Navigating Medicaid Coverage and Care Shouldn’t Be So Hard

Navigating Medicaid Coverage and Care Shouldn’t Be So Hard

May 17, 2023
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Medicaid provides health care insurance and health care services for more than 85 million eligible adults, children, pregnant people, elderly adults, and people with disabilities who have low income. Unfortunately for many families and individuals who are eligible for Medicaid, the processes involved in enrolling, maintaining enrollment, and finally accessing care can often feel overwhelming.

While rigorous standards and standardized processes provide accountability for the administration of government services, barriers to Medicaid enrollment and care are associated with substantial negative health outcomes. These include avoidable hospitalizations for common conditions such as asthma and diabetes and delays in needed medical care, prescriptions, and dental services. When the stakes are this high, there has to be a way to ensure people can get the care they need.

Recently, the Centers for Medicare & Medicaid Services (CMS) has placed a renewed focus on monitoring and improving access to coverage and care in state Medicaid programs, and Mathematica is helping to identify and lower obstacles along the way. In early 2022, CMS released a public Request for Information to gather ideas to improve access to coverage and care in Medicaid. As part of the process, Mathematica analyzed more than 7,000 comments from more than 800 individuals and organizations to help CMS understand the public’s priorities and inform efforts to remove barriers to care.

Starting line or first hurdle? For some people who are eligible for Medicaid, enrolling in the program can feel like more of a hurdle than a starting point. Medicaid applications are often complex and difficult to understand. After enrolling, maintenance of coverage should be routine for people who are still eligible for Medicaid and don’t have affordable access to other sources of health insurance—yet people are often disenrolled when they are unable to navigate complexities in the renewal process. Even before the pandemic, people frequently faced challenges in maintaining coverage.

Early in the pandemic, Congress, CMS, and states recognized the increased threat that inconsistent coverage could pose to Medicaid recipients, establishing mechanisms to ensure continuous coverage and access to essential services. Many of these policies expired on March 31, 2023, and states have begun the process of redetermining whether more than 85 million people enrolled in the program remain eligible. To help prepare for the end of continuous enrollment requirements (referred to as unwinding), CMS, with support from Mathematica, has developed a wide range of supports and requirements for states to keep eligible people enrolled. Many state Medicaid agencies have also streamlined application and renewal processes.

Beyond addressing the potential near-term stumbling blocks of unwinding enrollment requirements, CMS proposed rules in fall 2022 to lower other hurdles to getting and keeping Medicaid coverage, such as eliminating required in-person interviews and allowing people more time to submit required documents. The finalized version of these rules, along with concerted, ongoing efforts by state Medicaid programs and CMS, should help reduce the number of people who are hindered in their efforts to get and keep coverage.

Accessing timely and appropriate care. Even when people can enroll and maintain coverage, they often run into another obstacle: finding physicians, nurses, therapists, facilities, and other clinicians who are willing to provide care to people enrolled in Medicaid. Federal law requires state Medicaid programs to pay enough to enlist enough providers so that care is as available to Medicaid beneficiaries as those with other types of health insurance. But Medicaid payments have been historically much lower than other sources of coverage, and many clinicians and other providers do not accept Medicaid beneficiaries or limit the number they will serve.

As a result, Medicaid beneficiaries often can’t get the care they need. Quality and access measures, calculated each year for CMS by Mathematica, show that child and adult Medicaid beneficiaries often don’t receive recommended preventive and other services.

CMS recently released a range of proposed access regulations for fee-for-service and managed care Medicaid programs in general, and home- and community-based services specifically. These regulations seek to ensure that states stabilize and routinely assess the bridge to care through mechanisms such as provider payment rate transparency, access measurement and reporting, and advisory committees that include Medicaid beneficiaries. Ultimately, the responsibility for improving access to care for people with Medicaid falls on the states, and Mathematica has worked with CMS to support state efforts to improve access to services and clinicians through a range of mechanisms. These include increasing payment rates and creating toolkits for states to ensure Medicaid managed care plans include enough participating providers to meet enrollees’ needs.

Getting to the finish line. It won’t be easy to overcome all the obstacles that threaten access to coverage and care in Medicaid, but recent changes in federal and state Medicaid policies hold promise for removing the highest hurdles. It is up to CMS and state Medicaid agencies to address the remaining barriers so that everyone who qualifies for Medicaid can obtain timely, high-quality care for themselves and their families.

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