oversight

Medicaid: States Made Multiple Program Changes, and Beneficiaries Generally Reported Access Comparable to Private Insurance

Published by the Government Accountability Office on 2012-11-15.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to the Secretary of Health and
                             Human Services



November 2012
                             MEDICAID

                             States Made Multiple
                             Program Changes, and
                             Beneficiaries
                             Generally Reported
                             Access Comparable to
                             Private Insurance



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GAO-13-55
                                             November 2012

                                             MEDICAID
                                             States Made Multiple Program Changes, and
                                             Beneficiaries Generally Reported Access
                                             Comparable to Private Insurance
Highlights of GAO-13-55, a report to the
Secretary of Health and Human Services




Why GAO Did This Study                       What GAO Found
Medicaid enrollment has grown                From 2008 to 2011, more than half of states reported maintaining or decreasing
significantly in recent years due to the     their average Medicaid application processing times—the average number of
economic downturn. This growth is            calendar days between the receipt of a new application and the final
expected to continue as the Patient          determination of eligibility. The average processing times reported by 39 states
Protection and Affordable Care Act           ranged from 11 to 45 calendar days. For the same time period, however, GAO
potentially extends Medicaid eligibility     was unable to assess whether states processed applications at a rate that kept
in 2014 to millions of uninsured             pace with the number of new applications received each month, because most
individuals. To better understand            states provided incomplete or inconsistent data.
whether states are providing adequate
access to medical care for                   States reported making numerous changes to provider payments, provider taxes,
beneficiaries, this report examines          and beneficiary services since 2008. While more states reported provider-rate
(1) states’ experiences processing           and supplemental payment increases each year from 2008 through 2011, the
Medicaid applications, (2) states’           number reporting payment reductions and increased provider taxes also grew.
changes to beneficiary services and          More states reported increasing services than limiting them.
provider payment rates, (3) the
challenges states report to ensure           Over two-thirds of states reported challenges to ensuring enough Medicaid
sufficient provider participation, and       providers to serve beneficiaries—including dental and specialty care providers.
(4) the extent to which Medicaid             States cited Medicaid payment rates and a general shortage of providers as
beneficiaries reported difficulties          adding to the challenge. To attract new providers, over half the states reported
obtaining medical care. To examine           simplifying administrative requirements or increasing payment rates.
the first three objectives, GAO
administered a nationwide web-based          In calendar years 2008 and 2009, less than 4 percent of beneficiaries who had
survey to Medicaid officials on states’      Medicaid coverage for a full year reported difficulty obtaining medical care, which
experiences from 2008 through 2011           was similar to individuals with full-year private insurance; however, more
and obtained a response rate of              Medicaid beneficiaries reported difficulty obtaining dental care than those with
98 percent. To examine the last              private insurance. Beneficiaries with less than a full year of Medicaid coverage
objective, GAO analyzed data from the        were almost twice as likely to report difficulties obtaining medical care as those
2008 and 2009 Medical Expenditure            with full-year coverage. Medicaid beneficiaries reported delaying care for reasons
Panel Survey, the most current               such as long wait times and lack of transportation.
available at the time of our analysis, to
assess Medicaid beneficiaries’               Percentage of Individuals Who Reported Difficulties Obtaining Necessary Care or Services, by
                                             Full-Year Insurance Status, Calendar Years 2008-2009
reported difficulties obtaining care, and
the 2009 National Health Interview
Survey to assess their reasons for
delaying care. To provide context, we
compared their experiences to those of
individuals with private insurance or
who were uninsured.




View GAO-13-55. For more information,
contact Carolyn L. Yocom at (202) 512-7114
or yocomc@gao.gov.                           The Department of Health and Human Services reviewed a draft of this report
                                             and provided technical comments, which GAO incorporated as appropriate.
                                                                                          United States Government Accountability Office
Contents


Letter                                                                                   1
               Background                                                                5
               Some States Did Not Report Certain Application Processing Data;
                 Most Reported Decreasing or Maintaining Processing Times                9
               States Made Numerous Changes to Provider Payments and
                 Beneficiary Services                                                  12
               States Reported Challenges Ensuring a Sufficient Number of
                 Providers                                                             18
               Few Full-Year Medicaid Beneficiaries Reported Difficulty
                 Obtaining Care, but Experiences Varied                                24

Appendix I     Scope and Methodology                                                    33



Appendix II    States Use of Electronic Medicaid Application Processing and
               Renewal Procedures                                                       42



Appendix III   GAO Contact and Staff Acknowledgments                                    44



Tables
               Table 1: Factors States Reported That Affect Provider Participation
                        in Medicaid                                                    22
               Table 2: State Electronic Processing Procedures for New Medicaid
                        Applications                                                   42
               Table 3: State Medicaid Renewal Procedures                              43


Figures
               Figure 1: Number of States Attributing Decreased Application
                        Processing Times, since 2008, to Certain Streamlining
                        Procedures                                                     11
               Figure 2: Number of States Attributing Increased Average
                        Application Processing Times, since 2008, to Certain
                        Factors                                                        12
               Figure 3: Number of States Reporting Increases and Decreases to
                        Provider Payment Rates, Calendar Years 2008-2011               14



               Page i                                             GAO-13-55 Medicaid Access
Figure 4: Number of States Reporting Changes to Supplemental
         Payments, Calendar Years 2008-2011                            15
Figure 5: Number of States Reporting Changes to Provider Taxes,
         Calendar Years 2008-2011                                      16
Figure 6: Number of States Reporting Changes to Benefits or
         Services, Calendar Years 2008-2011                            18
Figure 7: Number of States Reporting Challenges to Ensuring
         Enough Participating Medicaid Providers, by Service Type      20
Figure 8: State Reported Efforts to Maintain Existing Pool or
         Attract New Medicaid Providers                                23
Figure 9: Percentage of Individuals Who Reported Difficulties
         Obtaining Necessary Care or Services, by Full-Year
         Insurance Status, Calendar Years 2008-2009                    25
Figure 10: Percentage of Working-Age Adults and Children with
         Full-Year Coverage Who Reported Difficulties Obtaining
         Necessary Dental Care, by Insurance Status, Calendar
         Years 2008-2009                                               27
Figure 11: Percentage of Individuals Who Reported Experiencing
         Difficulty Obtaining Necessary Medical Care, by
         Insurance Status, Partial or Full Year, Calendar Years
         2008-2009                                                     29
Figure 12: Percentage of Working-Age Adults (Age 18 to 64) Who
         Reported Difficulty Obtaining Necessary Medical Care, by
         Insurance Status, Partial or Full Year, Calendar Years
         2008-2009                                                     30
Figure 13: Percentage of Individuals Who Cited Specific Reasons
         for Delaying Medical Care in Calendar Year 2009, by
         Insurance Status                                              31




Page ii                                           GAO-13-55 Medicaid Access
Abbreviations

CHIP              State Children’s Health Insurance Program
CHIPRA            Children’s Health Insurance Program Reauthorization Act
                    of 2009
CMS               Centers for Medicare & Medicaid Services
DSH               Disproportionate Share Hospital
EPSDT             Early and Periodic Screening, Diagnostic, and Treatment
HCERA             Health Care and Education Reconciliation Act
HHS               Department of Health and Human Services
ICF/ID            Intermediate Care Facilities for Persons with Intellectual
                    Disabilities
MEPS              Medical Expenditure Panel Survey
NHIS              National Health Interview Survey
PPACA             Patient Protection and Affordable Care Act
UPL               Upper Payment Limit



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Page iii                                                       GAO-13-55 Medicaid Access
United States Government Accountability Office
Washington, DC 20548




                                   November 15, 2012

                                   The Honorable Kathleen Sebelius
                                   Secretary of Health and Human Services

                                   Dear Madam Secretary:

                                   Enrollment and expenditures in Medicaid, a federal-state health financing
                                   program for certain categories of low-income individuals, have grown
                                   significantly in recent years. During the nation’s recent economic crisis,
                                   Medicaid enrollment grew 14.2 percent from October 2007 through
                                   February 2010. During this time, total Medicaid expenditures grew nearly
                                   21 percent, from $332.2 billion in 2007 to $401.5 billion in 2010. 1 Since
                                   then, enrollment growth has slowed—averaging around 4 percent
                                   nationally—yet the growth in Medicaid spending continues to be a source
                                   of concern. 2 Economic downturns can create challenges for states
                                   because tax revenues can decrease, while unemployment—and
                                   enrollment in Medicaid—can increase. To reduce program spending,
                                   states generally may make certain changes to their Medicaid programs,
                                   such as altering payments to providers, limiting eligibility, eliminating
                                   optional services, or reducing the amount, duration, or scope of services.

                                   While recent laws have provided some fiscal relief to states through the
                                   provision of additional federal funding for Medicaid, they have also limited
                                   the ability of states to alter their programs. For example, the American
                                   Recovery and Reinvestment Act of 2009 (Recovery Act) provided a
                                   temporary increase in the rate at which the federal government matched
                                   state expenditures, but required states to maintain Medicaid program
                                   eligibility in order to receive the additional funding. 3 The Patient Protection


                                   1
                                    See 2001 Actuarial Report on the Financial Outlook for Medicaid (Office of the Actuary,
                                   Centers for Medicare & Medicaid Services, Department of Health and Human Services,
                                   Mar. 16, 2012).
                                   2
                                    See GAO, State and Local Governments’ Fiscal Outlook, April 2012 Update,
                                   GAO-12-523SP (Washington, D.C.: Apr. 2, 2012).
                                   3
                                    Pub. L. No. 111-5, § 5001,123 Stat.115, 496-502 (2009). The Recovery Act initially
                                   provided states with an estimated $87 billion in increased federal funds for Medicaid from
                                   February 2009 through December 2010. In August 2010, Congress extended the
                                   increased federal matching rate through June 2011, although at a lower level than what
                                   was provided under the Recovery Act. See Pub. L. No. 111-226, §201, 124 Stat. 2389,
                                   2393-4 (2010).




