Medicaid and SCHIP: States Use Varying Approaches to Monitor	 
Children's Access to Care (14-JAN-03, GAO-03-222).		 
                                                                 
Over 25 million children have health insurance coverage through  
Medicaid or the State Children's Health Insurance Program	 
(SCHIP). Coverage alone, however, does not guarantee that	 
services will be available or that children will receive needed  
care. GAO was asked to evaluate states' efforts to facilitate and
monitor access to primary and preventive services for children in
these jointly funded federal-state programs. The study surveyed  
16 states, covering over 65 percent of the Medicaid and SCHIP	 
population. GAO analyzed requirements relevant to managed care	 
and fee-for-service (FFS) delivery systems, including the number 
and location of physicians and their availability to see	 
beneficiaries, monitoring of health plan or physician compliance 
with these requirements, and collection and analysis of 	 
beneficiary service utilization data.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-222 					        
    ACCNO:   A05853						        
  TITLE:     Medicaid and SCHIP: States Use Varying Approaches to     
Monitor Children's Access to Care				 
     DATE:   01/14/2003 
  SUBJECT:   Child care programs				 
	     Health care services				 
	     Managed health care				 
	     Health care programs				 
	     Federal/state relations				 
	     State-administered programs			 
	     Comparative analysis				 
	     State Children's Health Insurance			 
	     Program						 
                                                                 
	     Medicaid Program					 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-03-222

Report to Congressional Requesters

United States General Accounting Office

GAO

January 2003 MEDICAID AND SCHIP

States Use Varying Approaches to Monitor Children*s Access to Care

GAO- 03- 222

Overall, states imposed more access- related requirements on participating
providers and more actively monitored children*s use of services in their
Medicaid managed care programs than in their Medicaid FFS or SCHIP
programs. Medicaid managed care: State requirements for managed care plans
ranged

from very broad provisions that health plans must have *adequate*
physician networks for serving their enrolled members to very specific
standards, such as the number and geographic proximity of physicians and
maximum time frames within which a new beneficiary receives a first
appointment. States less often verified data that plans submitted to show
compliance with these requirements or independently monitored physicians*
availability. In one instance of verification, a state found that a third
of a health plan*s physician network was not accepting new Medicaid
patients, thus limiting access for

new beneficiaries. The value of plan- submitted data that states used to
monitor children*s use of services was often compromised by continuing
problems with their completeness and reliability. Furthermore, information
derived from beneficiary satisfaction surveys was not necessarily
representative of all Medicaid managed care beneficiaries. Medicaid FFS:
Most states did not set goals for or analyze the availability of

participating primary care physicians even though a majority of
Medicaideligible children in half of the states reviewed are still served
in FFS programs. In most FFS programs, beneficiaries may seek care from
any providers participating in the Medicaid program and may change
providers at any time if they are dissatisfied. However, when FFS payment
rates are lower than those paid by other purchasers* which was the case in
most

states reviewed* providers can be discouraged from participating in
Medicaid and thus restrict beneficiaries* access. States did little to
monitor the use of services by Medicaid- eligible children in FFS programs
despite having a ready source of data in their claims payment systems.
SCHIP: Nine of the 16 states used the same providers, administrative
systems, and monitoring approaches for their SCHIP programs as they did

for Medicaid. The remaining 7 states, whose SCHIP programs were distinct
from Medicaid and used managed care almost exclusively, set few
requirements for or monitored providers* availability to SCHIP- eligible
children. States with distinct SCHIP programs also reported fewer efforts
to

monitor children*s use of services than in their Medicaid programs.
Comments on our report from the Department of Health and Human Services
highlighted new federal requirements for state oversight of managed care,
and design differences between Medicaid and SCHIP that can affect
monitoring approaches. States we reviewed provided clarifying or technical
comments regarding their oversight of access, which we incorporated in the
report as appropriate.

MEDICAID AND SCHIP

States Use Varying Approaches to Monitor Children's Access to Care

www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 222. To view the full report,
including the scope and methodology, click on the link above. For more
information, contact Kathryn G. Allen (202) 512- 7118. Highlights of GAO-
03- 222, a report to

Representatives Sherrod Brown; John Conyers, Jr.; Diana DeGette; John D.
Dingell; Gene Green; William J. Jefferson; Sander M. Levin; and Ted
Strickland

January 2003

Over 25 million children have health insurance coverage through Medicaid
or the State Children*s Health Insurance Program (SCHIP). Coverage alone,
however, does not guarantee that services will be available or that
children will receive needed care. GAO was

asked to evaluate states* efforts to facilitate and monitor access to
primary and preventive services for children in these jointly funded
federal- state programs. The study surveyed 16 states, covering over 65
percent of the Medicaid and SCHIP population. GAO analyzed

requirements relevant to managed care and fee- for- service (FFS) delivery
systems, including the number and location of physicians and their
availability to see beneficiaries, monitoring of health

plan or physician compliance with these requirements, and collection and
analysis of beneficiary service utilization data.

Page i GAO- 03- 222 Medicaid and SCHIP Access Letter 1 Results in Brief 4
Background 6 In Medicaid Managed Care, States Focused More on Setting Plan

Network Requirements than on Monitoring Plans or Analyzing Service
Utilization 14 For Medicaid FFS, State Requirements for Providers and

Monitoring of Service Utilization Were More Limited 33 Distinct SCHIP
Programs Had Fewer Network Requirements and Less Monitoring of Service
Utilization 40 Agency and State Comments and Our Evaluation 44 Appendix I
Medicaid HEDIS Measures Related to Service

Utilization 50

Appendix II Managed Care Plan Withdrawals from Medicaid in Four States 53

Massachusetts 53 Ohio 54 Tennessee 55 Texas 56 Appendix III Analysis of
Medicaid FFS Payment Rates in Selected States 58 Methodology for
Comparison of FFS Payment Rates 59 Appendix IV Comments from the
Department of Health and

Human Services 61

Appendix V GAO Contact and Staff Acknowledgments 65

Related GAO Products 66 Contents

Page ii GAO- 03- 222 Medicaid and SCHIP Access Tables

Table 1: SCHIP Design Choices for 16 States, as of March 2002 7 Table 2:
Share of Children Enrolled in Medicaid and Separate SCHIP Programs, by
Service Delivery Method, for 16 States 10 Table 3: Examples of Specific
State Standards for Plan Networks

and Appointment Waiting Times 17 Table 4: Examples of Medicaid HEDIS
Measures Related to Service Utilization for Children 25 Table 5: Estimated
Percentage of Medicaid Children Excluded from HEDIS 27 Table 6: Examples
of Beneficiary Satisfaction Questions for Children Covered by CAHPS 28
Table 7: Estimated Percentage of Medicaid Children Excluded from CAHPS 29
Table 8: Length of Medicaid Enrollment Required for Selected HEDIS
Measures for Children*s and Adolescents* Use of Services 51 Table 9:
Examples of Plan Withdrawal Transition Activities

Conducted by Four State Medicaid Programs 57 Table 10: Medicaid FFS
Payment Rates, Expressed as a Percentage of Medicare Payments, in 13
States with Traditional FFS or Primary Care Case Manager Delivery Systems
That Serve Children 59 Table 11: CPT 4 Codes Used in Comparing Medicaid
and Medicare

Fees 60 Figures

Figure 1: Selected Medicaid Managed Care Plan Network Requirements and
Standards in 14 States 16 Figure 2: Variation in 14 States* Monitoring of
Medicaid Managed

Care Plans* Provider Information 19 Figure 3: Selected Requirements for
Medicaid PCCM Providers in Seven States 37 Figure 4: Comparison of Seven
States* Requirements and Standards for Providers in Medicaid and SCHIP
Managed Care 42

Page iii GAO- 03- 222 Medicaid and SCHIP Access Abbreviations

ACG ambulatory care group AHRQ Agency for Healthcare Research and Quality
CAHPS Consumer Assessment of Health Plans CMS Centers for Medicare &
Medicaid Services CPT 4 Current Procedural Terminology, 4th edition EPSDT
Early and Periodic Screening, Diagnostic and Treatment FFS fee- for-
service HEDIS Health Plan Employer Data and Information Set

HHS Department of Health and Human Services HRSA Health Resources and
Services Administration NCQA National Committee on Quality Assurance PCCM
primary care case manager PCP primary care provider SCHIP State Children*s
Health Insurance Program

Page 1 GAO- 03- 222 Medicaid and SCHIP Access

January 14, 2003 The Honorable Sherrod Brown The Honorable John Conyers,
Jr. The Honorable Diana DeGette The Honorable John D. Dingell The
Honorable Gene Green The Honorable William J. Jefferson The Honorable
Sander M. Levin The Honorable Ted Strickland House of Representatives

Over 25 million children have health care coverage through Medicaid or the
State Children*s Health Insurance Program (SCHIP), joint federal- state
programs that finance health insurance for certain low- income adults and
children. Medicaid and SCHIP provide the financial means for low- income
children to receive primary, preventive, and specialty care, which are
important to ensuring a healthy child and adolescent population. Having a
regular provider, or usual source of care, also can help reduce the use of
services from high- cost sources such as emergency rooms and inpatient
hospital care. 1 While health insurance coverage can provide the financial
means to obtain

care, it does not by itself guarantee that health services will be
available and accessible or that beneficiaries will receive needed care.
Access to primary care services is significantly affected by local factors
that vary across and within states, such as physician supply, location,
and

willingness to participate in a state*s Medicaid and SCHIP programs. While
federal law establishes general requirements to ensure that Medicaid and
SCHIP beneficiaries have access to covered health services, the extent to
which children actually receive these health care services is influenced
by how states implement their programs and monitor access at the state and

local levels. The type of service delivery and financing system that
states use in their Medicaid and SCHIP programs potentially affects
beneficiaries* ability to 1 A provider may be a physician, a group of
physicians practicing together, or an outpatient clinic with physician
services. United States General Accounting Office Washington, DC 20548

Page 2 GAO- 03- 222 Medicaid and SCHIP Access

locate and obtain services. Managed care, which often entails states
making capitation payments to managed care plans to provide or arrange for
all services for enrolled beneficiaries, encourages participating plans to
offer and coordinate primary and specialty care for beneficiaries. Managed
care also may promote efficiency by attempting to ensure that only
necessary services are provided in the most appropriate setting.
Appropriate safeguards are important, however, as capitation payments can
also create an incentive to underserve or even deny beneficiaries access
to needed care since plans and, in some cases, providers can profit from
not delivering services for which they have already received

payment. In contrast, beneficiaries in fee- for- service (FFS) systems,
including those receiving care in a primary care case manager (PCCM)
system, 2 may be at risk for the overprovision of services as providers
seek to increase revenue. However, if FFS payment levels are too low,
physicians may underserve their patients or be unwilling to participate at
all.

Our prior work has shown that access to care in Medicaid has been
problematic for certain services* such as health screening for children,
oral health, and mental health* and for particular populations, such as
children with special needs. 3 Recent reports that some physicians are
unwilling to take more Medicaid patients and that some managed care plans
are exiting from the Medicaid program have raised additional concerns
about adequate access for eligible children. Now that SCHIP is beginning
its sixth year of implementation, a related concern is the experiences of
children in accessing care under SCHIP, where states have greater
flexibility to decide whom to cover, what services to provide, and how to
pay for services, including required beneficiary cost sharing.
Accordingly, you asked us to evaluate states* efforts to routinely monitor
access to primary and preventive care services in (1) Medicaid managed
care, including actions selected states took when participating health
plans withdrew from the program, (2) Medicaid FFS- based delivery systems,
including PCCM systems, and (3) SCHIP.

2 FFS systems include traditional FFS, in which a provider bills the
program for services provided to an eligible beneficiary, and PCCM
systems, in which a physician, physician group practice, or similar entity
contracts with the state to locate, coordinate, and monitor primary health
services for Medicaid beneficiaries for a nominal monthly, per capita case

management fee (usually around $3). 3 See related GAO products listed at
the end of this report.

