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Dollars And Doctors For Medicaid Shrink As Enrollment Grows

December 11, 2014

WASHINGTON, DC -- Just as access to Medicaid-funded treatment for autism is growing, two new reports show doctors face steep fee cuts and that half the providers listed as "participating" in state Medicaid managed care programs in fact do not participate or have stopped accepting new patients.

One third of American children with autism are covered through Medicaid and that coverage is expected to expand due to recent federal directives. In addition, 9.1 million new patients have enrolled in Medicaid under the Affordable Care Act. Medicaid is funded jointly by the federal and state governments and largely managed at the state level.

"When providers aren't available, it doesn't matter whether a state says they cover a particular benefit, such as applied behavior analysis, through their Medicaid program," said Angelo Lello, Autism Speaks' director of housing and community living. "The end result is Medicaid beneficiaries won't get those benefits. Access to benefits is essentially denied when providers are not available."

According to a new report issued by the U.S. Department of Health and Human Services' (HHS) inspector general, over half the doctors listed as participating physicians in Medicaid managed care plans run by the states were misidentifed, do not accept new patients or couldn't be found at their listed office address.

The HHS report was in response to a request from Congress to examine the access to care through Medicaid managed care plans offered by the states. Most states now provide some, if not all, of their Medicaid services through managed care plans which are run primarily by for-profit companies.

Surveying a random sample of 1,800 primary care providers and specialists, HHS found:

  • 35% couldn't be found at the location listed in the Medicaid plan
  • 8% said they did not participate in Medicaid
  • 8% said they were not accepting new Medicaid patients

While the median wait time for those physicians who do participate was two weeks, over a quarter had wait times exceding one month, and 10 percent had wait times longer than two months. While primary care providers were less likely to offer an appointment than specialists, the specialists tended to have longer wait times.

The second report, an analysis by the Urban Institute, forecasts that the average Medicaid payment to primary care providers will drop 42 percent in 2015 with the expiration of a two-year federal supplement at the end of December. The Urban Institute found 15 states that will continue the supplement with their own funds, but at least 23 others would not with the others undecided at the time of the survey in October.

"The 23 states included in this analysis that do not plan to continue the fee increase cover 71.3 percent of all Medicaid enrollees; the states that intend to continue the increase cover only 15.6 percent of Medicaid enrollees," according to the report. "In seven of the states that do not plan to continue the fee increase with state funds, Medicaid primary care fees for eligible codes will fall by 50 percent or more (Rhode Island, California, New York, New Jersey, Florida, Pennsylvania, and Illinois)."