                                   Page 1                                                         GAO-13-55 Medicaid Access
and Affordable Care Act of 2010 (PPACA) 4 requires states to expand
their Medicaid programs to cover additional individuals and provides an
enhanced federal match for this coverage. 5 PPACA also makes other
changes to Medicaid eligibility and payment, such as requiring states to
maintain their current levels of eligibility for Medicaid beneficiaries and
increasing payment rates for Medicaid primary care services in 2013 and
2014. 6 Potential Medicaid expansions under PPACA are estimated to
result in enrollment of about 7 million additional individuals in 2014




4
 Pub. L. No. 111-148, 124 Stat. 119 (2010) (PPACA), as amended by the Health Care
and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (HCERA).
For purposes of this report, references to PPACA include the amendments made by
HCERA.
5
 Effective January 1, 2014, states must expand Medicaid eligibility to non-pregnant
individuals under age 65 who have household incomes that do not exceed 133 percent of
the federal poverty level for the applicable family size, who are not entitled to or enrolled in
Medicare, and who are not already required to be covered under Medicaid. States will
receive an increased federal match for newly eligible adults starting at 100 percent in 2014
and gradually decreasing to 90 percent in 2020. 42 U.S.C. §§1396a(a)(10)(A)(i)(VIII),
1396d(y). As initially set forth in PPACA, states that chose not to expand Medicaid
coverage faced the potential loss of all federal Medicaid funds, including for the population
already covered under the current program. However, the U.S. Supreme Court has ruled
that states that choose not to expand Medicaid coverage will forgo only the enhanced
federal matching funds associated with such expanded coverage. See National
Federation of Independent Business, et al., vs. Sebelius, Sec. of Health and Human
Services, et al., 132 S. Ct. 2566, 2012 WL 2427810 (U.S. June 28, 2012).
6
  42 U.S.C. §§ 1396a(a)(13)(C), (gg),1396u-2(f). States must maintain Medicaid eligibility
standards for children from PPACA’s enactment, March 23, 2010, until October 1, 2019,
and for adults, until the Department of Health and Human Services (HHS) determines an
exchange in the state is operational. (PPACA requires states to establish exchanges—
marketplaces through which individuals can access private health plans.) Exceptions to
this maintenance-of-effort requirement may be granted for certain adults with income
above 133 percent of the federal poverty level for states experiencing or projecting a
budget deficit. In addition, payment rates for primary care services paid to Medicaid
providers either by states or Medicaid managed care plans generally must be increased to
Medicare reimbursement levels for those services; such increases relative to a state’s
December 2009 rates will be federally funded. On November 6, 2012, CMS published a
final rule implementing this requirement, in which the agency specifies which services and
types of providers qualify for the increased payments and the methods for calculating the
federal share for the increased payment amount. Under this rule, CMS also will require
states to report data on primary care provider participation before and after the increased
payments, which CMS will make publicly available. 77 Fed. Reg. 66,670 (November 6,
2012).




Page 2                                                            GAO-13-55 Medicaid Access
growing to 11 million in 2022. 7 While it is too early to assess the extent to
which states will expand Medicaid coverage to this newly eligible
population, any growth in Medicaid is likely to place additional pressure
on states to manage their programs, maintain or increase their pool of
providers, and ensure access to needed health care services for Medicaid
beneficiaries.

In October 2010, we reported on changes states were making to sustain
their Medicaid programs after certain federal funding increases from the
Recovery Act lapsed. Some of these changes could affect beneficiaries’
access to care. 8 Over half of the states reported making administrative
changes that could affect Medicaid application processing time, such as
decreasing the number of staff or staff hours available for processing
Medicaid applications and increasing furlough days. Additionally, states
reported changes to certain services and payments to providers that
could affect beneficiary access. Such changes raise questions about
whether Medicaid is meeting the health care needs of the current
beneficiaries and whether the expansion of Medicaid may further
exacerbate issues of access for beneficiaries. To assess factors that can
affect access and beneficiaries’ experiences obtaining care, this report
examines (1) states’ experiences processing Medicaid applications,
(2) changes that states have made to beneficiary services and provider
payment rates, (3) the challenges states report with regard to ensuring
sufficient provider participation, and (4) the extent to which Medicaid
beneficiaries’ reported difficulties obtaining medical care.

To address the first three objectives, we administered a web-based
survey from February 2012 to May 2012 to Medicaid officials in the
50 states, the District of Columbia, and the 5 largest U.S. territories, and




7
 Enrollment numbers reflect new enrollment in both Medicaid and the Children’s Health
Insurance Program. See Congressional Budget Office, Estimates for the Insurance
Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court
Decision (July 2012).
8
 See GAO, Recovery Act: Increased Medicaid Funds Aided Enrollment Growth, and Most
States Reported Taking Steps to Sustain Their Programs, GAO-11-58 (Washington, D.C.:
Oct. 8, 2010). In this report, we described actions states were taking to address program
sustainability after funding from the Recovery Act was no longer available.




Page 3                                                        GAO-13-55 Medicaid Access
obtained a response rate of 98 percent. 9 In this survey, we generally
asked about states’ experiences from 2008 through 2011. For the web-
based survey, we relied on the survey response reported by the primary
contact for the state’s Medicaid program. When we asked states about
implementing various efforts, such as application processing
improvements, we generally gave a time frame for implementation, and
state efforts implemented prior to that time frame are not included in the
report. We did not independently verify the accuracy of the data reported
by states, but we reviewed all survey responses for internal consistency.
In addition, we completed our state survey field work prior to the June 28,
2012, decision by the Supreme Court on certain aspects of PPACA,
including the Medicaid expansion provision. Accordingly, state responses
were provided to us before they had analyzed any potential effect of the
decision on their own state. To address the fourth objective, we analyzed
two national surveys, the National Health Interview Survey (NHIS) and
the Medical Expenditure Panel Survey (MEPS), to examine the extent to
which Medicaid beneficiaries reported difficulties obtaining care. Our
MEPS analysis was based on national survey data from 2008 and 2009,
the most recent data available at the time of our analysis. Our NHIS
analysis was based on the 2009 survey. 10 Both of these national surveys
rely on information reported by individuals. To provide context for
difficulties obtaining care reported by Medicaid beneficiaries, we
examined the extent to which individuals with private insurance or those
who are uninsured reported such difficulties. We also conducted the
analysis across different age groups, including children, working-age
adults, 11 and those 65 and older, but small sample sizes limited the
reliability of some analyses, and therefore we did not report them. For the
MEPS analysis, children with Medicaid also included those with coverage




9
 Fifty states, the District of Columbia, and 4 U.S. territories (American Samoa, Guam,
Puerto Rico and the Commonwealth of the Northern Mariana Islands) responded to the
survey. The U.S. Virgin Islands did not complete the survey. For the purposes of this
report, we are referring to all 56 jurisdictions that we surveyed as states.
10
  Data from the 2010 NHIS survey were available, but we chose to analyze the 2009
survey so the time period would be compatible with the MEPS analysis.
11
 In this report, the term “working-age adults” refers to those ages 18-64.




Page 4                                                         GAO-13-55 Medicaid Access
             under the State Children’s Health Insurance Program (CHIP). 12 We
             examined differences in reported difficulty obtaining care between
             beneficiaries reporting fair or poor health and those reporting better health
             and between those with full-year coverage and less than full-year
             coverage. 13 For the NHIS and MEPS surveys, we reviewed relevant
             documentation describing how these data are collected and processed,
             and examined other research that has used these data to report on
             potential delays in obtaining health care services to check our results
             against similar analyses. We determined that the data we used in this
             report were sufficiently reliable for the purposes of our engagement. (See
             app. I for additional information on our scope and methodology.)

             We conducted this performance audit from December 2011 through
             November 2012 in accordance with generally accepted government
             auditing standards. Those standards require that we plan and perform the
             audit to obtain sufficient, appropriate evidence to provide a reasonable
             basis for our findings and conclusions based on our audit objectives. We
             believe that the evidence obtained provides a reasonable basis for our
             findings and conclusions based on our audit objectives.


             Medicaid finances health care for certain categories of low-income
Background   individuals, including pregnant women, children, certain low-income
             parents, persons with disabilities, and persons who are elderly. 14 In
             addition, states can expand Medicaid eligibility to other individuals,


             12
               CHIP is a federal-state program that generally provides health care coverage to children
             in low-income families whose incomes exceed the eligibility requirements for Medicaid.
             States have the choice of three design approaches for their CHIP programs: (1) a
             Medicaid expansion program, (2) a separate child health program, or (3) a combination
             program, which has both a Medicaid expansion program and a separate child health
             program.
             13
               Individuals with less than full-year coverage reported having insurance coverage for
             between 1 to 11 months. Individuals may be covered under Medicaid for only part of the
             year for a variety of reasons, including changes in income. In this report, we used a
             95 percent confidence level and compared upper and lower confidence intervals to
             determine whether any differences we found were statistically significant. Statistical
             significance indicates that the difference between observations is unlikely due to chance
             alone.
             14
               Parents are eligible for Medicaid under certain circumstances. For example, states must,
             at a minimum, cover parents who meet the state’s 1996 Aid to Families with Dependent
             Children eligibility criteria, which vary among states and include both financial and
             categorical components.