Page 3 GAO- 03- 222 Medicaid and SCHIP Access

To examine these issues, we analyzed 16 states* approaches to monitoring
access to primary and preventive health care services in their Medicaid
and SCHIP programs. These states were Arkansas, California, Colorado,
Florida, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Nevada,
New York, Ohio, Pennsylvania, Tennessee, Texas, and Washington. We
selected these states to obtain wide representation of geographic regions,
managed care and FFS systems, and SCHIP program designs. 4 Over 65 percent
of all Medicaid and SCHIP beneficiaries resided in these 16 states. To
evaluate state approaches to monitoring access to care, we focused our
analysis of states* managed care and FFS delivery systems in three key
areas:

 specific requirements for participating managed care plans and
physicians to help ensure sufficient physician capacity and accessibility
for eligible beneficiaries;  actions to independently verify or otherwise
monitor provider

participation; and  routine data collection and analysis of information
on beneficiaries* actual

service utilization, including patient satisfaction surveys. For states*
Medicaid and SCHIP managed care programs, these service utilization data
included encounter data, which are individual- level data on service use
that plans are required to collect and report to the state; the

Health Plan Employer Data and Information Set (HEDIS), developed by the
National Committee for Quality Assurance (NCQA) to help purchasers and
consumers compare the performance of health plans in providing selected
services; and the Consumer Assessment of Health Plans (CAHPS), which is a
standardized patient satisfaction survey developed by the federal Agency
for Healthcare Research and Quality (AHRQ). We

conducted site visits in four states where managed care plan withdrawals
had been reported* Massachusetts, Ohio, Tennessee, and Texas* and analyzed
information from primary care providers (PCP); 5 representatives of
advocacy groups; state insurance departments; and managed care plans
participating in Medicaid, SCHIP, or both. At the federal level, we
interviewed officials at the Centers for Medicare & Medicaid Services

4 States can take three approaches in designing their SCHIP programs: (1)
expand Medicaid, (2) construct separate child health programs distinct
from Medicaid, or (3) use a combination of both approaches. 5 For purposes
of this report, PCPs are usually physicians trained in internal medicine,
pediatrics, family medicine, or obstetrics and gynecology who participate
in PCCM or managed care programs in Medicaid or SCHIP.

Page 4 GAO- 03- 222 Medicaid and SCHIP Access

(CMS), which oversees states* Medicaid and SCHIP programs, and the Health
Resources and Services Administration (HRSA), which has responsibility for
analyzing issues related to access to care, as well as joint
responsibility for oversight of SCHIP. We reviewed relevant documents,
including federal laws, federal regulations, state contracts with managed
care organizations, and various federal and state reports related to
access. We conducted our work from June 2001 through December 2002 in

accordance with generally accepted government auditing standards. Each of
the states we reviewed with Medicaid managed care programs set
requirements for participating plans* provider networks, which include the
physicians and specialists who have agreed to deliver or arrange for
health care services to beneficiaries enrolled in a health plan. These
state

requirements ranged from broad provisions that health plans must have
*adequate* networks for serving their enrolled members, to very specific
standards that set, for example, a maximum number of beneficiaries per
primary care physician or maximum time frames within which a provider must
see a new beneficiary for a first appointment. The states less frequently
verified data that plans submitted to them or independently collected or
analyzed data to ascertain compliance with the requirements. States that
did routinely monitor plans* compliance with network requirements often
identified potential access problems and took steps to address them. For
example, a state review of the physicians listed in a plan*s network found
that many physicians were not accepting new Medicaid patients, resulting
in too few physicians accessible to such patients. Beyond setting
requirements for or monitoring plans* network size and availability,
states attempted to assess the extent to which beneficiaries were actually
receiving services through three key routine data sources: encounter data
that states require plans to submit on individual- level service use,
assessments of managed care plans* performance on specified measures, and
periodic beneficiary satisfaction surveys. However, the value of these
data was compromised by continuing problems in most states with encounter
data*s completeness and

reliability; additionally, standardized data on plan performance and
beneficiary satisfaction surveys were not representative of all Medicaid
managed care beneficiaries. Potential issues of access to care associated
with managed care plans withdrawing from Medicaid in four states we
visited affected significantly different shares of eligible beneficiaries,
ranging from about 1 percent of Medicaid beneficiaries in Texas to almost
50 percent in Tennessee. While these four states had taken various steps
to help minimize disruption in access to care for beneficiaries affected
by plan withdrawals, it was not clear to what extent these efforts had
been Results in Brief

Page 5 GAO- 03- 222 Medicaid and SCHIP Access

successful in helping beneficiaries transition smoothly to new health
plans and avoid access- to- care problems.

States did considerably less in their Medicaid FFS programs* which still
serve the majority of children in half of the states we reviewed* to
establish requirements for or monitor provider availability or to assess
beneficiaries* utilization of services than in their managed care
programs. For traditional FFS programs, beneficiaries may seek care from
any

providers participating in the Medicaid program and may change providers
at any time if they are dissatisfied. However, Medicaid beneficiaries*
ability to easily change providers depends on the number, type, and
location of providers willing to take new Medicaid patients, which in turn
is strongly influenced by Medicaid payment rates and associated
administrative processes. We found that FFS payment rates in most states
we reviewed were significantly lower than those paid by other purchasers
for comparable services, which can discourage providers from participating
in the program and thus restrict beneficiaries* access to a broad supply
of

providers. Officials in several of the states we contacted with Medicaid
FFS programs said that anecdotal information and complaint data suggested
that low payment rates, slow payment, and other administrative issues
deterred physicians in primary care or in some specialties from
participating in the program. Most of the seven states we reviewed with

PCCM programs set certain requirements for participating physicians, such
as limiting the number of beneficiaries that a PCCM could enroll in an
effort to ensure that physicians had the capacity to serve each
beneficiary. However, these states did little to monitor the extent to
which beneficiaries were successful in obtaining appointments as needed.
In regard to routine data collection and analyses, all but one of these
seven

states analyzed their FFS claims data and provided PCCMs with comparative
data on service utilization patterns for their own practices and for other
PCCMs. However, these comparative data often focused on higher- cost
services, such as inpatient hospitalization or emergency room use.

The majority of the states we reviewed* 9 of the 16* designed their SCHIP
programs to be an expansion of their Medicaid programs or modeled them
after Medicaid, with the same providers and administrative systems.
Therefore, in these states, the requirements for, and monitoring of, SCHIP
provider participation and beneficiary service utilization mirrored that
of their Medicaid programs. In contrast to these states, 7 states chose to
serve all or most of their SCHIP beneficiaries through programs that were
distinct from Medicaid. These states did significantly less in their
distinct SCHIP programs in terms of setting requirements for,

Page 6 GAO- 03- 222 Medicaid and SCHIP Access

or monitoring, participating providers or beneficiary service use than
they did for their Medicaid programs.

We received comments on a draft of this report from the Department of
Health and Human Services (HHS), as well as from 13 of the 16 states that
were included in our review. In response to our findings, HHS highlighted
new federal requirements for state oversight of Medicaid managed care that
are to be fully implemented by August 2003. HHS also pointed out that

design differences between Medicaid and SCHIP may affect states*
approaches to monitoring access to care. State officials provided
clarifying and technical comments regarding their oversight of access to
care, which

we incorporated as appropriate throughout this report. States* Medicaid
and SCHIP programs are governed by various federal requirements regarding
eligibility, covered services, and access to care. Under these
requirements, states generally have some discretion in determining the
amount, duration, and scope of services their programs will provide, and
the delivery and financing systems through which beneficiaries will
receive care* that is, FFS, managed care, or both. Federal requirements
relating to Medicaid beneficiaries* access to care are established in
statute; for managed care service delivery systems, detailed federal
regulations regarding access were recently issued. 6 SCHIP requirements
are also set out in statute but are less specific than those for Medicaid
and do not include detailed managed care requirements or regulations
comparable to those for Medicaid.

Since 1965, Medicaid has financed health care coverage for certain
categories of low- income individuals* including over 22 million children
in 2000. Federal law requires states to extend Medicaid eligibility to
children aged 5 and under if their family incomes are at or below 133
percent of the federal poverty level and to children aged 6 through 18 in
families with incomes at or below the federal poverty level. At their

discretion, most states have set income eligibility thresholds for
families with children that expand their Medicaid programs beyond the
minimum federal statutory levels.

6 67 Fed. Reg. 40989 (2002). Background

Populations Covered and Program Characteristics

Page 7 GAO- 03- 222 Medicaid and SCHIP Access

In 1997, the Congress established SCHIP, which provides health care
coverage to low- income, uninsured children living in families whose
incomes exceed the eligibility limits for Medicaid. SCHIP covered over 4.6
million children in fiscal year 2001, generally targeting children in
families with incomes up to 200 percent of the federal poverty level. 7
Compared with Medicaid, which has specific minimum federal eligibility and
benefit requirements, the SCHIP legislation provides states more
flexibility in how they choose to structure their programs. States have
three options in designing SCHIP: They may expand their Medicaid programs,
develop a separate child health program that functions independently of
Medicaid, or create a combination of the two approaches. (See table 1 for
the program designs of the 16 states in our sample.) While Medicaid
expansion programs under SCHIP must use Medicaid*s provider networks and
delivery systems, SCHIP separate child health programs may depart from
Medicaid requirements particularly with regard to covered benefits and the
plans, providers, and delivery systems available to beneficiaries. 8 Table
1: SCHIP Design Choices for 16 States, as of March 2002

Design State

Medicaid expansion Arkansas, a Louisiana, Ohio, and Tennessee Separate
program Colorado, Nevada, Pennsylvania, and Washington Combination
California, Florida, Illinois, Maryland, b Massachusetts, b Michigan, New
York, and Texas

Source: CMS. a In February 2001, Arkansas received approval from CMS to
implement a separate SCHIP program;

however, this program had not been implemented as of February 2002. b The
state*s separate SCHIP portion of its combination program provides
coverage either through (1) a premium assistance program for families with
access to private insurance coverage or (2) Medicaid providers and
services. Premium assistance programs were not included in our study.

Medicaid and SCHIP differ in terms of the share of their program
expenditures that come from federal funds. No overall federal budget limit
exists for the Medicaid program; it is an open- ended entitlement whereby

7 The SCHIP statute allows a state to expand eligibility to 200 percent of
the poverty level or up to 50 percentage points above its Medicaid
eligibility standard as of March 31, 1997. As of January 2002, states*
upper income eligibility thresholds for SCHIP ranged from 133 to 350
percent of the federal poverty level.

8 Throughout this report, SCHIP beneficiaries enrolled in Medicaid
expansion programs are included in the discussion of Medicaid.

Page 8 GAO- 03- 222 Medicaid and SCHIP Access

state expenditures for services that are provided under a CMS- approved
state Medicaid plan are matched by the federal government using a formula
that results in federal shares that currently range from 50 to 76 percent
of expenditures, depending on a state*s per capita income in relationship
to the national average. The federal share of Medicaid expenditures is
about 57 percent. In contrast to Medicaid, federal funding for SCHIP is
limited. The Congress appropriated $40 billion over 10 years

(from fiscal years 1998 to 2007), with a specified amount allocated
annually to each of the 50 states, the District of Columbia, Puerto Rico,
and 4 U. S. territories. State SCHIP expenditures are matched by federal
payments up to the state*s annual appropriated allotment. 9 The SCHIP

statute provides for an *enhanced* federal matching rate, with each
state*s SCHIP rate exceeding its Medicaid rate. The federal share of each
state*s SCHIP expenditures ranges from 65 to 83 percent; the federal share
of total SCHIP expenditures is about 72 percent.

States provide Medicaid and SCHIP services through two distinct service
delivery and financing systems* managed care and FFS, with the latter
including PCCM. 10 Under a capitated managed care model, states contract
with a managed care organization and prospectively pay the plans a fixed

monthly fee per patient to provide or arrange for most health services.
Plans, in turn, pay providers either retrospectively for each service
delivered on a FFS basis or through prospective capitation payment
arrangements. In contrast, in a traditional FFS delivery system, the
Medicaid program reimburses providers directly and on a retrospective
basis for each service delivered. The PCCM model is similar to a
traditional FFS arrangement except that PCCMs are paid a monthly, per
capita case management fee, usually around $3, to coordinate care for
beneficiaries, in addition to FFS reimbursement for any health care
services they provide. PCCMs, which are selected by beneficiaries upon
enrollment, are responsible for treating and coordinating the care for
those beneficiaries. Coordination may involve referrals to specialists and

9 Annual allotments are made to states for use over a 3- year period. For
SCHIP annual allotments that remain unspent after 3 years, the Secretary
of HHS is required to determine an appropriate procedure for
redistributing any unused SCHIP funds to states that have exhausted their
allotments.

10 We included PCCMs as FFS- based arrangements because participating
providers are predominately paid on a FFS basis. Thus, throughout this
report, the term managed care only refers to capitated managed care
arrangements. Delivery Systems

Page 9 GAO- 03- 222 Medicaid and SCHIP Access

other providers. In some cases, receipt of specialty and other services
may require PCCM approval. The 16 states we reviewed often structured
their Medicaid and SCHIP

service delivery systems differently. As shown in table 2, the exclusive
use of managed care was less prevalent in Medicaid than in separate SCHIP
programs (3 and 6 states, respectively), with 3 states* Maryland,
Michigan, and Tennessee* using managed care for virtually all children in
both Medicaid and SCHIP. The states were more likely to use a combination
of managed care and FFS approaches for their Medicaid programs than for
SCHIP (11 and 5 states, respectively). Despite the recent growth in
states* use of managed care, FFS is still a major component of many
states* programs, especially for Medicaid.

