs across 13 states. Spoiler alert: not a lot.
Out of the 13 states included in the scan (Arizona, Georgia, Illinois, Iowa, Kansas, Kentucky, Mississippi, Missouri, Nevada, Pennsylvania, Tennessee, Utah, West Virginia), only three posted child enrollment on an MCO-specific basis, none posted MCO-specific Early and Periodic Screening, Diagnostic and Treatment services (EPSDT) screening metrics, and none posted MCO-specific quality metrics disaggregated by race or ethnicity. In fact, none of the states even posted all of the information that is required to be posted by federal regulation. The little information available hinted that quality and access to services varied widely between MCOs within states, between states, and across managed care parent firms.
While our sample of 13 states and 56 MCOs is not intended to be a proxy for all MCOs, it does suggest that there is a lot of room for improvement. Based on our findings, we offer recommendations for state agencies and CMS on how to improve the quality of Medicaid coverage for children and pregnant folks by increasing transparency:
- State Medicaid agencies should maintain a child health dashboard that contains MCO-specific performance data and is easily accessible.
- The Centers for Medicare & Medicaid Services (CMS) should monitor and enforce state Medicaid agency compliance with the minimum transparency requirements in its regulations.
- CMS should add a child health dashboard as a measure to the State Administrative Accountability pillar of its Medicaid & CHIP Scorecard.
Only when information is made publicly available can stakeholders judge whether the MCOs in their state are living up to the old North Carolina motto—to be, rather than to seem.
Transparency in Medicaid Managed Care: Findings from a 13- State Scan