             Page 5                                                         GAO-13-55 Medicaid Access
including children and eligible parents with incomes above the current
minimum levels. Under broad federal requirements, states administer the
day-to-day operations of their Medicaid programs; activities that include
determining whether applicants are eligible for Medicaid, setting the
scope of covered services, paying providers, and ensuring access to
covered services. The Centers for Medicare & Medicaid Services (CMS),
a federal agency within the Department of Health and Human Services
(HHS), oversees state Medicaid programs at the federal level. States are
required to ensure that all individuals who want to apply for Medicaid
coverage have the opportunity to do so and must, with reasonable
promptness, provide coverage to applicants who are determined
eligible. 15 In general, states are required to determine eligibility for
individuals who apply for Medicaid within 45 days from the date of
application, and within 90 days for those who apply on the basis of
disability. 16 In some states, Medicaid applications are reviewed and
eligibility is determined at the county level, while other states have
centralized their eligibility determination processes.

States’ Medicaid programs must cover a set of mandatory services,
including those provided by primary and specialty care physicians, as well
as services provided in hospitals, clinics, and other settings. States may
elect to cover additional optional benefits and services, such as home and
community-based services, personal care, and rehabilitative services,
under their Medicaid programs. In some cases, not all beneficiaries are
eligible for all services. For example, Medicaid requires states to cover
necessary dental care for children, but dental coverage for adults is
optional. 17 Subject to federal requirements, 18 states may establish the
amount, duration, and scope of the mandatory and optional services
covered in their Medicaid programs. For example, states may limit the
number of visits or the days of care that are provided.



15
 See 42 U.S.C.§ 1396a(a)(8).
16
  See 42 CFR § 435.911. These time standards cover the period from the date an
application is submitted to the date the state mails notice of the decision.
17
  As part of the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit,
states must provide comprehensive and preventive health care services, including dental
services, for individuals who are under 21 years of age who are enrolled in Medicaid.
42 U.S.C. §§ 1936a(a)(43), 1396d(r)(3).
18
  States must provide Medicaid services sufficient in amount, duration, and scope to
reasonably achieve their purpose. 42 C.F.R. § 440.230.




Page 6                                                        GAO-13-55 Medicaid Access
States are responsible for setting Medicaid provider payment rates within
certain federal requirements. Specifically, federal law requires that state
Medicaid payments to providers are consistent with efficiency, economy,
and quality of care and are sufficient to enroll enough providers so that
services are available to beneficiaries at least to the extent that they are
available to the general population in the same geographic area. 19 In
addition, states must identify the methodologies for making provider
payments in their state plans, and such methodologies must be approved
by CMS.

In addition to payments made directly to providers for services to
beneficiaries, most states also make supplemental payments that are
separate from and in addition to regular Medicaid payments.
Supplemental payments include Disproportionate Share Hospital (DSH)
payments, which states are required by federal law to make to hospitals
that treat large numbers of Medicaid and low-income individuals; DSH
payments cannot exceed the unreimbursed cost of furnishing inpatient
and outpatient services to Medicaid beneficiaries and the uninsured.
Many states also make other optional supplemental payments that are
above the standard Medicaid payment rates but within the Upper
Payment Limit (UPL). 20 We refer to these payments as non-DSH
supplemental payments. In fiscal year 2010, states and the federal
government made at least $32 billion in supplemental payments—
representing over 8 percent of the Medicaid program’s total
expenditures—with a federal share of at least $19.8 billion. CMS is
responsible for overseeing these payment arrangements, including
whether states are appropriately financing their share. 21




19
  See 42 U.S.C. § 1396a(a)(30)(A). On May 6, 2011, the Centers for Medicare & Medicaid
Services (CMS) issued a proposed rule entitled Medicaid Program: Methods for Assuring
Access to Covered Medicaid Services, regarding federal guidelines for approaches for
states to demonstrate compliance with some of these requirements. 76 Fed. Reg. 26342
(May 6, 2011). As of October 1, 2012, this rule had not been finalized.
20
  The Upper Payment Limit is the estimated amount that Medicare pays for comparable
services.
21
  Over the years, we and others have reported that states were shifting costs
inappropriately through several financing methods, notably the use of supplemental
payments. A variety of federal legislative, regulatory, and CMS actions have helped curb
inappropriate arrangements, but gaps remain. See GAO, High Risk Series: An Update,
GAO-11-278 (Washington, D.C.: February 2011).




Page 7                                                        GAO-13-55 Medicaid Access
States may also use provider taxes and certain other sources of revenue
to finance their Medicaid programs. Provider taxes are taxes, fees,
assessments, or other mandatory payments that states may impose on
the provision of or payment for certain types of health care items or
services, such as inpatient hospital and nursing facility services. States
may use revenue from provider taxes for their state share of Medicaid
expenditures only if the taxes meet certain criteria. 22 Many states use
revenue from a provider tax on a certain type of provider to increase
Medicaid payment rates for the same type of provider, and a state could
effectively increase a payment rate for a provider without using additional
state funds to finance the increase if the revenue from the provider tax
and the federal share of the payment rates account for the total
increase. 23

States also may implement certain options to streamline Medicaid
eligibility determinations. For example, the Children’s Health Insurance
Program Reauthorization Act of 2009 (CHIPRA) established new
performance bonuses for states adopting at least five of eight specified
policies to simplify Medicaid and CHIP enrollment and retention
procedures for children. Possible enrollment and retention simplification
measures include adopting 12-month continuous eligibility, eliminating in-
person interviews, adopting express lane eligibility, or implementing
presumptive eligibility. 24 PPACA also specified additional policies to
streamline enrollment and retention in Medicaid and CHIP. For example,
PPACA requires states to establish a process by which individuals can


22
   States may receive federal matching funds for provider taxes only if such taxes are
broad-based, uniformly imposed, and do not result in any taxpayers being held harmless
(i.e., receiving state funds to reduce the net payment to the state to below the amount of
the tax). CMS may waive the broad-based and uniform tax requirements if the net effect of
the tax is generally redistributive and the tax is not directly related to Medicaid payments.
42 U.S.C. § 1396b(w), 42 C.F.R. §§ 433.68, 72.
23
  See also Congressional Research Service, Medicaid Provider Taxes, RS22843
(Mar. 15, 2012).
24
  See Pub. L. No. 111-3, § 104, 123 Stat. 8, 17-23. States are eligible for these
performance bonuses for fiscal years 2009 through 2013. Under continuous eligibility,
states allow children to remain eligible for Medicaid or CHIP for a full year before any
redetermination of eligibility, regardless of changes in household income. Under the
express lane eligibility option, states may rely on findings, including income data, from
certain other state agencies for Medicaid or CHIP eligibility determination. For
presumptive eligibility, states may allow qualified entities, such as, community-based
organizations or schools, to screen for eligibility and immediately enroll eligible individuals
for a defined period of time.




Page 8                                                            GAO-13-55 Medicaid Access
                        apply for or renew enrollment in Medicaid using an electronic signature
                        beginning in 2014. 25


                        Of the 55 states that responded to our survey, 39 states provided specific
Some States Did Not     data on average application processing times for new Medicaid
Report Certain          applications in 2012, and 43 were able to report generally on whether
                        average application processing time increased, decreased, or remained
Application             the same since 2008. 26 The average application processing time is the
Processing Data; Most   average number of calendar days between the receipt of a new
Reported Decreasing     application and the final determination of eligibility. Among the 39 states
                        that reported data, the current application processing ranged from 11 to
or Maintaining          45 calendar days, with a median of 25 calendar days. 27 Sixteen states
Processing Times        could not report their average processing times, of which about half noted
                        that they do not track these data or that they track them differently than
                        how they were requested in our survey. For example, 4 states noted that
                        they only tracked whether an application met the mandated time frames
                        for the application—not the specific number of days. Another state
                        reported that its data on application processing times were not reliable
                        because of differences in the way the data were reported by counties.

                        We also asked more generally whether states’ application processing
                        times changed since 2008. Of the 55 states that responded, 30 reported
                        decreasing (19 states) or maintaining (11 states) their average processing
                        times for new Medicaid applications, 13 states reported increased
                        processing times, and 12 states reported not knowing whether their
                        processing times had changed.


                        25
                          42 U.S.C. §1396w-3. As a condition of receiving federal Medicaid funds, states must
                        establish an Internet website through which individuals can apply for or renew Medicaid
                        enrollment and may consent to enrollment or reenrollment through an electronic signature.
                        This enrollment website must be linked to the exchange and CHIP websites, ensuring that
                        individuals will be considered for eligibility for those programs if they are determined
                        ineligible for Medicaid.
                        26
                          The survey included a question that asked states to report average application
                        processing time in calendar days. A separate question asked states generally whether
                        application processing time had changed—increased, decreased, or remained the same—
                        since 2008, but did not ask states to report on the magnitude of the change.
                        27
                          Data presented here were for 95 percent of the sample of states reporting a current
                        average processing time. Data were excluded for one state that reported an average
                        processing time of 9 calendar days and for one U.S. territory that reported 120 calendar
                        days.




                        Page 9                                                         GAO-13-55 Medicaid Access
Among the 19 states that reported decreased average processing times
for new applications, 15 states attributed the decreases to efforts to
streamline application procedures. 28 These 15 states most frequently
cited the use of electronic applications and the elimination of face-to-face
interviews as streamlining procedures that facilitated decreases in
application processing times. (See fig. 1.) Some of these 15 states also
cited a decrease in documentation requirements, use of express lane
eligibility, revised or shortened applications, or use of presumptive
eligibility for helping decrease application processing times. Specifically:

•    Six states reported that the use of express lane eligibility—the
     reliance on findings from certain other state agencies or state income-
     tax data to determine eligibility for Medicaid—helped decrease
     application processing time. 29

•    Five states reported that their decreased processing times were
     related to the use of presumptive eligibility procedures, in which
     authorized entities, including community-based organizations and
     schools, can screen and immediately enroll eligible individuals into
     Medicaid for a defined period of time.

•    A few states also attributed decreases in application processing times
     to other factors not directly related to streamlining application
     procedures, including additional staff or staff hours (3 states), more
     intake facilities (2 states) or a reduction in the volume of new
     applications received (1 state).

(See app. II for further information on states’ efforts to use electronic
application processing and streamlining the renewal application process.)