Page 10 GAO- 03- 222 Medicaid and SCHIP Access

Table 2: Share of Children Enrolled in Medicaid and Separate SCHIP
Programs, by Service Delivery Method, for 16 States Medicaid Separate
SCHIP program a FFS- based FFS- based

State Traditional FFS PCCM Managed care Traditional FFS PCCM Managed care

Arkansas b 100% -- c c - California 29% b 71% -- -- 100% Colorado 28% 18%
54% -- -- 100% Florida d 53% 47% b 2% e 98% Illinois 87% -- 13% 99% -- 1%
Louisiana 88% 12% -- c c - Maryland d -- 100% -- -- f Massachusetts d 63%
37% -- 65% 35% Michigan d -- 100% -- -- 100% Nevada 41% -- 59% 13% -- 87%
New York 61% -- 39% b -- 100% Ohio 67% -- 33% c -- c Pennsylvania d 24%
76% -- -- 100% Tennessee -- -- 100% -- -- c Texas 42% 21% 37% -- -- 100%
Washington 34% b 66% 57% b 43%

Number of states using system 9 7 14 3 2 11

Source: State data, as of December 2001, except for New York data, which
are as of September 2001. a Includes the separate child health programs in
states with combination or separate SCHIP programs. b Although this
delivery system exists in the state, it includes less than 1 percent of
children enrolled in

Medicaid or SCHIP and thus was not included in our study. c Not
applicable. State*s SCHIP program is a Medicaid expansion; thus, delivery
systems are the same as those in the state*s Medicaid program.

d Delivery system exists for children with special needs, which is outside
the scope of this study. Additionally, state enrolls children in FFS until
they transition to a managed care or a PCCM delivery system. For example,
families with eligible children in Florida are allowed 90 days in which to
select a PCP in managed care or a PCCM; during these 90 days, they are
enrolled in Medicaid FFS. e In Florida, delivery systems under SCHIP vary
by age. Families with children under age 5 can select between managed care
and a PCCM, while older children are limited to managed care service

delivery. f Not applicable; Maryland*s separate SCHIP portion of its
combination program was not operational

when our study began and thus was not included in the study.

Page 11 GAO- 03- 222 Medicaid and SCHIP Access

A state is required by federal statute to ensure that its payment and
delivery systems will afford beneficiaries* access to services similar to
that of its general population; 11 further, Medical assistance must be
provided with reasonable promptness. 12 While Medicaid traditional FFS
delivery systems have no additional access requirements, managed care and
PCCM delivery systems do. States are required to ensure that
beneficiaries*

access to care in managed care and PCCM is equal to that available to
beneficiaries in traditional FFS. On June 14, 2002, CMS published final
rules to implement new provisions the Balanced Budget Act of 1997 set out
for states* Medicaid managed care programs. These new rules address the
requirements, prohibitions, and procedures for the provision of different
types of Medicaid managed care and PCCM delivery systems. Under these
rules, which became effective August 13, 2002, states have until August
13, 2003, to bring all aspects of their state managed care programs into
compliance with the new requirements. 13 States that wish to use managed
care and PCCMs to deliver Medicaid

services must have CMS approval to do so. CMS approval is in part intended
to ensure that adequate protections are in place to safeguard the
interests of beneficiaries enrolled in managed care who may find their
freedom to seek the care of any participating provider at any time more
restricted than in FFS. In managed care, states may *lock in*
beneficiaries to one managed care plan and its network of providers for up
to 1 year in order to provide the plan sufficient time and opportunity to
manage the care of its enrollees most efficiently and appropriately.
States request CMS approval for their managed care programs through one of
two methods: (1) as a waiver from certain statutory requirements or (2) as
an amendment to the state*s Medicaid plan. 14 Fifteen of the 16 states we
reviewed received CMS approval to provide managed care through two types
of waivers of statutory provisions, program and demonstration waivers,
while one state* Nevada* received approval through a state plan amendment.

11 See 42 U. S. C. S: 1396a( a)( 30); 42 C. F. R S: 438. 2. 12 See 42 U.
S. C. S:1396a( a)( 8). 13 The new Medicaid managed care rules have more
detailed requirements for states than in the past, such as requiring
assurances from participating plans concerning the availability of
services, adequate capacity and services, coordination and continuity of
care, and coverage and authorization of services.

14 Implementing managed care service delivery by amending a state*s
Medicaid plan has been an option for states since passage of the Balanced
Budget Act of 1997. Federal Requirements for Access to Care

Page 12 GAO- 03- 222 Medicaid and SCHIP Access

Of the states we reviewed, 12 had approved *freedom- of- choice* program
waivers, under section 1915( b) of the Social Security Act, which
permitted them to direct beneficiaries to enroll in a managed care system.
15 In reviewing and approving program waivers, CMS requires states that
wish to limit beneficiaries* enrollment to managed care to offer a choice
of at least two managed care plans or allow beneficiaries to choose
between

one managed care plan and a PCCM system. CMS also requires states to
ensure that (1) managed care plans* physician networks under the waiver
include approximately the same number or more physicians than were
available before the waiver*s implementation and (2) services under
program waivers are provided within reasonable time frames and are
furnished within reasonable distances for the beneficiaries to travel. As
a condition of waiver approval, during the period of our review CMS asked
states to specify whether they had established access- related
requirements for participating plans in areas such as provider capacity,
or maximum times frames for beneficiaries to schedule appointments, travel
to

physicians* offices, or wait in physicians* offices to be seen. CMS did
not require states to establish specific requirements in these areas, but
if they did, they were asked to describe in their waiver applications how
they

planned to monitor compliance with any established requirements. Initial
approval of a program waiver is for a 2- year period, at which time the
waiver can be reviewed and approved for renewal by CMS. Waiver renewals
can result in changes in specific requirements for states.

Six of the states we reviewed* Arkansas, California, Maryland,
Massachusetts, New York, and Tennessee* had approved comprehensive
research and demonstration waivers, authorized by section 1115 of the
Social Security Act, to test concepts likely to further program
objectives. 16 A demonstration waiver provides a state with greater
flexibility to design

its Medicaid programs in areas such as eligibility standards, covered
benefits, and reimbursement rules. In reviewing and approving
demonstration waivers, CMS often establishes terms and conditions with
which states must comply that are more prescriptive than requirements for

15 The freedom of choice waiver is established by section 1915( b) of the
Social Security Act and is set forth at 42 U. S. C. S:1396n( b). The 12
states that we reviewed with program waivers were Arkansas, California,
Colorado, Florida, Louisiana, Michigan, New York,

Ohio, Pennsylvania, Tennessee, Texas, and Washington. 16 The demonstration
waiver is set forth at 42 U. S. C. S: 1315( a). In addition to
comprehensive waivers, states can also use section 1115 waivers for
specific populations or services, such as pharmacy or extending coverage
to parents. Four of the 15 states* California, Colorado, Florida, and
Illinois* have noncomprehensive section 1115 waivers.

Page 13 GAO- 03- 222 Medicaid and SCHIP Access

program waivers. For example, in approving demonstration waivers, CMS has
required states to (1) specify ratios that set the maximum number of
enrolled beneficiaries per participating PCP, (2) establish the maximum

time or distance for beneficiaries to travel to a physician*s office, and
(3) limit beneficiaries* waiting times when scheduling appointments for
urgent, routine, or specialty care. Initial approval of a demonstration
waiver is for a 5- year period, at which time the waiver can be reviewed
and approved for renewal by CMS.

In contrast to Medicaid, in their SCHIP programs states may require
mandatory beneficiary enrollment in managed care without offering a choice
among health plans. Federal SCHIP access- related requirements are also
less extensive than those for Medicaid. The SCHIP statute requires that
states have methods in place to ensure access to covered services,
including emergency services, but does not specify precise requirements.
17 States must describe their methods to ensure access to covered
services,

including any monitoring procedures, in their SCHIP state plans. In
addition, the SCHIP statute required each state to submit to the Secretary
of HHS a one- time program evaluation in March 2000. 18 States must also
submit to the Secretary annual reports that show their progress toward
reaching their strategic objectives and performance goals, some of which
may relate to access to care.

17 See 42 U. S. C. S: 1397bb. 18 A state*s SCHIP evaluation was required
to address several areas, including (1) the quality of health coverage
provided, (2) choices of heath benefits coverage, (3) activities to
coordinate SCHIP with other public and private programs, (4) changes in
trends in the states that affect the provision of health insurance, and
(5) recommendations for improving SCHIP.

Page 14 GAO- 03- 222 Medicaid and SCHIP Access

In attempting to ensure access to care in Medicaid managed care, states
focused more on setting requirements for managed care plans than on
monitoring compliance with these requirements or on analyzing
beneficiaries* use of services. The 14 states we reviewed with Medicaid
managed care programs reported varying levels of effort (1) to establish
certain requirements and standards for participating plans* physician
networks and to monitor their implementation and (2) to collect and
analyze data on service utilization, such as encounter data from
participating plans and beneficiary satisfaction surveys. State

requirements for plans* physician networks varied widely in their
specificity, from broad statements that health plans must have *adequate*
physician networks serving their enrolled members to very specific

standards that set, for example, a maximum average number of beneficiaries
per PCP or a maximum time frame for scheduling a first appointment. All
but 1 of the 14 states required managed care plans to routinely submit
lists of physicians participating in their networks, ranging from weekly
to quarterly reporting. However, fewer states independently verified or
routinely monitored aspects of the submitted data on managed care plans*
provider networks. For example, 8 of the 13 states receiving

plans* routine lists of participating physicians periodically verified the
number of physicians accepting new Medicaid patients, but only 5 states
analyzed the number of physicians to identify those participating in
multiple plans, which could overstate overall physician capacity.
Moreover, only 5 states routinely or independently assessed plans*
compliance with maximum waiting times for beneficiaries* scheduling
appointments. In some cases, states left it to plans to establish time
frames for scheduling appointments, rather than setting statewide
standards for all plans.

Beyond network- related requirements and any associated monitoring, states
attempted to assess beneficiaries* actual use of services through various
routine data sources and occasional special studies. Routine data sources
included encounter data, where states require health plans to

submit data for each service provided to each enrollee, periodic
assessments of plans* performance against standardized measures, and
beneficiary satisfaction surveys. But continuing problems with the
reliability of encounter data* and the fact that standardized data on plan
performance and beneficiary satisfaction surveys were not representative

of all Medicaid managed care enrollees* tended to undermine the utility of
these data sources in describing the experiences of beneficiaries and
their service utilization. The four states we visited that had experienced
the withdrawal of managed care plans from their Medicaid programs had

taken various steps to help minimize disruption in care for affected In
Medicaid Managed

Care, States Focused More on Setting Plan Network Requirements than on
Monitoring Plans or Analyzing Service Utilization

Page 15 GAO- 03- 222 Medicaid and SCHIP Access

beneficiaries. However, it is not clear to what extent these states
monitored service utilization for beneficiaries affected by such changes
and their experiences in transitioning to new plans and physicians.

To oversee access to care in their Medicaid managed care programs, the
states we reviewed established requirements for participating plans that
most often focused on the size and structure of their physician networks,
such as the number and geographic location of PCPs and specialists, and
beneficiaries* ability to schedule appointments. Some states, such as
Colorado, Texas, and Washington, had broad requirements that physician
networks must be adequate to serve beneficiaries, as shown in figure 1.
Among the 14 states that used managed care in their Medicaid programs,

broad network requirements were more prevalent for specialists than for
PCPs. In contrast, 11 of 14 states set specific standards or ratios
relating to the number of enrolled beneficiaries per PCP, and 13 set
standards for

providers* geographic proximity to beneficiaries, such as the maximum
distance or travel time for a beneficiary to reach a provider*s office.
More variation was evident in states* requirements for plans in terms of
appointment scheduling for beneficiaries. All 14 states set maximum time
frames to schedule routine and urgent appointments, while 6 states also
set maximum time frames for a newly enrolled beneficiary*s first
appointment and 8 states set maximum in- office waiting times. Most States
Set Plan

Network Requirements but Less Frequently Monitored Plans* Compliance

Page 16 GAO- 03- 222 Medicaid and SCHIP Access

Figure 1: Selected Medicaid Managed Care Plan Network Requirements and
Standards in 14 States a State does not have a specific standard but does
require plans to monitor this measure.

b State only has a standard for selected populations, such as children
with special needs.

States took varying approaches in setting their requirements for plan
networks and appointment waiting times, as shown in table 3. For example,
Florida required physicians to certify that their overall practice did not
exceed 3,000 patients, whereas other states established specific

Medicaid beneficiary- to- PCP ratios ranging from 1,000 to 1 in
Pennsylvania to 2,500 to 1 in Tennessee. With regard to appointment
waiting times, some states required plans to set their own standards
rather than establishing a consistent statewide standard.

Source: GAO analysis of states* data, as of December 2001. State Network
size and structure PCPs Geographic

distribution Appointment waiting times

Specialists First visit In- office waiting time Appointment scheduling

California Colorado Florida Illinois Maryland Massachusetts Michigan
Nevada New York Ohio Pennsylvania Tennessee Texas Washington

Specific Standard General requirement that health plans* networks be
adequate to serve their members No standard

b a a

a

Page 17 GAO- 03- 222 Medicaid and SCHIP Access

Table 3: Examples of Specific State Standards for Plan Networks and
Appointment Waiting Times Availability measure Examples of standards used
Plan network PCPs  Florida requires physicians to certify that their
overall practice does not exceed 3,000 patients.

