Medicaid network adequacy

The reality is that Medicaid has had a "Network Adequacy" requirement for sometime, BUT many, if not most, if not all states were failing to attain Network Adequacy.

Some very influential federal government reports from the  General Accounting Office (GAO) and the Office of Inspector General (OIG) highlighted the problem in both Medicare and Medicaid. [See the Orchid Menu under Hot Topics for links to the reports].

Subsequently new regulations and guidance were provided on the issue of Network Adequacy, and in our case Medicaid Managed Care.

As the prior Federal reports found -- it is easy enough to say one has Network Adequacy without really having it [kinda like Parity.|

So a lot of the idea of this is to nail down Managed Care Network Adequacy Standards while still giving states the benefit of local insight.

Okay, basically under CO's Medicaid Contracts with Managed Care Providers --- everybody should have access to services for their:
  • primary, or 
  • behavioral health care needs

CO Medicaid provides a lot of services.  BUT many people find that the high level services they need to stay off the Street or Jail or Prison -- are not there.  AND there are other issues as well with other disability categories, etc.

So it is pretty hard to follow the Code of Federal Regulation required elements of consideration from CO's Managed Care Contracts, but the Contract does have some time and distance requirements spelled out for broad categories of service like "Behavioral Health."

Further, there are requirements on the Managed Care providers to help identify gaps -- it's pretty broad and pretty vague.

When something isn't getting solved, we often have to dig deeper and become more specific.  

So many of these issues are related:  Olmstead, Parity, Medicaid Network Adequacy.  AND so the legislation, court decisions, guidance, regulations are all trying to get at consistent failures in Systems from slightly different points of view.

We have made progress -- BUT you really can't get to Legal Compliance of Medicaid Network Adequacy or most complicated legal requirements in the Disability Systems if there isn't a whole lot of HOW on problematic issues such as Intensive Mental Health Services.
       


​CMS:  States to Develop Network Adequacy Standards --- CMS Answering Questions of States & Other Stakeholders
ManagedCareRule@cms.hhs.gov

 II. Identifying Enrollee Needs and Provider Supply/Capacity .............................................................. 21
A. Identify enrollee needs
 ............................................................ 21
1. Estimate enrollment during contract period .............................................................22
2. Estimate service utilization ...............................................................22
3. Taking into account special health care needs ................................................................26
B. Determine provider supply and capacity ..................................................................28
1. Define eligible providers for each service category ....................................................................28
2. Estimate provider supply ..........................................................................29
C. Match enrollee needs to provider capacity ...................................................................... 31
1. Assessing current supply and distribution ....................................................................... 31
2. Projecting supply and capacity into the future .....................................................................32
References .....................................................................33
We currently are having a very constructive dialogue with mental health representatives on the "Too Dangerous, Too Difficult to Treat" problem under CO Medicaid.  During the course of this dialogue we have said that we want it to be clear that providers have a responsibility:
  • To make reasonable accommodations,
  • Transfer to a higher level of care when necessary,
  • Provide for FEE FOR SERVICE mental health services when the Mental Health Center is unwilling or unable to serve the person.  Under CO Medicaid FEE FOR SERVICE is NOT available for Mental Health Residential Services -- and those may often be the services people most need and there is no viable alternative other than the Mental Health Institutes, and they have a chronic and disastrous bed shortage.
  • Seek Mental Health Certification either 72-hour Hold for "imminent danger" or gravely disabled" or Petition for Court-Ordered Evaluation for "danger" or "gravely disabled."
  • The goal of all this is to avoid the all too convenient alternative of JAIL.

       So what did this very nice and reasonable Mental Health Representative say -- "That's a big ask."  -- Is It?

      One of the problems in Government is we put a lot of legal responsibilities on people and we don't really give them the resources to do it.  AND then, we encourage LAWLESS behavior.  "Oh yeah, we've got Parity, we've got Medicaid Network Adequacy, we're complying with Olmstead, etc."

​       Yeah, we're doing some stuff -- BUT we just can't seem to fully comply.   The problem is CO still has a Medicaid Network Adequacy problem -- this contract isn't going to solve it, and we don't think it complies with the law.  We will probably include Parity concerns as well in our Draft Letter to CMS.

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​ROCKY MOUNTAIN MANAGED CONTRACT
STATEMENT OF WORK, EXHIBIT B
9. NETWORK DEVELOPMENT & ACCESS STANDARDS, P. 52
HTTPS://WWW.COLORADO.GOV/PACIFIC/SITES/DEFAULT/FILES/ROCKY%20MOUNTAIN%20HEALTH%20PLAN%20%28REGION%201%29_1.PDF