28
  Survey results do not indicate the number of states that use a particular application
procedure—only the extent to which a state considered this a factor that affected its
application processing time. States could cite more than one type of effort to streamline
application procedures.
29
 These agencies may include those administering programs including Supplemental
Nutrition Assistance, National School Lunch Program, Temporary Assistance for Needy
Families, and Head Start.




Page 10                                                         GAO-13-55 Medicaid Access
Figure 1: Number of States Attributing Decreased Application Processing Times, since 2008, to Certain Streamlining
Procedures




                                         Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
                                         responded to the 2012 GAO survey. Fifteen states attributed decreased application time to one or
                                         more application streamlining procedures, as described in the figure above. Survey results do not
                                         indicate the number of states that use a particular application procedure—only the extent to which a
                                         state considered this a factor that affected its application processing time.
                                         a
                                          Express lane eligibility allows states to rely on findings from certain other state agencies or state
                                         income tax data to determine eligibility for Medicaid.
                                         b
                                          Under presumptive eligibility, states allow authorized entities, such as community-based
                                         organizations or schools, to screen for eligibility and immediately enroll eligible individuals for a
                                         defined time period.


                                         Almost all of the 13 states that reported an increase in average
                                         processing times since 2008 attributed these increases to a growth in the
                                         volume of new applications received. (See fig. 2.) States could cite more
                                         than one factor, and 9 of these states also identified reductions in staff as
                                         a result of layoffs, hiring freezes, or furloughs as factors related to
                                         increased application processing time. One state that reported an
                                         increase in application processing times indicated that, in addition to an
                                         increase in the volume of applications received, its staff were learning to
                                         use a new computer system to process applications.




                                         Page 11                                                                    GAO-13-55 Medicaid Access
Figure 2: Number of States Attributing Increased Average Application Processing Times, since 2008, to Certain Factors




                                         Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
                                         responded to the 2012 GAO survey. Thirteen states attributed their increased application processing
                                         time to one or more factors.


                                         Because of data limitations, we were unable to assess the extent to which
                                         the number of applications states processed kept pace with the number of
                                         new applications received each month from January 2008 through
                                         December 2011. Most states provided incomplete or inconsistent data on
                                         new applications received and processed. For example, 25 states
                                         provided incomplete data for 2008 and 15 states provided incomplete
                                         information for 2011. States cited various reasons for providing
                                         incomplete applications data, including upgrades to their data systems
                                         since 2008 and data systems that do not differentiate between
                                         applications received and applications processed. For the states that did
                                         submit monthly applications data, there were differences among states in
                                         the way these data were reported. For example, one state reported totals
                                         of Medicaid applications processed that were cumulative over time, rather
                                         than just those processed within a month. (For more information, see
                                         app. I.)


                                         States reported changes—both increases and decreases—to provider
States Made                              payment rates, provider taxes, and beneficiary services since 2008. In a
Numerous Changes to                      given year, states could make both increases and decreases; for
                                         example, states could reduce payment rates to certain types of providers,
Provider Payments                        while increasing payment rates to others. Overall, more states reported
and Beneficiary                          payment and service increases than decreases. However, the number of
Services                                 states reporting payment decreases and service limitations grew since
                                         2008.




                                         Page 12                                                                GAO-13-55 Medicaid Access
The Number of States       The number of states that reported making at least one payment rate
Reducing Providers’        reduction grew from 13 in 2008 to 34 in 2011, while the number of states
Payments or Implementing   increasing at least one provider payment rate fell over the same period.
                           Overall, more states reported increasing provider payment rates in 2011
Supplemental Payments      than reducing them. 30 (See fig. 3.) States most frequently reported
Grew                       reducing payment rates for hospitals across all 4 years. For example, in
                           2011, 19 states reported payment rate reductions for inpatient hospitals
                           and 17 reported reductions for outpatient hospitals. Of the states that
                           increased provider payment rates, more states generally reported
                           increasing payment rates for nursing facilities than any other provider
                           type across all 4 years. For example, in 2011, 19 states reported an
                           increase in rates for nursing facilities, 18 states reported increased
                           payment rates for Intermediate Care Facilities for Persons with
                           Intellectual Disabilities (ICF/ID), and 14 states reported increased
                           payment rates for clinics.




                           30
                             The survey asked states to report whether a certain type of change was made for a
                           provider type in a year, but did not ask for a detailed description of the change, including
                           the magnitude of the change. A state may have made more than one type of change for a
                           provider type in a year.




                           Page 13                                                         GAO-13-55 Medicaid Access
Figure 3: Number of States Reporting Increases and Decreases to Provider
Payment Rates, Calendar Years 2008-2011




Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
responded to the 2012 GAO survey. Fifty-five states responded to questions on changes to payment
rates for 13 provider types. States could report multiple increases and decreases in payment rates in
a year to different provider types. States that reported more than one increase or decrease in
payment rates in a year were counted for one increase or one decrease, respectively, or both, for that
year.


From 2008 through 2011, 20 or more states reported increasing their use
of supplemental payments, which are payments separate from and in
addition to regular Medicaid payments. 31 This included both states that
added new supplemental payments or increased existing ones. The
number of states that reduced supplemental payments was greater in
2011 (10 states) than 2008 (4 states). (See fig. 4.) States most often cited
inpatient hospitals, outpatient hospitals, and nursing facilities as recipients
of new or increased supplemental payments across all years. These



31
  Supplemental payments include DSH and non-DSH supplemental payments.




Page 14                                                               GAO-13-55 Medicaid Access
                           increases in additional supplemental payments coincided with states
                           reporting more payment rate increases for nursing facilities and more rate
                           decreases for inpatient and outpatient hospitals.

                           Figure 4: Number of States Reporting Changes to Supplemental Payments,
                           Calendar Years 2008-2011




                           Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
                           responded to the 2012 GAO survey. Fifty five states responded to this question. States could report
                           both implementing a new or increasing an existing supplemental payment and decreasing a
                           supplemental payment in a year. States that reported more than one increase or decrease in
                           supplemental payments in a year were counted for one increase or one decrease, respectively, or
                           both, for that year.



The Number of States       The number of states implementing new or increasing existing provider
Implementing New or        taxes more than doubled from 12 states in 2008 to 26 states in 2011. In
Increased Provider Taxes   contrast, the number of states that reported decreasing or eliminating
                           provider taxes fell during the same time period—from 13 states in 2008 to
Grew                       4 states in 2011. (See fig. 5.) Almost all of the provider taxes that states
                           reported implementing or increasing were for institutional providers—
                           inpatient hospitals, outpatient hospitals, nursing facilities, inpatient mental
                           health providers, and ICF/ID. States most frequently reported that the



                           Page 15                                                                GAO-13-55 Medicaid Access
purpose was to avoid cuts in services or payment rates, rather than
expanding services or increasing provider payment rates.

Figure 5: Number of States Reporting Changes to Provider Taxes, Calendar Years
2008-2011




Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report
both implementing a new or increased provider tax and implementing a decrease in provider taxes.
States that reported more than one increase or decrease in provider taxes in a year were counted as
one increase or one decrease, respectively, or both, for that year.




Page 16                                                               GAO-13-55 Medicaid Access
The Number of States       The number of states reporting service increases was relatively stable—
Implementing Beneficiary   ranging from 26 to 31 states—while the number of states reporting
Service Limitations Grew   service limitations generally grew from 2008 through 2011. 32 (See fig. 6.)
                           From 2008 through 2011, states reported making more changes to
                           coverage for dental, primary, and specialty care services and prescription
                           drug benefits than for other services. For example, in 2011, six states
                           reported increasing coverage for dental services, and nine states reported
                           decreases. Similarly, eight states reported that they increased
                           prescription drug formularies, and seven states reported that they limited
                           them in 2011. From 2008 through 2011, states reported the fewest
                           changes to coverage for ICF/ID and nursing facility services.




                           32
                             States were asked about changes to a variety of specific Medicaid services by provider
                           and benefit type. Changes to benefit types included changes to managed care plan
                           benefits, prescription drug formularies, and beneficiary copays and premiums. For the
                           purposes of this report, services include provider-type services and these Medicaid
                           benefits.




                           Page 17                                                       GAO-13-55 Medicaid Access
                        Figure 6: Number of States Reporting Changes to Benefits or Services, Calendar
                        Years 2008-2011




                        Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
                        responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report
                        both an increase and limitation in benefits and services in a year. States that reported more than one
                        increase or limitation on a benefit or service in a year were counted as one increase or one decrease,
                        respectively, or both, for that year.



                        Thirty-eight states reported that they experienced challenges ensuring
States Reported         enough participating Medicaid providers. 33 In general, states attributed
Challenges Ensuring a   these challenges to a shortage of providers and Medicaid payment rates,
Sufficient Number of    but also cited other issues, such as missed appointments and
                        administrative burden, as factors that influenced provider participation.
Providers               States reported efforts to simplify administrative processes to retain and



                        33
                          The state responses described here reflect their experiences ensuring a sufficient
                        number of Medicaid providers in fee-for-service Medicaid, primary care case
                        management, and with managed care organizations.




                        Page 18                                                                GAO-13-55 Medicaid Access
                            attract Medicaid providers and, to a lesser extent, reported efforts to
                            increase payment rates or other financial incentives.


Over Two-Thirds of States   Of the 55 states responding to our survey, 38 states reported
Reported Challenges         experiencing challenges to ensuring enough participating providers for
Ensuring Sufficient         Medicaid beneficiaries. 34 Ensuring sufficient dental providers was
                            particularly challenging—but states also reported that ensuring sufficient
Providers, Including
                            provider participation in specialty care was problematic. Specifically,
Dental and Specialty        states most frequently reported having difficulty ensuring sufficient
Providers                   Medicaid providers for psychiatry, obstetrics and gynecology, surgical
                            specialties, and pediatric services. To a lesser extent, states also cited
                            challenges ensuring enough dermatology and orthopedic service
                            providers. In contrast, fewer states indicated challenges to ensuring
                            adequate nursing facility and community long-term care providers. (See
                            fig. 7.)