 Maryland requires each health plan to have enrolled beneficiaries- to-
PCP ratios that do not exceed 2,000: 1 for adults and PCPs should have no
more than 1,500 beneficiaries under age 21. Tennessee uses a maximum
2,500: 1 beneficiaries- to- PCP ratio.

 Ohio*s contracts with health plans specify a required number of PCPs
based on the number of beneficiaries and plans in a county. Specialists 
New York requires each participating plan to have 30 specialties: 14 with
specific ratios of enrolled

beneficiaries to specialists and 16 specialties for which health plans
must have at least two providers.

 Ohio requires health plans to have a specified number of 6 types of
specialists, including dentists, allergists, and general surgeons, per
county or service area.  Pennsylvania requires health plans to provide
beneficiaries with a choice of at least 2 appropriate

specialists within a reasonable geographic distance. Geographic
distribution  Ohio requires health plans to ensure that 40 percent of
beneficiaries reside within 10 miles of a PCP.

 Texas requires health plans to have a PCP within 30 miles of a
beneficiary*s residence and specialty care within 75 miles.

 Washington requires health plans in urban areas to have two PCPs within
10 miles of 90 percent of beneficiaries; plans in rural areas must have
one PCP within 25 miles of most beneficiaries.

Appointment waiting times

First visit  California requires that the first visit of newly enrolled
beneficiaries be within 120 days.

 Michigan requires health plans to set a standard for when new
beneficiaries should first visit a PCP.

 Pennsylvania requires that health assessments, general physical
examinations, or first examinations be scheduled within 3 weeks of
enrollment. Appointment scheduling  California requires health plans to
provide urgent care within 24 hours and to set a standard for

routine appointments.

 Nevada requires appointments for urgent care within 2 days, and that
routine care be scheduled within 2 weeks of request.

 New York requires that appointments be scheduled within 24 hours for
urgent care, 4 weeks for routine and preventive care, and 4 to 6 weeks for
specialist care. In- office waiting time  Florida requires that
explanations be given to beneficiaries if they must wait more than 30
minutes; if

the wait will exceed an hour, the provider is to reschedule the
appointment.

 Michigan requires health plans to set an in- office waiting time
standard.

 Pennsylvania requires that beneficiaries wait no more than 20 minutes on
average or 1 hour maximum past their scheduled appointment times.

Source: GAO analysis of states* data, as of December 2001.

Routinely monitoring plan performance, especially with established network
requirements and standards, is critical because providers can* and do*
change their participation in Medicaid managed care, which in turn can
affect beneficiaries* access to care. In some cases, a state may not have
set a specific network requirement but nonetheless independently monitors
plan performance. States that monitor the extent to which participating
plans* network providers are actually available to beneficiaries are
better able to systematically identify and respond to access problems. For
example, see the following.

Page 18 GAO- 03- 222 Medicaid and SCHIP Access

 In 1999, Tennessee reviewed each managed care plan*s contracts with its
providers and contacted providers directly to independently verify their
participation with the plan and whether they were open to new Medicaid
patients. The state found that, for one health plan, only 44 percent of
the participating PCPs accepted new Medicaid patients; of the remaining 56
percent of PCPs, 33 percent had Medicaid patients but would not accept any
new ones, and 23 percent either did not accept any Medicaid patients or
could not be reached by telephone. Determining that the plan did not
comply with requirements for PCP availability, the state required the plan
to add providers who would accept new Medicaid beneficiaries before
assigning any additional beneficiaries to the plan. State officials also
reported that they now conduct a regular telephone survey of providers to
verify the provider data that participating plans submit.  Washington has
a broad requirement that physician networks be adequate to serve enrolled
beneficiaries but does not set as many additional specific

standards as do some other states. The state does, however, require
participating plans to routinely report which physicians are participating
in their Medicaid networks and independently verifies plan reports by
periodically placing test calls to physicians. Washington also compiles
the physician- level information into a centralized database to review
physician participation across health plans in order to better ensure that
capacity is not overstated.

To monitor plan performance in terms of provider availability to
beneficiaries, 13 of the 14 states we reviewed routinely obtained periodic
data from participating plans on the number of physicians in their
networks, ranging from weekly reports in Maryland to quarterly reports in
California, Massachusetts, and New York. As a part of this routine data
collection, 12 states also reviewed the geographic distribution of
physicians in their networks. Fewer states, however, took additional steps
to determine, on an ongoing basis, whether the plan- submitted data
adequately reflected network capacity to serve Medicaid beneficiaries. For
example, in 9 states the plans* provider lists identified those physicians
who were accepting new Medicaid patients, which would help indicate the
extent to which plan networks were open to new public beneficiaries, and 7
states independently verified the accuracy of the submitted provider
lists. Five states analyzed information across the plans* provider lists
to help identify the unduplicated number of PCPs available to the Medicaid
managed care population and to help avoid overstating overall physician
availability. (See fig. 2.)

Page 19 GAO- 03- 222 Medicaid and SCHIP Access

Figure 2: Variation in 14 States* Monitoring of Medicaid Managed Care
Plans* Provider Information

a In some counties in California, plans are required to update their
provider lists semiannually. b The state imposed specific standards
regarding the number of PCPs in a health plan*s network (such as
beneficiaries- to- PCP ratios) but did not account for providers that may
be enrolled in multiple plans. c The state plans to reinstitute
requirements for health plans to submit provider information quarterly in

the next contract period. d The state requires health plans to limit the
total number of patients a physician may have across all

lines of business (for example, private pay, Medicaid, and other types of
insurance coverage), but the state does not monitor compliance with this
limit. e The state does not obtain lists from health plans that indicate
the number of providers accepting new patients. Instead, it tracks the
number of patients each provider is willing to accept through a health
plan and compares this information to the number of beneficiaries enrolled
with a particular physician. Based on this comparison, the state
identifies which physicians should be accepting new patients.

Compared to state monitoring of provider network information, even fewer
states monitored compliance with their requirements for appointment
waiting times. Five of the 14 states with Medicaid managed

Yes No Not applicable

State

California Colorado Florida Illinois Maryland Massachusetts Michigan
Nevada New York Ohio

Pennsylvania Tennessee Texas Washington Total

Source: GAO analysis of states* data, as of December 2001.

How frequently do plans submit provider

lists to the state?

Do lists identify providers accepting new

Medicaid patients?

Does the state account for

providers enrolled in multiple plans? Does the state

verify the accuracy of provider

lists?

Quarterly a Monthly Monthly

Weekly Quarterly Bi- weekly Bi- weekly Quarterly

Monthly Monthly Monthly Monthly Monthly

9 7 5 d

d d d

b b b b

N/ A N/ A c N/ A

N/ A N/ A N/ A

e

Page 20 GAO- 03- 222 Medicaid and SCHIP Access

care* California, Massachusetts, New York, Tennessee, and Washington*
routinely collected data or otherwise independently verified health plans*
compliance with specific appointment- related standards such as maximum
time frames to schedule an initial health assessment (first visit) or
routinecare appointment and in- office waiting times. To determine whether
beneficiaries newly enrolled in a plan received initial health assessments
within 120 days of enrollment, California regularly reviews health plan
reports and physician office medical records for a sample of new
beneficiaries in each plan. To verify physician compliance with
appointment scheduling standards, New York makes random calls to
physicians (200 offices per plan service area per year), requesting
information on the next available appointment for a specified need, such
as routine care, urgent care, or after- hours care. In contrast,

Massachusetts directs plans to develop and monitor compliance with their
own appointment scheduling requirements, and the state annually reviews
and critiques the methodology and results reported by each plan.

Absent routine verification or monitoring of plans* compliance with
network and availability requirements, states do not have an adequate
assurance that such requirements are having their intended effect on
beneficiaries* access to managed care providers. Officials in one state
that did not verify requirements indicated that the standards served as a
basis for legal recourse in the event that beneficiaries raised complaints
regarding appointment availability. Undertaking additional measures to
verify plan compliance, as Tennessee did, can identify more comprehensive
network problems that limit access to care for Medicaid beneficiaries and
that might otherwise go undetected.

The new Medicaid managed care regulations, effective August 13, 2002, and
to be fully implemented by August 13, 2003, will likely require some
states to alter their approaches to requirements for their participating
plans and provider networks. In general, the regulations require that
states ensure* through their contracts with managed care plans* that
participating plans demonstrate their capacity to serve the needs of their
enrollees for any specific standards that states set for access to care.
Among other things, the regulations require states to ensure that
participating plans

 maintain and monitor their networks of providers to provide adequate and
timely access to all services covered under their contracts with the
states, including monitoring the numbers of network providers who are not

accepting new Medicaid patients; New Regulations May Alter

States* Approaches to Monitoring Managed Care

Page 21 GAO- 03- 222 Medicaid and SCHIP Access

 ensure that network providers offer hours of operation that are no less
than the hours offered to commercial enrollees or comparable to those of
Medicaid FFS;  make services included in the contract available 24 hours
a day, 7 days a

week, when medically necessary; and  establish mechanisms to ensure
compliance by providers with state standards for access to care. The
regulations require states to certify to CMS* at the time the state enters
into a contract with a plan or when there are significant changes that
would affect the ability of plans to provide adequate capacity or
services* that plans have complied with state requirements for the
availability of services covered by managed care contracts. To the extent
that states have not made specifications regarding health plan physician
network capacity or assurances of access to care, states may need to
revise their contracts with plans to comply with this new requirement.
States that verify or monitor participating plans* actual compliance with
the terms of their contracts will likely have greater direct and routine
information on whether the access- related requirements they have set out
for participating plans are achieving their intended benefit for covered
beneficiaries.

Determining the extent to which Medicaid beneficiaries are utilizing* and
are satisfied with* covered program services is an important test of the
effectiveness of any state requirements for managed care plans* network
capacity and accessibility. To assess beneficiaries* service utilization
and satisfaction, the states we reviewed generally required participating
plans to routinely provide data from two key sources: encounter data,
which are individual- level data on service use, and HEDIS, which provides
comparative information across participating plans for designated service
measures. Most states also administered CAHPS, which is a standardized
beneficiary satisfaction survey. However, for the majority of states we
reviewed, the utility of these data for routine monitoring was often
handicapped because of the frequent failure of plans to submit reliable
encounter data and the exclusion of significant shares of beneficiaries
from the HEDIS and CAHPS data. CAHPS survey results were further limited
by poor response rates in most states. A few states reported making
sufficient progress in their efforts to improve the quality of their
encounter data that they could use them to routinely analyze service
utilization in their Medicaid managed care programs. In addition to these
routine data sources, a few states reported conducting occasional special
Routine Monitoring of Service Utilization Often

Handicapped by Poor Data

Page 22 GAO- 03- 222 Medicaid and SCHIP Access

studies that enabled them to identify and focus on access issues
pertaining to beneficiaries* use of services or satisfaction with services
received.

Encounter data are intended to capture information on beneficiaries* use
of primary and preventive care as well as other services, such as
emergency room visits. These data can help states identify patterns of
care along several dimensions, such as by type of visit or patient (such
as wellchild visits by age), by health condition or disorder (such as
asthma or diabetes), and by plan. As a condition of their approved federal
managed care waivers, states must require Medicaid managed care plans to
submit encounter data. But obtaining reliable and useful encounter data
has proven to be a difficult undertaking, as we have earlier reported. 19
According to CMS and several of the states we reviewed, many states

continue to struggle with obtaining reliable and complete encounter data.
One state we contacted found that the lack of standardized provider coding
and formatting procedures resulted in missing and incomplete data. As a
result, only 16 percent of the provider identifiers in the submitted
encounter data could be matched to the state*s Medicaid provider master
file. Another state noted that its encounter data were of limited use
because many health plans were unable to obtain complete data from their
providers. Two of the 14 states we reviewed reported that obtaining
complete encounter data was more problematic for health plans

that paid their physicians a monthly capitated payment that is not linked
to the delivery of specific services.

For states providing Medicaid services through managed care, encounter
data often are the basis for states* responses to federal reporting
requirements under Medicaid*s Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) services. EPSDT is designed to provide children and
adolescents with access to comprehensive, periodic evaluations of health,
developmental, and nutritional status, as well as hearing, vision, and
dental services. 20 The EPSDT annual reports that states must submit to
CMS are designed to capture, by age group, information such as the

19 See U. S. General Accounting Office, Medicaid Managed Care: Challenge
of Holding Plans Accountable Requires Greater State Effort, GAO/ HEHS- 97-
86 (Washington, D. C.: May 16, 1997). 20 Federal law requires that EPSDT
include services that are necessary to correct or

ameliorate defects and physical and mental illnesses and conditions
discovered through screening, regardless of whether those services are
covered by the state*s Medicaid plan. Encounter Data

Page 23 GAO- 03- 222 Medicaid and SCHIP Access

number of children who (1) received EPSDT health screenings, 21 (2) were
referred for corrective treatment, (3) received dental treatment or
preventive services, and (4) were enrolled in managed care plans. However,
we have previously reported that managed care plans, particularly those
that pay their participating physicians on a capitated basis, often had
difficulty collecting and reporting complete and accurate EPSDT data. 22
Thus, EPSDT reports that are based on encounter data are

often incomplete or inaccurate, compromising the reliability of states*
data on use of these services. Despite these widespread problems with
encounter data, a few states we reviewed noted that the reliability and
usefulness of their encounter data have improved over time. Maryland, New
York, and Michigan, for example, reported sufficient progress with
improving the quality of their encounter data that they are now able to
use them to analyze service utilization in their Medicaid managed care
programs, as indicated below.  Maryland officials noted that after
spending several years developing and

refining its system for obtaining encounter data, the state is now able to
use them as the basis to make risk- adjusted payments to plans and to
routinely assess Medicaid managed care beneficiaries* utilization of
wellchild, ambulatory, and emergency room visits. The state publicly
reports performance information by health plan, creating a strong
incentive for health plans to ensure that all encounters are reported. To
ensure that the reported encounter data accurately portray services
delivered, the state

conducts validation studies on the data submitted by health plans. The
state also reviews the distribution and frequency of diagnoses reported
through the encounter data over time to monitor whether the mix of
diagnoses across the population changes.  New York established a data
warehouse for Medicaid managed care in

1997. The warehouse includes encounter data submitted by health plans as
well as data from other providers* FFS claims for reimbursement for
services provided to managed care beneficiaries outside of their health

21 The components of an EPSDT health screening include a comprehensive
health and developmental history, a comprehensive unclothed physical exam,
appropriate immunizations, laboratory tests (including a blood lead- level
assessment), and health education. 22 See U. S. General Accounting Office,
Medicaid: Stronger Efforts Needed to Ensure Children*s Access to Health
Screening Services, GAO- 01- 749 (Washington, D. C.: July 13,

2001).

Page 24 GAO- 03- 222 Medicaid and SCHIP Access

plan. A variety of reports on utilization and access data are generated
and shared with plans on a restricted access web site.  Michigan is
developing a data warehouse that will combine managed care

encounter data with FFS claims and public health data, such as vital
statistics and immunization records, into a single information system that
it will use to analyze beneficiaries* service utilization. The data
warehouse will also be able to create utilization profiles by managed care
plan. The state has begun testing the data warehouse that is expected to
be operational within the next year.

HEDIS is a set of standardized performance measures that helps purchasers
and consumers compare the performance of managed health care plans. 23
HEDIS performance measures are organized into eight categories, four of
which include measures directly related to beneficiary service
utilization. 24 The Medicaid version of HEDIS includes various access-
related measures that attempt to capture beneficiaries* use, often by age,
of various preventive and other services from specified providers, as
illustrated in table 4. (See app. I for a more detailed list of Medicaid
HEDIS measures related to service utilization.)

23 NCQA, an independent foundation, has managed HEDIS since 1992.
Originally designed for private employers as purchasers of health care, it
has been adapted for public purchasers, regulators, and consumers,
including Medicaid.

24 The four general HEDIS categories that directly relate to service
utilization are effectiveness of care, access/ availability of care, use
of services, and satisfaction with the experience of care. The remaining
four general categories are health plan stability, cost of care, informed
health care choices, and health plan descriptive information. HEDIS

Page 25 GAO- 03- 222 Medicaid and SCHIP Access

Table 4: Examples of Medicaid HEDIS Measures Related to Service
Utilization for Children General HEDIS category Specific HEDIS measure
Description

Childhood immunization status The percentage of enrolled children who
turned 2 years old during the

measurement year, who were continuously enrolled for 12 months preceding
their second birthdays and who were identified as having the recommended
number of specific immunizations by their second birthdays. Adolescent
immunization status The percentage of enrolled adolescents who turned 13
during the measurement

year, who were continuously enrolled for 12 months immediately preceding
their 13th birthdays and who were identified as having had the recommended
number of specific immunizations by their 13th birthdays. Effectiveness of

care Use of appropriate medications for people with asthma

Whether members with persistent asthma are being prescribed medications
acceptable as primary therapy for long- term control of asthma.

Children*s access to PCPs The percentage of enrolled members age 12 months
through 24 months, 25 months through 6 years, and 7 years through 11 years
who had a visit with a network PCP. Access/ availability

of care Annual dental visit The percentage of enrolled members age 4
through 21 who were continuously

enrolled during the measurement year and who had at least one dental visit
during the measurement year (when dental services are a covered benefit
under Medicaid).

Well- child visits in years 3, 4, 5, and 6 of life The percentage of
members who were 3, 4, 5, or 6 years old during the

measurement year, who were continuously enrolled during the measurement
year, and who received one or more well- child visits with a primary care
practitioner during the measurement year. Use of services Adolescent well-
care visits The percentage of enrolled members who were age 12 through 21
years during the

measurement year, who were continuously enrolled during the measurement
year, and who had at least one comprehensive well- care visit with a PCP
or an obstetrician/ gynecologist practitioner during the measurement year.

Source: NCQA, HEDIS 2000: Technical Specifications (Washington, D. C.:
1999).

Twelve of the 14 states we reviewed used HEDIS measures to help assess
Medicaid beneficiaries* utilization of services. Eleven states required
participating plans to submit HEDIS performance results, while 1 state*
Ohio* conducted its own HEDIS analysis using encounter data submitted by
plans. 25 Some states used the full set of HEDIS measures, while others
used selected measures corresponding to areas of interest.

Despite the potential of HEDIS to provide valuable information regarding
beneficiaries* use of managed care services, its narrow focus in
identifying beneficiaries to be included in the assessments often limits
the ability to generalize results to all beneficiaries within a plan or
within a state. Many HEDIS measures require beneficiaries to have 12
months of continuous 25 Tennessee and Texas did not use HEDIS to assess
plan performance.

Page 26 GAO- 03- 222 Medicaid and SCHIP Access

enrollment in a single managed care plan in the assessment year in order
to be included in the measures. 26 As a measurement criterion, the
continuous enrollment requirement is intended to ensure that comparisons
of performance across health plans are made on the basis of sample
populations that have been enrolled for similar periods of time. However,
because beneficiaries* average length of time in the Medicaid program can
be less than 12 months* ranging from 6 to 9 months in three states* this
12- month enrollment requirement excluded at least one quarter of Medicaid
beneficiaries from most of the states we reviewed and more than half in
four states, as shown in table 5. 27 Consequently, HEDIS

measures may not provide a representative measure of service utilization
for a significant share of children covered by Medicaid managed care.
Another limitation of the HEDIS measures is that they are often based on

encounter data and are thus subject to the reliability concerns previously
raised.

26 Although some HEDIS measures have a 12- month continuous enrollment
requirement, individuals with one gap in enrollment of up to 45 days or
less can be included in the sample. However, to be included, individuals
must remain with the same health plan after a break in enrollment. 27
According to one report, at least one state* Iowa* analyzed HEDIS measures
for

individuals that were continuously enrolled in Medicaid for less than 12
months. See NCQA, Medicaid HMO and Fee- For- Service Comparison Strategy:
Methodological Issues (Washington, D. C.: NCQA, n. d.). http:// www. ncqa.
org/ Programs/ qsg/ medicaidcomparison. html (downloaded July 8, 2002).

Page 27 GAO- 03- 222 Medicaid and SCHIP Access

Table 5: Estimated Percentage of Medicaid Children Excluded from HEDIS
State a Percentage excluded from HEDIS b

Colorado 79 Ohio 75 Washington 52 Florida 51 New York 40 Michigan 33
Maryland 32 Pennsylvania 31 Massachusetts 29 California 26 Illinois 24
Nevada c Tennessee d Texas d

Source: GAO analysis of states* data, as of December 2001. a States were
asked for enrollment information for the most recent year for which data
were available,

which was generally 2001. b Percentages represent the portion of the
population excluded from the required sample for some of

the HEDIS measures because they were enrolled for less than 12 months. c
State could not provide exclusion data.

d State does not use HEDIS data.

Several states we reviewed provided examples of how they used the HEDIS
data they received from participating plans. These included using the
information to compare each plan*s performance against national Medicaid
averages for selected measures and developing report cards to compare
results across plans. Given issues we identified with the completeness of
the data, however, such uses and comparisons may not be reliable
indicators of beneficiaries* use of services and may render a false
impression of beneficiaries* actual experience in service utilization.

State Medicaid managed care programs are required to have an internal
quality assurance system, which can involve administering beneficiary
satisfaction surveys. 28 Thirteen of the 14 states we reviewed reported
using CAHPS to assess beneficiaries* experiences with their Medicaid
managed

28 42 C. F. R. S: 434.34. CAHPS

Page 28 GAO- 03- 222 Medicaid and SCHIP Access

care plans. 29 CAHPS is a standardized survey designed to compare the
performance of managed care plans on the basis of beneficiaries*
perceptions regarding the care they received through their plans. 30 The
CAHPS survey covers a range of topics related to service utilization,
including appointment scheduling, waiting time in a physician*s office,
and the use of specialty services, as shown in table 6. Table 6: Examples
of Beneficiary Satisfaction Questions for Children Covered by CAHPS

Measure Question

First visit  Did you get an appointment for your child*s first visit to a
doctor or other health care provider for a checkup, or for shots or drops,
as soon as you wanted? Appointment scheduling  In the last 6 months, how
often did your child get an appointment for regular or routine

health care as soon as you wanted?

 In the last 6 months, when your child needed care right away for an
illness or injury, how often did your child get care as soon as you
wanted? Ambulatory care  In the last 6 months (not counting times your
child went to an emergency room), how

many times did your child go to a doctor*s office or clinic? In- office
waiting time  In the last 6 months, how often did your child wait in the
doctor*s office or clinic more than

15 minutes past the appointment time to see the person your child went to
see? Referral to specialist  In the last 6 months, how much of a problem,
if any, was it to get a referral to a specialist

that your child needed to see? Source: CAHPS 2.0, Child Medicaid Managed
Care Questionnaire and Child Supplemental Questions, (Rockville, Md.:
AHRQ, 1998).

Like HEDIS, however, information from CAHPS is only gathered from a subset
of beneficiaries. CAHPS has a 6- month continuous enrollment requirement
for Medicaid beneficiaries to be included in the survey sample. While this
is a shorter minimum enrollment period than for HEDIS, it still resulted
in excluding about one quarter or more of covered beneficiaries in five
states we reviewed, and nearly half or more in two

states, as shown in table 7. Moreover, several states using CAHPS reported
that they had low response rates from the sampled population; in some
cases, surveys targeted only those beneficiaries with telephones, a

29 Tennessee opted to use a state- designed beneficiary satisfaction
survey rather than CAHPS. In most cases, the states we reviewed
administered CAHPS directly or through the use of an independent
contractor. Three states* Colorado, Illinois, and Pennsylvania* required
participating plans to administer CAHPS. 30 CAHPS was developed in 1995 by
the federal AHRQ to provide information to help beneficiaries compare
health plans.

Page 29 GAO- 03- 222 Medicaid and SCHIP Access

practice that has the potential to bias the results for beneficiaries who
could not be reached by that method. 31 Table 7: Estimated Percentage of
Medicaid Children Excluded from CAHPS

State a Percentage excluded from CAHPS b

Colorado 61 Ohio 49 Texas 31 Florida 30 Washington 24 Michigan 17 Maryland
16 Massachusetts 15 New York 15 Pennsylvania 13 California 11 Illinois 10
Nevada c Tennessee d

Source: GAO analysis of states* data, as of December 2001. a States were
asked for enrollment information for the most recent year for which data
were available,

which was generally 2001. b Percentages represent the portion of the
population excluded from CAHPS because this group was

enrolled for less than 6 months. c State could not provide data.

d Tennessee does not use CAHPS, although it does conduct a state- designed
survey of a sample of all state residents about insurance coverage and
satisfaction with services, including access to care.

Gauging beneficiary satisfaction with services solely through a
satisfaction survey is an inherently difficult process, especially when a
sample is not representative or response rates are low. To augment
information on beneficiary satisfaction, states also had available the
results of their complaints and grievances processes, which they are
required to have as a condition of their managed care programs. Nearly all
of the states we reviewed with Medicaid managed care operated a central
hotline or complaint number, where beneficiaries could obtain program
information

31 Among the nine states in our sample that reported their response rates,
the response rates for the CAHPS survey of families with children ranged
from 27 percent in Nevada to 85 percent in Illinois.