                            34
                              One recent study found that physicians’ acceptance rate of new Medicaid patients
                            varied across the states, ranging from about 40 to 99 percent of physicians accepting new
                            Medicaid patients in 2011. Overall, physicians were less likely to take new Medicaid
                            patients than they were to take patients with Medicare, private insurance, or who self-pay.
                            See S. Decker, “In 2011 Nearly One-third of Physicians Said They Would Not Accept New
                            Medicaid Patients, but Rising Fees May Help, Health Affairs,” vol. 31, no. 8 (August 2012).




                            Page 19                                                        GAO-13-55 Medicaid Access
Figure 7: Number of States Reporting Challenges to Ensuring Enough Participating
Medicaid Providers, by Service Type




Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
responded to the 2012 GAO survey. Fifty-five states responded to this question. States could select
more than one service for which they considered it challenging to ensure enough participating
providers.


To monitor provider participation, states reported using provider
enrollment data, utilization or claims data, and datasets such as the
Healthcare Effectiveness Data and Information Set. 35 For example,
34 states reported that they analyze provider enrollment data and
24 states reported that they analyze utilization or claims data to monitor
provider participation in primary or specialty care, or both. 36 Additionally,
18 states indicated that they have identified data sources that they plan to


35
  The Healthcare Effectiveness Data and Information Set, which is managed by the
National Committee for Quality Assurance, is a tool used by health plans across the
country to measure the plans’ performance on certain dimensions of care and service.
36
  These data reflect states’ fee-for-service Medicaid programs.




Page 20                                                                GAO-13-55 Medicaid Access
use to meet future requirements to measure beneficiary access to
services under CMS’s proposed regulation, which if finalized, would
require states to conduct access reviews for a subset of services each
calendar year and release the results to the public. 37 Most states reported
that they will analyze claims data or provider enrollment data to meet this
requirement. To a lesser extent, states noted that they will assess other
sources such as provider and beneficiary surveys as a means to measure
access to services in the state. States that use managed care
organizations also cited oversight of contract requirements as a way to
ensure access.

When asked about factors affecting provider participation, states cited an
overall shortage of providers, low payment rates, and other factors—such
as missed appointments, and physicians’ difficulties referring Medicaid
patients to specialists. 38 (See table 1.) The factors cited by states are
similar to those found in published research. For example, some studies
have shown that Medicaid payment rates strongly influence provider
willingness to participate in the program, 39 while other studies have
indicated that the level of payment was not the sole driver of the decision
to participate. For example, a study that examined the willingness of
primary care providers to accept new Medicaid patients found that while
higher Medicaid payment rates were associated with a greater probability
of primary care providers accepting all or most new Medicaid patients, the
effects were relatively modest—suggesting that other factors affect the
decision to accept Medicaid patients. 40 According to this study, other


37
 See 76 Fed. 26342 (May 6, 2011).
38
  Our prior work also found that physicians reported difficulties referring Medicaid children
to specialists. See GAO, Medicaid and CHIP: Most Physicians Serve Covered Children
but Have Difficulty Referring Them for Specialty Care, GAO-11-624 (Washington, D.C.:
June 30, 2011).
39
  One study that analyzed data the years before and after Maryland increased Medicaid
payment rates to physicians found that physician participation had increased in the state
following the rate increases. See S. H. Fakhraei, “Payments for Physician Services: An
Analysis of Maryland Medicaid Reimbursement Rates,” International Journal of Healthcare
Technology and Management, vol. 7, numbers 1 / 2 (2006). Also, another study found a
positive relationship between state Medicaid payment levels and pediatrician participation.
See S. Berman, J. Dolins, S. Tang, and B. Yudkowsky, “Factors That Influence the
Willingness of Private Primary Care Pediatricians to Accept More Medicaid Patients,”
Pediatrics, vol. 110, no. 2 (2002).
40
 P. Cunningham, State Variation in Primary Care Physician Supply: Implications for
Health Reform Medicaid Expansions, Research Brief, no. 19 (Center for Studying Health
System Change, March 2011).




Page 21                                                         GAO-13-55 Medicaid Access
factors, such as the structure of the practice and Medicaid administrative
requirements can affect the decision to participate as well.

Table 1: Factors States Reported That Affect Provider Participation in Medicaid

                                                                                         Number of
 Factors affecting provider participation                                                   states
 Shortage of providers serving all insurance groups                                                33
 Low Medicaid payment rates                                                                        33
 Missed appointments                                                                               31
 Administrative burden of enrolling as a Medicaid provider                                         17
 Administrative burden relating to submitting claims and claims
 processing                                                                                        15
 Difficulty referring to specialists                                                               14
Source: GAO analysis of states’ survey responses.

Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report
more than one factor.


Another study of physicians found that, in light of the multiple factors that
may influence willingness to serve Medicaid beneficiaries, an increase in
Medicaid payment rates must be accompanied by other program
simplifications in order to influence physician participation. 41 Similarly, in a
study on dental care, states reported particular challenges ensuring
enough participating dental providers. While this study found that dental
provider participation increased following rate increases in the states
examined, the rate increases were not sufficient on their own to improve
Medicaid beneficiaries’ access to dental care. The study also noted that
streamlining administrative processes and changing dentists’ perception
of Medicaid could improve participation among them as well. 42




41
  See P. Cunningham and A. O’Malley, “Do Reimbursement Delays Discourage Medicaid
Participation by Physicians?” Health Affairs, Web Exclusive, (November 2008), doi:
10.1377/hlthaff.28.1.w17.
42
 See A. Borchgrevink, A. Snyder, S. Gehshan, The Effects of Medicaid Reimbursement
Rates on Access to Dental Care (National Academy for State Health Policy, March 2008).




Page 22                                                                GAO-13-55 Medicaid Access
States Implemented   Thirty-eight states reported making at least one administrative or payment
Administrative and   rate change to encourage provider participation. These efforts included
Payment Changes to   streamlining enrollment, increasing payments, increasing the speed of
                     claims processing, and reducing administrative burdens. (See fig. 8.)
Encourage Provider   Other efforts cited by states included direct recruitment of providers,
Participation        improved prior authorization of services, and assistance to providers
                     through training, education efforts, and improved claims resolution.

                     Figure 8: State Reported Efforts to Maintain Existing Pool or Attract New Medicaid
                     Providers




                     Note: The term “states” includes the 50 states, the District of Columbia, and 4 U.S. territories that
                     responded to the 2012 GAO survey. Fifty-five states responded to this question. States could report
                     more than one type of effort to maintain existing or attract new Medicaid providers. Survey results do
                     not indicate the overall number of states that use a particular application procedure—only the extent
                     to which a state considered this an effort to maintain existing or to attract new Medicaid providers.




                     Page 23                                                                GAO-13-55 Medicaid Access
                            PPACA provided an increase in Medicaid payments for primary care
                            services in 2013 and 2014, and we asked states the extent to which these
                            payments will assist in increasing primary care participation. Of the
                            55 states that responded to this question, 24 indicated that they were
                            uncertain whether such an increase would assist the state in boosting
                            participation of Medicaid primary care providers. Seventeen states
                            reported that the increase will help to some extent, while 3 reported it will
                            help a great extent. Nine states reported that the increase will not help
                            with participation. Various states reported a number of possible reasons
                            that the increase may not help with provider participation, including its
                            temporary nature, because provider payment with the increase will still fall
                            below commercial rates, and because of a provider shortage in the state,
                            among other reasons.


                            In calendar years 2008 and 2009, less than 4 percent of all Medicaid
Few Full-Year               beneficiaries enrolled for a full year reported difficulty obtaining necessary
Medicaid                    medical care or prescription medicines, a percentage similar to individuals
                            with full-year private insurance. The extent to which Medicaid
Beneficiaries               beneficiaries reported difficulties obtaining medical care varied by age
Reported Difficulty         and whether they were enrolled for a full or partial year. Medicaid
Obtaining Care, but         beneficiaries also reported delaying care for a variety of reasons, most
                            commonly due to not having transportation, a long wait once at the
Experiences Varied          doctor’s office, and being unable to get an appointment soon enough.


Full-Year Medicaid          Beneficiaries covered by Medicaid for a full year reported low rates of
Beneficiaries Reported      difficulty obtaining necessary medical care and prescription medicine,
Similar Difficulty          similar to those with private insurance for a full year. 43 In calendar years
                            2008 and 2009, approximately 3.7 percent of Medicaid beneficiaries
Obtaining Needed Medical
                            enrolled for a full year and 3 percent of individuals enrolled in private
Care as Privately Insured   insurance for a full year reported difficulties obtaining needed medical
Individuals                 care; the difference between these two groups was not statistically
                            significant. In addition, 2.7 percent of full-year Medicaid beneficiaries
                            reported difficulty obtaining needed prescription medicines and about
                            2.4 percent of individuals with full-year private insurance reported the
                            same issue—also not statistically significant. Full-year Medicaid



                            43
                              We added together those individuals who reported being unable to obtain or had delays
                            in obtaining needed medical care to report on those who had difficulty obtaining care.




                            Page 24                                                      GAO-13-55 Medicaid Access
beneficiaries did however, report experiencing greater difficulty obtaining
necessary dental care than those with full-year private insurance. (See
fig. 9.) Individuals who were uninsured for a full year reported the greatest
difficulty obtaining medical care, prescription drugs, and dental services—
at least twice the reported rate of full-year Medicaid beneficiaries.