Page 30 GAO- 03- 222 Medicaid and SCHIP Access

or request assistance locating providers in addition to filing complaints.
The states we reviewed generally focused on ensuring that complaints and
questions raised by beneficiaries* calls were addressed. For example, five
states* Ohio, Maryland, Michigan, New York and Washington* had information
databases that tracked complaints from their inception to their
resolution. New York, Ohio, and Washington complaint reports were also
analyzed by managed care plan, which allowed officials to identify any
trends in beneficiary complaints.

As a tool to assess overall problems with access to care, records of
complaints and grievances had several limitations. In some cases, states*
hotline or complaint data did not distinguish between requests for
assistance and complaints about provider services, thus making it
difficult to assess the extent of any systemic access problems. In
addition, a small

number of complaints could be difficult to interpret at face value; while
few complaints or grievances could indicate overall satisfaction with
care, it could also indicate a general lack of knowledge about or ability
to file a

formal complaint or grievance. A small number of complaints also could
limit the state*s ability to identify any specific trends of systemic
problems with access to care with a specific plan or within a state*s
Medicaid managed care program as a whole.

A few states we contacted reported that they occasionally conducted
special studies, in addition to any routine monitoring they did, to assess
service utilization issues for their Medicaid beneficiaries. For example,
Maryland*s 4- year evaluation of its Medicaid managed care program,
published in January 2002, concluded that providers and consumers felt

that PCP networks were *under stress* in certain areas of the state, with
a notable lack of physicians in rural areas of the state. 32 The
evaluation also identified significant inaccuracies with plan- submitted
data on physician providers, including duplicate provider entries,
incorrect provider

affiliation status with participating plans, and missing information. As a
result, the state took steps to develop and implement more rigorous
methods of monitoring plan- submitted data. In particular, the state now
monitors plans* PCP networks, including verification calls to samples of
physicians, so that PCP shortage areas can be identified and addressed. In
the future, the state also plans to develop more specific standards for

32 Maryland Department of Health and Mental Hygiene, HealthChoice
Evaluation, Final Report and Recommendations (Washington, D. C.: Jan. 15,
2002). Special Studies

Page 31 GAO- 03- 222 Medicaid and SCHIP Access

commonly used specialists and monitor plans* compliance with these
standards.

In 2001, Washington conducted a survey of new Medicaid managed care
beneficiaries in 14 counties as a result of concerns raised by beneficiary
advocates in light of managed care plans* withdrawal from program
participation. The study examined these beneficiaries* experiences with
accessing medical care, including emergency room use. The study found that
90 percent of new beneficiaries reported having a PCP after enrollment in
Medicaid, compared to 62 percent having a PCP before enrollment in
Medicaid managed care. Additionally, there were no significant differences
between the experiences of managed care and FFS beneficiaries who had
obtained medical, specialist, or emergency room care. However, the study
did find that the majority of beneficiaries were

unfamiliar with several key processes concerning their managed care plans,
such as how to change PCPs within a health plan, contact their health
plans when questions or problems arose, and make complaints. Based on
these findings, the state plans to work with managed care plans to improve
beneficiaries* awareness regarding PCP selection and communication with
their health plans.

The managed care industry* in the commercial as well as public sectors*
has experienced considerable changes in recent years following periods of
rapid entry of multiple managed care plans in certain markets and
subsequent retrenchment based on plans* willingness or ability to compete
in those markets. Many communities and states have experienced changes in
the number of managed care plans as a result of numerous health plan
mergers, acquisitions, and closures as the managed care industry has
evolved and matured. State Medicaid programs have often been affected by
the withdrawal of some managed care plans from their programs; in

some cases, states have intentionally acted to reduce the number of
participating plans. The four states we visited* Massachusetts, Ohio,
Tennessee, and Texas* had experienced such changes to varying degrees.
These states had taken various measures to help minimize any adverse
effects on beneficiaries* access to care due to participating plans
leaving the Medicaid program. It is not clear, however, to what extent
these states*

efforts had been successful in helping beneficiaries transition smoothly
to new health plans and physicians and thus avoid problems with access to
care. States Attempted to

Minimize Impact of Managed Care Plan Withdrawals on Access to Care, but
Effect on Beneficiaries Is Uncertain

Page 32 GAO- 03- 222 Medicaid and SCHIP Access

The potential amount of disruption that occurs when a health plan
withdraws from a state or community can vary considerably, depending on a
number of circumstances. Health plan mergers can result in minimal changes
for beneficiaries if they are able to maintain established relationships
with their providers and can even strengthen the network of available
providers within a plan. In Massachusetts, for example, a merger between
two health plans in the early 1990s was considered by state

officials to have increased physician availability for Medicaid
beneficiaries enrolled in managed care. Officials in Massachusetts also
noted that reductions in the number of health plans ensured that
participating plans have enough enrolled beneficiaries to spread the costs
and risks associated with capitation payments. In other cases, however,
the extent of disruption may be more severe, particularly when large
numbers of

beneficiaries are affected and a significant number of plans struggle to
remain financially viable.

Each of the four states we visited experienced varying levels of health
plan withdrawals from their Medicaid managed care programs. Plan
withdrawals over several years have affected almost 50 percent of
beneficiaries in Tennessee and over 15 percent in Ohio, raising concerns
about the accessibility of care to beneficiaries in these states. The
magnitude of health plan withdrawals in Tennessee necessitated state
efforts to recruit additional plans, at least one of which was later found
by the state to have deficiencies related to failure to pay physicians

accurately and promptly. In Ohio, at least one health plan that withdrew
from the state program also failed to pay some of its network providers
for services already rendered. In such cases, delayed reimbursement by
managed care plans can seriously jeopardize providers* willingness to
continue participating in the Medicaid program and provide services to
eligible beneficiaries. In contrast to Tennessee and Ohio, plan
withdrawals in Massachusetts and Texas have affected a smaller share of
beneficiaries. Massachusetts estimated that about 4 percent of its
beneficiaries were affected by an early period of plan fluctuation as the
state was implementing its mandatory managed care program; since 2000,
however, the program has been stable with the same four managed care plans
participating. In Texas, approximately 1 percent of beneficiaries have
been affected by withdrawals of participating plans since the state
implemented

managed care in 1996. To avoid disruptions in care for beneficiaries when
plans ceased their participation in the Medicaid program, these states had
implemented various procedures to help smooth beneficiaries* transition to
other plans or providers. For example, in cases where a withdrawing health
plan

Page 33 GAO- 03- 222 Medicaid and SCHIP Access

intended to sell its membership to another plan, Ohio first compares the
provider network of the withdrawing plan with the health plan that is
purchasing the membership. The state does not approve the sale of
membership unless most of the providers participating in the withdrawing
plan also participate in the purchasing plan. In other cases, a state*s

contract with its managed care plans required certain actions. Ohio*s
contract, for example, requires a minimum of 75 days advance notice of a
plan*s intention to terminate its participation in the program and
includes

provisions to collect a monetary assurance from the withdrawing plan or to
withhold payments until all contractual requirements are completed,
including required payments to network providers. Ohio and Texas provided
examples of efforts to inform beneficiaries directly affected by a plan*s
withdrawal about options available to them to continue care, such as
information on other participating plans and how to choose another plan.
These four states indicated that they believed their efforts to respond to
changes in managed care participation were sufficient to minimize
disruption to care for Medicaid- eligible beneficiaries. However, the
extent to which the states* efforts adequately ensured beneficiaries*
access to continuous care was uncertain. Appendix II provides more detail
on managed care plan withdrawals in these four states.

For states* FFS- based Medicaid delivery systems, which continue to serve
the majority of children in half of the states we reviewed, requirements
for participating providers and monitoring of provider availability were
significantly more limited than for managed care. State analysis of
service utilization data to assess the frequency and patterns of care that
beneficiaries received was also more limited, despite the ready
availability of such data through states* claims payment systems. For
traditional FFS programs, beneficiaries may seek care from any providers
participating in the Medicaid program and may change providers at any time
if they are dissatisfied. However, Medicaid beneficiaries* ability to
easily change providers is dependent on the number, type, and location of
providers

willing to take new Medicaid patients, which in turn is strongly
influenced by Medicaid payment rates and associated administrative
processes. We found that Medicaid FFS payment rates were significantly
lower than rates for comparable Medicare services in the majority of
states we reviewed, which can discourage provider participation and thus
restrict beneficiaries* access to a broad supply of providers. States that
used PCCM programs as part of their FFS service delivery systems were
somewhat more prone to set certain requirements for participating PCCMs,
such as a maximum number of assigned beneficiaries and their geographic
proximity to beneficiaries, than were states with traditional For Medicaid
FFS,

State Requirements for Providers and Monitoring of Service Utilization
Were More Limited

Page 34 GAO- 03- 222 Medicaid and SCHIP Access

FFS systems. States with FFS programs generally did not set requirements
for specialists or for physicians* appointments, such as maximum waiting
times to schedule an appointment, as they did for their managed care
plans. States were more likely to conduct beneficiary satisfaction surveys
for their PCCM programs than for their traditional FFS systems; the survey
results, however, had the same constraints as previously discussed for
managed care due to the limited share of beneficiaries participating in
the surveys and low response rates.

States are required to ensure that their Medicaid service delivery and
payment systems will afford beneficiaries access to services similar to
those provided to the state*s general population. To do this, states
determine which providers may enroll in the Medicaid program to provide
services, set payment rates for covered services, and pay claims that
providers submit for the services they provide. In several of the states
we reviewed with Medicaid FFS programs, program officials said that
provider survey information and beneficiary complaint data suggested that
low payment rates, slow payment, and other administrative issues

deterred physicians in primary care or in some specialties from
participating in the program. As we reported earlier, if payment rates
decline to the point that they cause physicians to leave Medicaid or to
reduce the number of beneficiaries they serve, then beneficiary access may
be restricted. 33 Our analysis of payment rates indicated that Medicaid
FFS payments to

physicians for primary and preventive services for children were often
significantly lower than what Medicare paid for comparable services in
many of the states we reviewed. For the 13 states that paid physicians on
a FFS basis for Medicaid- eligible children, payment rates ranged from 32
percent to 89 percent of Medicare rates. Nine of these states* Medicaid
rates were two- thirds or less of Medicare rates for comparable services.
(See app. III for more detail.) Officials in many of these states said
that Medicaid rates were also below those of commercial payers, although
they generally had not conducted systematic studies to document these
differences.

33 See U. S. General Accounting Office, Medicaid and SCHIP: States*
Enrollment and Payment Policies Can Affect Children*s Access to Care, GAO-
01- 883 (Washington, D. C.: Sept. 10, 2001). Low FFS Payment Rates

Can Reduce Provider Participation and Restrict Access to Care

Page 35 GAO- 03- 222 Medicaid and SCHIP Access

Despite the potential for low FFS rates to limit the number of providers
willing to participate in the program, the nine states we reviewed with
traditional FFS programs did not set specific goals for the number of
physicians participating in their Medicaid programs and did not actively
monitor the number and location of providers. 34 While states had lists of
physicians who were enrolled as Medicaid providers and who submitted
claims for services provided, in most cases these lists were not
frequently or comprehensively updated and thus did not provide an accurate
count of actively participating physicians. Some states* Medicaid
physician

databases included physicians who had not provided services to Medicaid
patients for years. In one state, the database doublecounted providers who
had more than one service location or billing identifier. In addition,
although states have claims data that serve as the basis for paying
providers for services rendered, only some analyzed this information to
identify PCPs, specialists, or other providers who were actively treating
Medicaid beneficiaries. Even when they did, states often defined *active*
providers to include those who submitted a single claim during the past
year. With respect to appointments, such as maximum waiting times to
schedule a routine or urgent appointment, none of the states we reviewed
with traditional FFS programs had specific standards comparable to those
we saw for managed care programs.

States also did little to monitor service utilization by Medicaid
beneficiaries participating in traditional FFS care despite having a ready
source of data in their claims payment systems. Claims data contain the
type and frequency of services Medicaid beneficiaries have received and

the type of provider delivering the care, which can be used to analyze
service utilization. States did report using claims data to develop
utilization statistics to meet federal requirements for annual reporting
on EPSDT services for children. However, we have reported earlier that
state EPSDT reports are often incomplete and unreliable, thus compromising

their utility in assessing whether children are receiving required
services. 35 Beyond EPSDT, only one state with a Medicaid traditional FFS
system reported analyzing claims data to evaluate access to care on
primary and

34 These nine states were California, Colorado, Illinois, Louisiana,
Nevada, New York, Ohio, Texas, and Washington. The share of Medicaid-
eligible children participating in these states* traditional FFS programs
ranged from a low of about 30 percent in California and Colorado to about
90 percent in Illinois and Louisiana. (See table 2 for more detail by
state.)

35 GAO- 01- 749. Most Traditional FFS

Programs Set Few Goals Regarding the Number of Providers, and Conducted
Minimal Monitoring of Service Utilization

Page 36 GAO- 03- 222 Medicaid and SCHIP Access

preventive services, such as annual well- child and dental visits. 36
Rather than evaluate access to primary care, at least three states used
claims data to assess inappropriate utilization of higher- cost services,
such as emergency room care. For example, Texas collects and analyzes
information on beneficiaries who potentially overuse care* defined as
those at or above the 90th percentile of use for particular services,
including physician, emergency room, and pharmacy services. Patients
suspected of misusing services may be restricted to using a specific
physician or pharmacy, with the goal of reducing their use of services to
a more appropriate level. Four of the nine states with traditional FFS
systems reported periodically using beneficiary satisfaction surveys, such
as CAHPS, to help assess

issues regarding access to care. These states were Colorado, Illinois,
Ohio, and Washington. As with Medicaid managed care, however, the utility
of these surveys is diminished when there are low response rates and a
lack

of beneficiary representation in the sample selection. In one state, the
survey sample was limited to individuals who had received at least one
service in the prior 6 months, thus excluding individuals who may have
tried but failed to obtain services. Another state reporting a low
beneficiary response rate found that while the cooperation rate was high
among those who were reached, many potential respondents in the survey
sample could not be contacted because of address or telephone number
changes.

States* PCCM programs are a hybrid of FFS and managed care service
delivery approaches. They emulate FFS programs in the sense that the state
has a direct relationship with providers who are enrolled to participate
in the program and paid retrospectively for services actually delivered.
PCCM programs share characteristics of managed care in the sense that
beneficiaries are assigned to a PCCM* a physician, or a practice or other
entity* that is responsible for coordinating their care as a case manager.
The seven states we reviewed with PCCM programs had more requirements for
participating PCCMs than they did for providers in traditional FFS
programs, but fewer than PCPs in managed care

36 Since 1995, Ohio has used HEDIS primary care access measures for
beneficiaries in its traditional FFS program. PCCM Programs Had Some
Requirements for

Providers, but Monitoring of Service Utilization Was Limited

Page 37 GAO- 03- 222 Medicaid and SCHIP Access

programs. 37 Similar trends were evident in terms of states* routine
monitoring of PCCM availability and beneficiaries* service utilization:
more than FFS, less than managed care.

The states we reviewed with Medicaid PCCM programs most often set
requirements for the maximum number of beneficiaries that a PCCM could
serve and the geographic proximity of PCCMs to their enrolled
beneficiaries. None set limits on the number of beneficiaries a specialist
could serve, and few set specific standards for appointment waiting times
with their PCCMs; overall, PCCM programs had fewer standards than those
imposed under managed care, as shown in figure 3.

Figure 3: Selected Requirements for Medicaid PCCM Providers in Seven
States a This type of standard exists in this state*s managed care program
but not its PCCM program. b This type of standard exists in the state*s
PCCM program, but not its managed care program.

37 The seven states we reviewed with PCCM programs were Arkansas,
Colorado, Florida, Louisiana, Massachusetts, Pennsylvania, and Texas.
Arkansas and Louisiana do not have Medicaid managed care programs other
than PCCM, whereas the other five states do. The share of Medicaid-
eligible children participating in the seven states* PCCM programs

ranged from a low of 12 percent in Louisiana to a high of 100 percent in
Arkansas. (See table 2 for more detail.)

State Arkansas Colorado Florida Louisiana Massachusetts Pennsylvania Texas
Total

Source: GAO analysis of states* data, as of December 2001. 5 05 2 2 3

a a a a a

a a a

b b a a

d d a

b

Number and location of providers Appointment waiting times PCCMs
Specialists Geographic

distribution First visit Appointment

scheduling In- office

waiting time

Ye s No

Page 38 GAO- 03- 222 Medicaid and SCHIP Access

States* PCCM capacity requirements were most often based on setting a
maximum number of beneficiaries that a PCCM or practice could serve,
ranging from 1,000 beneficiaries per PCCM in Arkansas and Pennsylvania to
1,500 in Florida and Massachusetts. Louisiana set a limit of 1,200

beneficiaries per PCCM, or 4,800 for a group practice, and allowed an
additional 300 beneficiaries to be enrolled for each nurse practitioner.
With regard to geographic requirements, all five of the PCCM programs that
had requirements for this standard specified a basic maximum of 30

minutes or 30 miles for beneficiaries to reach their PCCMs. Four of these
states set a higher maximum for rural areas* such as 50 miles in Colorado
or 60 minutes in Pennsylvania* or allowed general exceptions to the 30-
minute standard for beneficiaries living in some rural areas.

States typically monitored provider participation in their PCCM programs
by compiling weekly or monthly lists of participating PCCMs and the number
of beneficiaries each PCCM was assigned, which could serve as the basis
for paying the monthly PCCM fee. Monitoring these relative numbers also
allowed states to ascertain whether PCCMs could be assigned additional
beneficiaries. States therefore had current information on those providers
actively participating as PCCMs and the numbers of assigned beneficiaries.
This information alone, however, would not yield insights into how easily
beneficiaries could see their PCCMs. When states had both managed care and
PCCM delivery systems, they less

frequently set requirements for PCCM appointment waiting times than they
did for managed care. 38 Three states that operated both PCCM and managed
care programs* Colorado, Florida, and Pennsylvania* did not set any
appointment waiting time standards for PCCMs as they did for managed care.
In contrast, Massachusetts required its PCCMs to see new patients within a
specific time frame in its PCCM program, but not in managed care. Of the
four states that did set specific requirements for appointment waiting
times, only Texas reported conducting routine monitoring to assess PCCM
compliance with those requirements. Texas officials reported conducting
audits of a random sample of 20 PCCMs per quarter per service area to
evaluate compliance with respect to appointment scheduling and in- office
waiting time.

38 Some states* contracts with PCCMs may include a general requirement
that PCCMs provide care on a *timely basis.*

Page 39 GAO- 03- 222 Medicaid and SCHIP Access

To monitor service utilization within their PCCM programs, states most
often relied on analyses of their FFS claims data. Six of the seven states
with PCCM programs provided PCCMs that had a certain minimum number of
assigned beneficiaries with periodic data profiles that compare service
utilization patterns in their Medicaid practices with those of the overall
program or other PCCMs. 39 These data profiles often focused on high- cost
services or those at risk of overutilization, such as inpatient
hospitalization or emergency room use. Three states also included
information related to primary and preventive services use. For example,
see the following.

 Massachusetts provided PCCM practices that had 200 or more enrolled
beneficiaries with practice- specific and comparative information about
the percentage of children who received a recommended number of well-
child visits, by age group. The state further identified, for each
practice, individual patients who had not received the recommended number
of well- child visits. State program staff members met with each provider
twice annually to discuss approaches to address problems identified in
these data that may indicate limited access.  Texas provided
participating PCCMs with comparative information on

selected services per beneficiary, including EPSDT visits, family
planning, and immunizations.

In contrast, states typically did not monitor the utilization of services
provided by specialists, although several state PCCM programs required
documentation of PCCM referrals to specialists. Officials in several
states were aware of problems with access to some types of providers and
specialists in their PCCM programs, including dentists, dermatologists,
and pediatric neurosurgeons. In an attempt to address such problems,
Arkansas conducted a survey of dentists and Florida conducted a survey of
physicians to identify obstacles to their willingness to accept Medicaid
patients. While such one- time surveys can provide insightful information
about problems and potential solutions in a specific period, they do not
take the place of routine or targeted monitoring that can more
systematically pinpoint problems for particular specialties, geographic
areas, or beneficiaries.

39 Targeting such profiles and analyses to PCPs with a certain minimum
volume of beneficiaries allows more meaningful data comparisons with the
program and other PCPs than would be possible for PCPs with only a few
beneficiaries.

Page 40 GAO- 03- 222 Medicaid and SCHIP Access

Each of the states we reviewed with PCCM programs conducted beneficiary
satisfaction surveys. In addition, Colorado administers its CAHPS survey
to individuals participating in all three of the states* Medicaid service
delivery systems* managed care, traditional FFS, and PCCM* in order to
help assess experiences of program beneficiaries

relative to one another. However, given the shortcomings identified
earlier* low response rates and exclusions of certain beneficiaries from
sample selection* states could not with confidence generalize the results
of these beneficiary surveys to the larger population.

States have used the flexibility provided by SCHIP to take varying
approaches for their service delivery systems for eligible children. Of
the 16 states we reviewed, 9 states chose to serve their SCHIP
beneficiaries through programs that were primarily designed as expansions
of Medicaid or modeled on their Medicaid programs in terms of benefits and
provider networks. 40 These 9 states used the same health plan contracts
for Medicaid and SCHIP managed care, and the same provider lists for both
programs* FFS- based delivery systems. In these cases, the extent of SCHIP
monitoring would mirror that of the states* Medicaid programs. On the
other hand, 7 states designed at least part of their SCHIP programs to be
distinct from Medicaid. These programs relied almost exclusively on
managed care to deliver services. Although most of these states also had

significant shares of their Medicaid beneficiaries in managed care, they
set significantly fewer provider network requirements for their distinct
SCHIP programs than for Medicaid and did less monitoring of providers
enrolled in their SCHIP programs and of children*s use of services in
SCHIP. In general, few states with distinct SCHIP programs routinely
collected and analyzed data to ensure that SCHIP- eligible children were
receiving covered services.

40 These states were Arkansas, Illinois, Louisiana, Maryland,
Massachusetts, Nevada, Ohio, Tennessee, and Washington. Distinct SCHIP

Programs Had Fewer Network Requirements and Less Monitoring of Service
Utilization

Page 41 GAO- 03- 222 Medicaid and SCHIP Access

The seven states that chose to serve all or most of their SCHIP
beneficiaries through programs that were distinct from Medicaid used
managed care delivery systems almost exclusively. 41 These states were not
bound by access- related requirements comparable to those for Medicaid
PCCM or managed care programs. As such, they set provider network
requirements and monitored service utilization less often in their
distinct SCHIP managed care programs than they did in their Medicaid
managed care programs. As shown in figure 4, only two of these seven
states set specific beneficiary- to- PCP ratios for SCHIP, compared to
five states for Medicaid, and no state set specific requirements for
specialists, compared to three states for Medicaid. Similarly, only one of
the seven states with distinct SCHIP programs set a maximum waiting time
for a first appointment with a PCP and none had a requirement for in-
office waiting times; in contrast six of these states* Medicaid managed
care programs set specific requirements for one or both of these access
measures. Only four of the distinct SCHIP programs in these states set any
specific standards

for appointment scheduling, compared to all seven of the states* Medicaid
managed care programs.

41 These states were California, Colorado, Florida, Michigan, New York,
Pennsylvania, and Texas. With the exception of Florida, all of the states
used managed care delivery systems for all of their SCHIP programs;
Florida enrolled a small number of SCHIP children into a PCCM program.
States with SCHIP Programs Distinct from

Medicaid Set Few Provider Requirements

Page 42 GAO- 03- 222 Medicaid and SCHIP Access

Figure 4: Comparison of Seven States* Requirements and Standards for
Providers in Medicaid and SCHIP Managed Care

Note: Table does not include Medicaid and SCHIP programs that have only a
general requirement that health plans* networks be adequate to serve their
members. a Although the state did not have a specific standard, it did
require plans to monitor this measure.

b Florida*s separate SCHIP programs vary by beneficiary age category. The
SCHIP column in this table refers to the program for older children, as
the program for children under age 5 is modeled after Medicaid and thus
has the same standards as the Medicaid program. c Michigan*s data reflect
its arrangement with all participating health plans except for one plan,
which

operates under different requirements.

The seven states with distinct SCHIP programs also monitored the
availability of PCPs in plan provider networks less frequently than in
Medicaid. In contrast to Medicaid managed care where nearly all states
monitored providers at least quarterly, just three states required plans
to submit provider lists periodically throughout the year* Colorado, New
York, and Texas. To confirm provider information submitted by plans
participating in SCHIP, only New York systematically contacted physicians

State

California Colorado Florida b Michigan c New York Pennsylvania Texas
Number of states with standards for Medicaid

Number of states with standards for SCHIP

Source: GAO analysis of states* data, as of December 2001. 5

2 3 7

6 0 5

1 4

0 7

4 a

a

Network size and structure Appointment waiting times PCP Specialists
Geographic

distribution First visit Appointment

scheduling In- office

waiting time

Medicaid managed care provider availability standard SCHIP provider
availability standard No standard for Medicaid or SCHIP

Page 43 GAO- 03- 222 Medicaid and SCHIP Access

to verify information about whether network PCPs were accepting new SCHIP
patients. 42 Four states required SCHIP plans to submit physician data
annually or every several years during state licensure reviews or for the
contract renewal process. Among these, California*s SCHIP program required
plans to indicate the number and percentage of PCPs and specialists
accepting new patients and also to notify the state when there was a
change in the provider network that resulted in disruption of 25 or more
beneficiaries.