Figure 9: Percentage of Individuals Who Reported Difficulties Obtaining Necessary
Care or Services, by Full-Year Insurance Status, Calendar Years 2008-2009




Note: This figure includes only those individuals who reported insurance coverage or lack of coverage
for the entire year (2008 or 2009, or both). The difference between the percentage of individuals with
Medicaid and the percentage of individuals with private insurance who reported difficulty obtaining
necessary dental care is statistically significant at the 95 percent confidence level. The difference
between the percentage of individuals with Medicaid and the percentage of the uninsured who
reported difficulty obtaining dental care is also statistically significant at the 95 percent confidence
level. The differences between the percentage of individuals who were uninsured who reported
difficulty obtaining medical care and the percentages of individuals with Medicaid or private insurance
were statistically significant at the 95 percent confidence level. Other differences—such as
comparisons between Medicaid and private insurance for medical care and prescription medicine—
were not statistically significant. The 95 percent confidence intervals for estimates in this figure are
within +/- 1.5 percent of the estimates themselves. Medicaid data include children enrolled in the
Children’s Health Insurance Program.




Page 25                                                                 GAO-13-55 Medicaid Access
                              The percentage of individuals experiencing difficulty accessing needed
                              care was higher for those who reported fair or poor health status, with
                              little difference in the rates between those with Medicaid or private health
                              insurance. Approximately 9.9 percent of full-year Medicaid beneficiaries
                              and 8.4 percent of individuals with full-year private insurance reporting fair
                              or poor health indicated difficulty obtaining necessary medical care;
                              again, the difference between these two groups was not statistically
                              significant. The percentage of individuals who were uninsured for an
                              entire year, reported being in fair or poor health, and indicated difficulty
                              obtaining medical care was significantly higher—approximately
                              29.3 percent.


Working-Age Adult             When looking specifically at the experience of working-age adults,
Medicaid Beneficiaries        individuals aged 18 through 64, 44 we found differences between those
Reported Greater              with Medicaid and those with private health insurance. Working-age
                              adults with full-year Medicaid coverage reported greater difficulty
Difficulties Obtaining Care
                              obtaining needed medical care than similar adults with private health
Than Those with Private       insurance. Specifically, about 7.8 percent of working-age adults with full-
Insurance                     year Medicaid reported difficulty obtaining care compared with
                              3.3 percent of similar adults with private insurance—a statistically
                              significant difference. 45 With respect to dental care, working-age adults
                              with full-year Medicaid were nearly three times more likely to report
                              difficulty obtaining services than similar adults with private insurance, and
                              about six times more likely than children with Medicaid. Children with full-
                              year Medicaid were reported to have no greater difficulties obtaining
                              dental care than children with full-year private insurance. 46 (See fig. 10.)




                              44
                               This includes all working-age adults, including those with disabilities.
                              45
                                We also explored reported difficulties obtaining medical care for children but the sample
                              sizes were too small to provide reliable results and so we are not presenting them here.
                              46
                                We reported in more detail on difficulties children enrolled in Medicaid have in obtaining
                              dental care in GAO, Medicaid: Extent of Dental Disease in Children Has Not Decreased,
                              and Millions Are Estimated to Have Untreated Tooth Decay, GAO-08-1121 (Washington,
                              D.C.: Sept. 23, 2008). The MEPS analysis in that report examined children who were
                              enrolled in Medicaid for any part of the year, and thus included both full-year and part-year
                              beneficiaries.




                              Page 26                                                         GAO-13-55 Medicaid Access
Figure 10: Percentage of Working-Age Adults and Children with Full-Year Coverage
Who Reported Difficulties Obtaining Necessary Dental Care, by Insurance Status,
Calendar Years 2008-2009




Note: Working-age adults include individuals aged 18 through 64, including those with disabilities.
This figure includes only those individuals who reported insurance coverage for the entire year (2008
or 2009, or both). Sample sizes for uninsured children and for adults age 65 and older were below
100, limiting confidence in their results. As such, the results for the uninsured and for beneficiaries 65
and older are not included in the figure. The difference between the percentage of adults with
Medicaid and private insurance who reported difficulty obtaining necessary dental care is statistically
significant at the 95 percent confidence level. The difference between children with Medicaid and
private insurance was not statistically significant. The 95 percent confidence intervals for estimates in
this figure are within +/- 1.8 percent of the estimates themselves. Medicaid data include children
enrolled in the Children’s Health Insurance Program.




Page 27                                                                   GAO-13-55 Medicaid Access
Individuals with Partial-   Individuals with partial year health insurance—coverage for between 1
Year Coverage Reported      and 11 months—were more likely to report difficulties obtaining needed
Almost Double the Rate of   care, whether covered by Medicaid or private health insurance. In
                            calendar years 2008 and 2009, the percentage of Medicaid beneficiaries
Difficulty Obtaining        enrolled for a partial year who reported difficulties obtaining needed
Medical Care                medical care was almost double that of full-year Medicaid beneficiaries. 47
                            Similarly, individuals with private insurance for a partial year also reported
                            difficulties at more than double the rate of those with full year coverage.
                            Finally, individuals who were uninsured for a partial year reported less
                            difficulty obtaining care than those uninsured for a full year—likely
                            because they had some type of insurance for part of the year. There were
                            no statistically significant differences across all groups with partial year
                            coverage. (See fig. 1.)




                            47
                              Partial year insurance groups overlap. For example, some individuals had both Medicaid
                            and private insurance for part of the year, or had Medicaid and were uninsured for part of
                            the year.




                            Page 28                                                       GAO-13-55 Medicaid Access
Figure 11: Percentage of Individuals Who Reported Experiencing Difficulty
Obtaining Necessary Medical Care, by Insurance Status, Partial or Full Year,
Calendar Years 2008-2009




Note: The differences between individuals who had insurance (Medicaid or private) or were uninsured
for a full year versus those with the same insurance status for a partial year were statistically
significant at the 95 percent confidence level. Among those who had insurance or were uninsured for
a partial year, there were no statistically significant differences. The 95 percent confidence intervals
for estimates in this figure are within +/- 1.2 percent of the estimates themselves. Medicaid data
include children enrolled in the Children’s Health Insurance Program.


Among working-age adults with Medicaid, 7.8 percent with full-year
coverage and 11.9 percent with partial-year coverage reported difficulty
obtaining necessary medical care. Those with partial year Medicaid were
more likely to report difficulty obtaining medical care than those with
partial year private insurance or who were uninsured for part of the year.
(See fig. 12).




Page 29                                                                 GAO-13-55 Medicaid Access
                             Figure 12: Percentage of Working-Age Adults (Age 18 to 64) Who Reported
                             Difficulty Obtaining Necessary Medical Care, by Insurance Status, Partial or Full
                             Year, Calendar Years 2008-2009




                             Note: The differences between adults who had insurance (Medicaid or private) for a full year versus
                             those with the same insurance status for a partial year were statistically significant at the 95 percent
                             confidence level. Similarly, differences between those who were uninsured for a full year versus a
                             partial year were statistically significant at the 95 percent confidence level. Those with partial-year
                             Medicaid were more likely to report difficulty obtaining Medical care than those with partial-year
                             private insurance or who were uninsured for part of the year. The 95 percent confidence intervals for
                             estimates in this figure are within +/- 1.7 percent of the estimates themselves.



Medicaid Beneficiaries       Medicaid beneficiaries were more likely than individuals with private
Most Frequently Reported     insurance to report factors such as lack of transportation and long wait
Delaying Care Due to Lack    time as reasons for delaying medical care. In 2009, approximately
                             9.6 percent of Medicaid beneficiaries reported delaying medical care
of Transportation and Long   because they had no transportation, compared with less than 1 percent of
Wait Times                   individuals with private insurance. Similarly, about 9.4 percent of Medicaid
                             beneficiaries indicated that they delayed medical care because they could
                             not get an appointment soon enough, or once they arrived for the
                             appointment, the wait was too long. In contrast, 4.2 percent of individuals


                             Page 30                                                                  GAO-13-55 Medicaid Access
                                        with private insurance reported delaying care because, once they arrived
                                        for the appointment, the wait was too long. Individuals who were
                                        uninsured were the most likely to cite cost as a reason for delaying care.
                                        (See fig. 13.)

Figure 13: Percentage of Individuals Who Cited Specific Reasons for Delaying Medical Care in Calendar Year 2009, by
Insurance Status




                                        Note: This figure reflects individuals who reported their insurance status at the time the survey was
                                        administered. The responses related to delays in care for cost reasons are from the Person file of the
                                        National Health Interview Survey (NHIS) and include all age groups. The remaining reasons for
                                        delayed responses were from the Sample Adult component of NHIS and include only adults over
                                        18 years old. The differences between Medicaid beneficiaries and individuals with private insurance
                                        reporting delaying medical care to due to a lack of transportation, too long of a wait time once at an
                                        appointment, not being able to get an appointment soon enough, and being unable to get through on
                                        the phone were all statistically significant at the 95 percent confidence level. While there was not a
                                        statistically significant difference between individuals with Medicaid and private insurance citing cost
                                        as a reason for delayed medical care, the uninsured were significantly more likely than both to report
                                        delaying care due to cost. Among individuals reporting that a provider was not open when he or she
                                        could get there, there were no statistically significant differences across insurance statuses. The
                                        95 percent confidence intervals for estimates in this figure are within +/- 1.4 percent of the estimates
                                        themselves.




                                        Page 31                                                                 GAO-13-55 Medicaid Access
We provided a draft of this report to HHS for its review and comment.
HHS provided technical comments, which we incorporated as
appropriate. This report is intended for use by HHS management. We are
sending copies of this report to interested congressional committees and
members, and other interested parties. The report is also available at no
charge on the GAO website at http://www.gao.gov. If you or your staff
have any questions about this report, please contact me at (202) 512-
7114 or yocomc@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last page
of this report. Key contributors to this report are listed in appendix III.

Sincerely yours,




Carolyn L. Yocom
Director, Health Care




Page 32                                             GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology
                   Appendix I: Scope and Methodology




                   To examine states’ experiences processing Medicaid applications,
                   changes states made to provider payment rates and beneficiary services,
                   and challenges, if any, states face ensuring sufficient provider
                   participation, in February 2012 we surveyed Medicaid officials in all
                   50 states, the District of Columbia, and the 5 largest territories. 1 The
                   survey was e-mailed to the Medicaid officials on February 22, 2012.
                   Respondents were initially given 3 weeks to respond, and extensions
                   were granted to encourage survey participation. The survey was available
                   online through May 22, 2012. Fifty states, the District of Columbia, and
                   4 U.S. territories completed the survey, for a response rate of 98 percent.
                   The U.S. Virgin Islands did not complete the survey.


                   To examine states’ experiences processing Medicaid applications, states
Development and    were asked to report their current average processing time for new
Analysis of GAO    regular Medicaid applications—those not based on disability—and how
                   those times changed since 2008. 2 The survey also included questions
Survey of States   about the factors states attributed to any reported changes in the average
                   processing time for Medicaid applications. In addition, to assess the
                   extent to which states were keeping pace with processing new
                   applications, the survey asked for monthly data on the number of new
                   regular applications received and processed from January 2008 through
                   December 2011.

                   The survey also asked states about changes to benefits, provider
                   payment rates, provider taxes, and supplemental payments in each year
                   from 2008 through 2011. The questions in this section asked about
                   changes by provider and benefit type, including both those benefits that
                   are mandatory and optional. 3 The survey asked, generally, about any



                   1
                    The U.S. territories included in our sample are American Samoa, Guam, the
                   Commonwealth of the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.
                   For the purposes of this report, we are referring to all 56 jurisdictions we surveyed as
                   states.
                   2
                    Average processing time is the average number of calendar days between the day that a
                   new application is received and the day that a final eligibility determination is made.
                   3
                    States were asked to report on a number of provider and service types, including
                   inpatient hospitals, outpatient hospitals, nursing facilities, intermediate care facilities for
                   the intellectually disabled, primary care, specialty care, dental, home health services,
                   clinics, targeted case management, rehabilitative and therapeutic services, managed care
                   plans, beneficiary copayments or premiums, and prescription drug formularies.




                   Page 33                                                           GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology




changes by provider type (i.e., increased, decreased, eliminated, etc.)
and did not ask states to report the details of these changes. States could
report more than one type of change for a provider type in a year. For
example, a state could report both an increase and a decrease in a
provider payment rate for a given provider type in a year. The survey
asked whether the state made a particular change for a provider type in a
year and did not ask for the actual number of those changes it made in a
year or the magnitude of those changes. The survey also asked about the
purpose of any new or increased provider taxes, including avoiding cuts
in benefits, expanding benefits, avoiding cuts in payment rates, increasing
payment rates, or other purposes. Finally, states were asked to report any
changes to supplemental payments by provider type and the role of
provider taxes or county and local government funds in any changes to
the supplemental payments. 4

To examine any challenges to ensuring sufficient provider participation,
the survey included questions asking how states monitor whether they
have sufficient providers, which provider types are challenging for states
to ensure sufficient participation, and any steps the states have taken
since January 2008 to maintain their existing pools of providers. The
survey asked how the states monitor the sufficiency of providers across
three service delivery arrangements—fee-for-service, primary care case
management, and risk-based managed care organizations. The survey
included questions about any planned efforts to meet potential increases
in demand for primary care providers due to the Medicaid expansion
under the Patient Protection and Affordable Care Act as amended by the
Health Care and Education Reconciliation Act of 2010 (PPACA), and
whether the increase in payment rates for primary care providers under
PPACA would likely assist in increasing provider participation in Medicaid.
The survey also asked states about plans to measure access to care for
Medicaid beneficiaries in response to recently proposed federal
regulations that, if finalized, would provide a framework under which




4
 Supplemental payments are payments separate from and in addition to those made at a
state’s standard Medicaid payment rate, including Disproportionate Share Hospital
payments and Upper Payment Limit payments. Disproportionate Share Hospital payments
are payments required under federal law that are made to hospitals that treat large
numbers of Medicaid and uninsured individuals. Upper Payment Limit payments are
payments to certain providers above the standard Medicaid payment rates but within the
Upper Payment Limit, the estimated amount that Medicare pays for comparable services.




Page 34                                                    GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology




states can demonstrate Medicaid payments are adequate for access to
providers. 5

We took steps in developing the survey and collecting and analyzing the
data to minimize nonsampling errors. 6 However, any survey may
introduce nonsampling errors, such as difficulties in interpreting a
particular question or limited sources of information available to
respondents. We pretested the draft survey with Medicaid officials in
three states in January 2012 to ensure that the questions were relevant,
clearly stated, and easy to understand. The states selected for a pretest
were diverse with respect to the population size, geography, and total
Medicaid spending in 2009. We modified the survey as appropriate as a
result of the pretests. Finally, since this was a web-based survey,
respondents entered their answers directly into the electronic survey,
eliminating the need to key data into a database, which helps to minimize
error. We did not independently verify the data reported by states in the
survey; however, we reviewed published data submitted by state
Medicaid programs to us for another engagement and to outside
researchers to assess the reasonableness of the data reported. We also
assessed the internal consistency of answers to certain questions. We
determined that the data from the survey included in this report were
sufficiently reliable for the purposes of this report.

It is important to note that while the data that we reported were sufficiently
reliable for the purposes of this report, we did not use the data on monthly
application processing submitted by states for 2008 through 2011,
because much of the data were either incomplete or inconsistently
reported. In particular, we noted that for some states, data provided to us
in a 2010 survey did not match the data provided for our current survey. 7
We contacted four states to inquire about the inconsistencies in the data
about which the states provided differing responses. For example:




5
76 Fed. Reg. 26342.
6
The survey was not a sample survey and so sampling errors were not a concern.
7
 We used data provided in response to our 2010 survey of Medicaid directors to
determine any changes in states’ application processing volumes and rates between
October 2007 and February 2010. See GAO, Recovery Act: Increased Medicaid Funds
Aided Enrollment Growth, and Most States Reported Taking Steps to Sustain Their
Programs, GAO-11-58 (Washington, D.C.: Oct. 8, 2010).




Page 35                                                   GAO-13-55 Medicaid Access
                      Appendix I: Scope and Methodology




                      •   One state official was not certain why the data would be reported
                          differently in the prior survey and suggested that it could be related to
                          interpretation of the prior survey question because the state does not
                          collect information in the way we requested it.

                      •   Officials from two states noted that there were changes in the staff
                          that responded to the survey and could not be certain why the data
                          reported were different.

                      •   An official from a third state indicated that the data provided to us in
                          2010 appeared to have included a broader array of applications (such
                          as those for disability, long-term care, and food stamps), noting that
                          the same application process is used for multiple programs in the
                          state.


                      To examine the extent to which Medicaid beneficiaries reported difficulties
Analysis of Other     obtaining care, we analyzed data from the Medical Expenditure Panel
Federal Health Care   Survey (MEPS) and the National Health Interview Survey (NHIS). 8 MEPS
Consumer Survey       is administered by the Department of Health and Human Services’ (HHS)
                      Agency for Healthcare Research and Quality and collects data on the use
Data                  of specific health services; NHIS is conducted by the National Center for
                      Health Statistics, Centers for Disease Control and Prevention. We
                      analyzed results from the MEPS household component, which collects
                      data from a sample of families and individuals in selected communities
                      across the United States. These families and individuals are drawn from a
                      nationally representative subsample of households that participated in the
                      prior year’s NHIS.


MEPS                  Our MEPS analysis was based on data from surveys conducted in 2008
                      and 2009, the most recent data available at the time of our analysis.
                      MEPS includes insurance status for respondents for each month of the
                      year and NHIS includes respondent information on insurance status at a
                      point in time. Analyzing MEPS allowed us to use information on insurance
                      status for each month to create variables for full-year and partial-year


                      8
                       We considered using data from other federal surveys, such as the Consumer
                      Assessment of Healthcare Providers and Systems Health Plan Survey, but determined
                      that the questions in the MEPS and NHIS made them better surveys to use to determine
                      the extent to which Medicaid beneficiaries had difficulty accessing medical care and the
                      reasons for any difficulties.




                      Page 36                                                       GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology




coverage. 9 As a result, we determined that the MEPS insurance status
data provided more options to report on the extent to which Medicaid
beneficiaries reported difficulties obtaining medical care. In addition to
determining the extent to which full-year Medicaid beneficiaries had
difficulty accessing care, we also compared Medicaid beneficiaries’
reported experiences to the experience of respondents with private
insurance and respondents who were uninsured, in order to provide
context. 10 Further, we examined whether working-age adults 18 to 64 in
Medicaid for a full year reported greater difficulty accessing medical care
than children in Medicaid or full-year Medicaid beneficiaries 65 and older.
We also compared full-year and partial-year Medicaid beneficiaries, to
determine if the extent of reported difficulties obtaining care varied by
length of coverage. Finally, we compared responses from full-year and
partial-year privately insured individuals, and full-year and partial-year
uninsured individuals to provide additional context for the Medicaid
beneficiaries’ reported difficulties.

The MEPS household interviews feature several rounds of interviewing
covering 2 full calendar years. MEPS is continuously fielded; each year a
new sample of households is introduced into the study. MEPS collects
information for each person in the household based on information
provided by one adult member of the household. This information
includes demographic characteristics, use of medical services, reasons
for medical visits, and health insurance coverage. We analyzed
responses to MEPS questions about individuals’ reported delays and
inability to obtain necessary medical care, dental care, and prescription
medicine, the reasons for those delays, and the perceived health status of
those individuals who delay or are unable to obtain care.

For the delays and inability to obtain care measures we used responses
to the following questions:

•    In the last 12 months, was anyone in the family delayed in getting
     medical care, tests, or treatments they or a doctor believed
     necessary?



9
 In contrast, the variable “any Medicaid” includes individuals with coverage that could
range from 1 to 12 months for a given year.
10
  The Medicaid category in MEPS includes children enrolled in the Children’s Health
Insurance Program.




Page 37                                                         GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology




•    Which of these best describes the main reason (PERSON)
     (were/was) delayed in getting medical care, tests, or treatments
     (he/she) or a doctor believed necessary? 11

•    In the last 12 months, was anyone in the family unable to obtain in
     getting medical care, tests, or treatments they or a doctor believed
     necessary?

•    Which of these best describes the main reason (PERSON)
     (were/was) unable to obtain medical care, tests, or treatments
     (he/she) or a doctor believed necessary?

We also analyzed responses to similar questions related to delays or the
inability to obtain needed dental care and prescription medicines. To
address sample size concerns and obtain frequencies above 100
responses, we combined data from 2008 and 2009 and the responses
from the questions on both the delays and inability to obtain needed
health care.

We examined the insurance status of respondents who answered that
they delayed or were unable to obtain needed health care. 12 To
understand the differences in responses by insurance status we identified
the percentage of respondents who delayed or were unable to obtain care
with a variety of insurance statuses as well as those who were uninsured.
We looked at those respondents who indicated they had Medicaid and
private insurance for each month of the year, as well as looking at the
responses for those with Medicaid or private insurance for a partial year
(1-11 months). We also examined the percentage of respondents who
were uninsured for a full and partial year as well as those with mixed
insurance statuses, such as Medicaid part year and uninsured for part of
the year. In addition, we examined demographic variables—such as age,


11
  Possible answers to this question were: could not afford care, insurance company would
not approve/cover/pay, doctor refused family insurance plan, problems getting to doctor’s
office, different language, could not get time off work, could not get child care, did not
have time or took too long, don’t know where to go to get care, was refused services, and
other.
12
   MEPS respondents were asked whether they needed medical care, and if they
responded that they did, they were then asked if they were able or unable to receive care.
If they responded they were unable to receive care, they were then asked about the main
reason they were unable to receive care. A similar pattern of questions asked about
whether a respondent had delayed care.




Page 38                                                       GAO-13-55 Medicaid Access
       Appendix I: Scope and Methodology




       sex, education, and perceived health status—for those respondents who
       indicated they delayed or were unable to obtain care as well as those that
       did not delay care. We also looked at responses to the questions by age
       group and insurance status to identify potential differences. Small sample
       sizes for some analyses limited the reliability of the results, and in those
       cases, we did not report the analyses. In this report, we used a
       95 percent confidence level and compared upper and lower confidence
       intervals to determine whether any differences we found were statistically
       significant. Statistical significance indicates that the difference between
       observations is unlikely due to chance alone.


NHIS   We supplemented our MEPS analysis with analysis of data from the 2009
       NHIS survey. NHIS data are collected continuously throughout the year
       for the National Center for Health Statistics, Centers for Disease Control
       and Prevention, by interviewers from the U.S. Bureau of the Census.
       NHIS collects information about the health and health care of the civilian,
       noninstitutionalized U.S. population. Interviews are conducted in
       respondents’ homes, but follow-ups to complete interviews may be
       conducted over the telephone. We analyzed NHIS data to obtain
       information on reasons Medicaid beneficiaries reported delays obtaining
       needed medical care, and compared those to privately insured individuals
       and the uninsured, for context. We analyzed NHIS data for these
       questions because the sample size for those questions in NHIS was
       larger than for similar questions on delays or the inability to obtain care in
       MEPS. Because NHIS asks about insurance coverage at a point in time,
       individuals identified as Medicaid beneficiaries would include those with
       full-year and partial-year coverage. Data from the 2010 NHIS survey were
       available, but we chose to analyze the 2009 survey so the time period
       would be compatible with the MEPS analysis.

       NHIS collects information from the civilian, noninstitutionalized population
       about demographic characteristics, use of medical services, and health
       insurance coverage and organizes the data into several data files. NHIS
       collects information on each family member. More information is collected
       on a randomly selected adult (the Sample Adult component) and a
       randomly selected child (the Sample Child component) within each family
       if a child is present. More information is collected on a sample of adults
       and children within each family and household. To match the insurance
       status variables with the answers to the selected questions, we merged




       Page 39                                               GAO-13-55 Medicaid Access
Appendix I: Scope and Methodology




data from the Person file, which has information on each family member,
with the Sample Adult file, which has more information on sampled
adults. 13 We analyzed responses to the following NHIS question from the
Person file of the survey: During the past 12 months, [have you delayed
seeking medical care/has medical care been delayed for anyone in the
family] because of worry about the cost?

From the Sample Adult component of the survey, we looked at the
following questions:

•     Have you delayed getting care for any of the following reasons in the
      past 12 months? 14
      •    You couldn’t get through on the telephone

      •    You couldn’t get an appointment soon enough

      •    Once you get there, you have to wait too long to see the doctor

      •    The (clinic/doctor’s) office wasn’t open when you could get there

      •    You didn’t have transportation.

We examined the insurance status of respondents to those questions
using the suggested variables for Medicaid, private insurance, and
uninsurance.

For all estimated percentages for both MEPS and NHIS, we calculated a
lower and upper bound at the 95 percent confidence level using the
appropriate sampling weights and survey design variables provided for
each survey.




13
    Information from the Sample Child file was not used for the purposes of our analysis.
14
 Each of these questions is asked separately. Possible answers included: Yes, No,
Refused, Don’t Know.




Page 40                                                          GAO-13-55 Medicaid Access
                            Appendix I: Scope and Methodology




Data Reliability for MEPS   To determine the reliability of the MEPS and NHIS data, we reviewed
and NHIS                    related documentation, and identified other studies that used MEPS to
                            address similar research questions to compare the published data with
                            our findings. We determined that the MEPS and NHIS data were
                            sufficiently reliable for the purposes of our report.




                            Page 41                                           GAO-13-55 Medicaid Access
Appendix II: States Use of Electronic
               Appendix II: States Use of Electronic Medicaid
               Application Processing and Renewal
               Procedures


Medicaid Application Processing and
Renewal Procedures
               Given the potential of electronic application processing to reduce
               processing time and related provisions of the Patient Protection and
               Affordable Care Act of 2010 (PPACA), we asked all of the states about
               their use of electronic application processing. PPACA required states to
               begin to accept electronic signatures by 2014, as part of a coordinated
               enrollment process that includes using a federally defined uniform
               application and verifying income electronically through a federally
               managed data hub.

               We found states varied in the extent to which new Medicaid applications
               were currently available and processed electronically. (See table 2.) For
               example, fewer states reported that the application is submitted
               electronically with an electronic signature than those reporting that the
               application is available electronically. Twenty-six states reported the
               percentage of their new Medicaid applications that were accessed,
               signed, and submitted electronically. In these 26 states, the median
               proportion of applications accessed, signed, and submitted electronically
               was 25 percent. Only 11 states reported that the applications were
               approved or denied electronically.

               Table 2: State Electronic Processing Procedures for New Medicaid Applications

                Procedure                                                            Number of states
                Medicaid applications available electronically                                     35
                Medicaid applications can be submitted electronically                              31
                Processed at least some Medicaid applications electronically, with                 26
                electronic signature
                Medicaid applications approved or denied electronically                            11
               Source: GAO analysis of state-reported survey data.

               Note: States could report more than one procedure.


               We also asked all states about their efforts to streamline processing
               through improved renewal procedures, and a number of states reported
               implementing procedures to streamline the renewal application process
               for adults and children since 2008. (See table 3.) Such efforts can help
               limit interruptions in Medicaid coverage for beneficiaries. For children, the
               streamlined procedures states most frequently reported using were
               12-month renewal periods, as opposed to shorter renewal periods;
               telephone or electronic renewals, or both, instead of in-person interviews;




               Page 42                                                       GAO-13-55 Medicaid Access
Appendix II: States Use of Electronic Medicaid
Application Processing and Renewal
Procedures




and prepopulated renewal forms. 1 For adult Medicaid beneficiaries, the
most commonly reported efforts were 12-month renewal periods and
telephone or electronic renewal, or both, instead of in-person interviews.

Table 3: State Medicaid Renewal Procedures

                                                                            Number of states
 Procedure                                                             For children         For adults
 Twelve-month renewal periods                                                      26                 24
 Telephone or electronic renewals, or both, instead of
 in-person interviews                                                              24                 24
 Prepopulated renewal forms                                                        22                 15
                                                                                                         a
 Continuous eligibility                                                            18               n/a
Source: GAO analysis of state-reported survey data.

Notes: n/a = not applicable. The term “states” includes the 50 states, the District of Columbia, and 4
U.S. territories that responded to the 2012 GAO survey. Fifty-four states responded to this question.
States could report more than one procedure.
a
 States may use continuous eligibility to allow children to remain eligible for Medicaid or the Children’s
Health Insurance Program for up to a full year before any redetermination of eligibility.




1
 Some states send families renewal forms pre-populated with the families’ information. If a
family’s circumstances, as reflected on the form, have not changed, the family simply
returns the signed form to renew their eligibility.




Page 43                                                                  GAO-13-55 Medicaid Access
Appendix III: GAO Contact and Staff
                  Appendix III: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov
GAO Contact
                  In addition to the contact named above, Sheila K. Avruch, Assistant
Staff             Director; Carolyn Fitzgerald; Sandra George; Mollie Hertel; Joanne Jee;
Acknowledgments   Eagan Kemp; Drew Long; JoAnn Martinez-Shriver; Janet Sparks; and
                  Hemi Tewarson made key contributions to this report.




(290993)
                  Page 44                                           GAO-13-55 Medicaid Access
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