The extent of states* monitoring of participating plans* SCHIP provider
networks did not appear to be related to whether SCHIP- eligible
beneficiaries had access to commercial or noncommercial networks within
the plans. Some states* such as New York and Texas* did not know whether
SCHIP- eligible beneficiaries had access to the same providers as were
participating in plans* commercial networks. Other states* such as
Florida, Michigan, and Pennsylvania* stated that most if not all of their
SCHIP populations did have access to the same providers as in the plans*
commercial networks. However, without direct monitoring of PCPs enrolled
in SCHIP plan networks, states had little or no direct knowledge of the
extent to which PCPs would see SCHIP beneficiaries, including whether
enrolled PCPs would accept new SCHIP patients at all or limited their
practice to only a small number.

States with SCHIP programs distinct from Medicaid reported fewer efforts
to monitor children*s utilization of services than in their Medicaid
managed care programs. This held true for their use of encounter data as
well as for HEDIS measures and CAHPS beneficiary satisfaction survey data.

CMS does not require states to collect encounter data from managed care
plans participating in SCHIP, as it does in Medicaid managed care. Of the
states we reviewed with distinct SCHIP programs, we found that two states*
Florida and Texas* were attempting to collect as well as analyze encounter
data for SCHIP- eligible children in order to assess the type and
frequency of services they received. Florida*s distinct SCHIP program uses

encounter data to compare the number of ambulatory visits made by SCHIP
beneficiaries to the number of visits that would be expected for

42 To achieve this purpose, the state contacted a sample of 50 to 200
providers for each plan participating in Medicaid and SCHIP, twice a year.
Distinct SCHIP Programs Monitored Service

Utilization Less than Medicaid

Page 44 GAO- 03- 222 Medicaid and SCHIP Access

those children based on their diagnoses. 43 Texas* distinct SCHIP program,
which was initiated in 2000, has used encounter data to compare
immunization rates by plan with rates in commercial plans.

Four of the seven states* California, Michigan, New York, and
Pennsylvania* required plans to submit HEDIS data so that the states could
assess plans* performance with respect to access to various preventive and
other services. 44 Compared to Medicaid, these HEDIS data may be more
complete in three of these states* California, Michigan, and Pennsylvania*
because they had opted to provide SCHIP- eligible children with continuous
eligibility for a 12- month period, thus increasing the

likelihood that a more representative share of eligible children and their
families would be included in the assessments.

Five of the seven states* California, Florida, Michigan, Pennsylvania, and
Texas* used CAHPS to assess beneficiaries* satisfaction with care.
Compared to Medicaid, the CAHPS data for four of these states* SCHIP
programs may be more complete than for their Medicaid programs because
these states provide continuous eligibility for a 12- month period. We
provided a draft of our report for comment to HHS, as well as to

Medicaid and SCHIP officials in the 16 states included in our analysis. We
received comments from HHS and from 13 states. Three states did not
respond with comments.

With regard to states* Medicaid managed care programs, HHS highlighted new
requirements included in CMS*s June 2002 regulation implementing Medicaid
managed care provisions of the Balanced Budget Act of 1997. HHS commented
that, among other things, the regulation requires states to develop a
quality strategy setting access standards for network adequacy and
timeliness of access to care. HHS described this new regulation as

also making clear the states* responsibility to continually monitor plans*
compliance with these standards. While many states, including 13 of the 14
43 Florida*s distinct SCHIP program uses the Ambulatory Care Groups (ACG)
Case- Mix

Adjustment System to assign beneficiaries to 1 of 53 ACG categories for
the purpose of this analysis. 44 Although these four states used HEDIS in
both their separate SCHIP and Medicaid programs, only New York reported
comparing the results across the two programs. Agency and State

Comments and Our Evaluation

HHS Comments

Page 45 GAO- 03- 222 Medicaid and SCHIP Access

states we reviewed with Medicaid managed care delivery systems, were
already subject to certain access requirements as a condition of receiving
waivers of federal Medicaid requirements to operate their managed care

programs, these requirements were not consistent from state to state. This
new regulation, which must be fully implemented by August 13, 2003, has
the potential to bring a more systematic approach to access requirements.
More importantly, its emphasis on state monitoring could better ensure
that such requirements are achieving their intended purposes.

For states* Medicaid FFS delivery systems, HHS acknowledged the
relationship between reimbursement rates and provider participation,
noting that states can increase payment rates in geographic areas and
specialties where access has been demonstrated to be a problem. Beyond
reimbursement rates, HHS commented that our draft report pointed out a

lack of data to quantify whether there is an access problem in Medicaid
FFS. To the contrary, our report indicates that despite a ready source of
information* claims data* for evaluating access to care in a FFS
environment, states generally did not do so.

HHS agreed that our placement of PCCM programs in the FFS category was
accurate from a reimbursement standpoint, but stated that PCCM should be
considered a managed care delivery system because PCPs are expected to
coordinate care. We continue to believe that a PCCM program is better
described as an FFS- based delivery system because the differences between
PCCM and managed care reimbursement approaches can differentially affect
provider incentives in providing covered services. Our report does
distinguish, however, the degree to which managed care,

traditional FFS, and PCCM programs employ access standards and monitoring.
Overall, states with PCCM programs tended to establish more standards and
conduct somewhat more monitoring than for their traditional FFS programs,
but less than for their managed care programs.

With regard to our finding that states with distinct SCHIP programs did
significantly less to monitor access to care than for their Medicaid
managed care programs, HHS stated there was a key difference in design and
intent by the Congress between SCHIP and Medicaid. HHS commented that
SCHIP allows states to have the flexibility to design programs that mirror
private insurance and rely on private insurance mechanisms to ensure
access to and quality of care, rather than laying out specific
requirements. Acknowledging that states may not have comparable
requirements for SCHIP and Medicaid monitoring provider participation and
beneficiary service utilization, HHS said that states are monitoring
enrollment, health access, and outcomes in their SCHIP

Page 46 GAO- 03- 222 Medicaid and SCHIP Access

programs. However, with regard to access, we found that few states with
distinct SCHIP programs monitored provider network participation or
routinely collected and analyzed data to ensure that SCHIP- eligible
children were receiving covered services. We did not intend to suggest
that states should use the same processes for their SCHIP and Medicaid
programs, but rather simply to contrast states* monitoring of access to
care for low- income children eligible for these two programs.

HHS*s comments are reprinted in appendix IV. Additionally, HHS provided
technical comments, which we incorporated as appropriate.

Several states provided clarifying comments regarding their oversight of
access to care in Medicaid and SCHIP. These comments generally pertained
to additional factors affecting access to care, the relationship between
monitoring and access, and the extent of monitoring in traditional FFS and
distinct SCHIP programs.

Two states identified factors that affect access to care within their
Medicaid and SCHIP programs but are not easily controlled by the states.
One state noted that the supply of physicians is severely limited in some
states and in some regions of states, affecting all payers, including
commercial payers as well as Medicaid and SCHIP. Another state raised the
point that the extent to which children receive health care services is
influenced by how well their parents or guardians understand and comply
with recommended levels of health care set by providers or by the Medicaid
program. We agree that provider supply and parental decision making are
important determinants in children*s access to care and can be difficult
factors for state programs to address. However, the type of

monitoring activities addressed in this report can help to identify such
factors and areas or locations where problems may be more pronounced, thus
leading to more targeted solutions.

Four states identified certain activities that they believed facilitated
access to care, but were not addressed in the report. One state, for
example, noted that its Medicaid program helped beneficiaries locate a
source of medical care, and another state described an initiative to send
letters to parents of beneficiaries reminding them to schedule medical
appointments. Although we recognize that these activities may help promote
access to care for the Medicaid and SCHIP populations, this report did not
address activities that primarily facilitated access, such as providing
outreach to beneficiaries or offering provider payment incentives.
Instead, we focused on states* efforts to (1) establish and State Comments

Page 47 GAO- 03- 222 Medicaid and SCHIP Access

monitor requirements for provider availability and (2) gather and analyze
data on receipt of care. In this regard, one state commented that the
report had a *narrow perspective* on what constitutes monitoring in
managed care and cited a range of indicators that it used, including
beneficiary complaints, grievance reports, state fair- hearing requests,
utilization data, and immunization rates. While such sources of data and
activities hold strong potential for providing information concerning
access to care, this report identified certain shortcomings of some of
these indicators as programwide measures of access. For example, complaint
and grievance system data can yield important information about
problematic providers

or services, but are not reliable measures of programwide access. Four
states cautioned against what they saw as a correlation made in the report
between the amount of monitoring that a state does and the degree of
access to care for program beneficiaries. For example, one state said that
the report suggested that if monitoring is limited, access is also
limited, and disagreed that this is necessarily the case. We did not
intend to present such a direct correlation. However, if a state does not
monitor data related to its access standards and to utilization of
services, it may not know the extent to which beneficiaries encounter
problems locating and obtaining services. During the course of our work,
we identified instances where state data collection and monitoring
revealed access problems that were then addressed to improve beneficiary
access.

A few states emphasized that they considered HEDIS and CAHPS important
tools that had helped them monitor health plan performance or achieve
improvements in quality of care for Medicaid and/ or SCHIP beneficiaries.
One state noted that HEDIS was important in identifying and helping to
reduce gaps between commercial and Medicaid plan performance. Another
state questioned whether the continuous enrollment requirements for HEDIS
(12 months) and CAHPS (6 months) would in fact bias the results of any
analysis of beneficiaries* access to care because it excludes some
beneficiaries. In particular, this state believed that the benefits of
improvements made by health plans are not limited to individuals enrolled
for the full 6- or 12- month period. We agree that HEDIS and CAHPS are
important tools in monitoring and comparing performance across plans,
which necessitates that the sample population be defined by a comparable
enrollment period. However, we do not

believe that states can assume that all beneficiaries have access to care
on the basis of HEDIS and CAHPS results that exclude a significant portion
of the program population from their samples.

Page 48 GAO- 03- 222 Medicaid and SCHIP Access

Two states discussed the extent to which they monitored access in Medicaid
traditional FFS compared with Medicaid managed care delivery systems. One
state said it analyzes data on key health outcomes for children, such as
ambulatory- sensitive hospital admissions and trends in health care
utilization. Both states specifically noted their efforts to comply with
federally required reporting of EPSDT utilization for their FFS programs.
Nevertheless, most of the states in our sample had few or no goals
regarding the number of providers available to FFS beneficiaries

and, with the exception of federally required EPDST reporting, few
analyzed data related to access to primary care.

Similar to HHS*s view, one state noted that the report did not account for
the fact that distinct SCHIP programs may choose approaches to program
design and monitoring that differ from Medicaid, including approaches used
in monitoring states* commercial managed care plans. For example, this
state and others reported relying on state insurance department licensure
of health plans as the means of monitoring provider network adequacy,
rather than imposing additional SCHIP- specific requirements. We
acknowledge in our report that states* SCHIP programs may rely on
different design and monitoring options than Medicaid. Overall, however,

states with distinct SCHIP programs reported fewer efforts to monitor
children*s access and use of services than in their Medicaid managed care
programs.

Several states also provided technical comments, which we incorporated as
appropriate.

As arranged with your offices, unless you release its contents earlier, we
plan no further distribution of this report until 30 days after the issue
date. At that time, we will send copies of this report to the
Administrator of the Centers for Medicare & Medicaid Services and the
Administrator of the Health Resources and Services Administration. We also
will make copies available to others upon request. In addition, the report
will be available at

no charge on the GAO Web site at http:// www. gao. gov.

Page 49 GAO- 03- 222 Medicaid and SCHIP Access

If you or members of your staffs have any questions regarding this report,
please contact me on (202) 512- 7118. Other contributors to this report
are listed in appendix V.

Kathryn G. Allen Director, Health Care* Medicaid

and Private Health Insurance Issues

Appendix I: Medicaid HEDIS Measures Related to Service Utilization

Page 50 GAO- 03- 222 Medicaid and SCHIP Access

Four of the eight general categories of the Health Plan Employer Data and
Information Set (HEDIS) measures for Medicaid managed care plan
performance relate directly to beneficiary service utilization. These four
categories include effectiveness of care, access/ availability of care,
use of services, and satisfaction with the experience of care. 1 Many of
the

measures in these categories require beneficiaries to be continuously
enrolled for some period, often 12 months, in order to be assessed. Table
8 details selected HEDIS measures that pertain to service utilization for
children and adolescents enrolled in Medicaid managed care programs and
the length of continuous enrollment required.

1 The remaining four general categories are health plan stability, cost of
care, informed health care choices, and health plan descriptive
information. Appendix I: Medicaid HEDIS Measures

Related to Service Utilization

Appendix I: Medicaid HEDIS Measures Related to Service Utilization

Page 51 GAO- 03- 222 Medicaid and SCHIP Access

Table 8: Length of Medicaid Enrollment Required for Selected HEDIS
Measures for Children*s and Adolescents* Use of Services

Category Measure name Length of continuous enrollment a Childhood
immunization status 12 months

Adolescent immunization status 12 months Cervical cancer screening 12
months Chlamydia screening 12 months Prenatal care in first trimester
About 9 months prior to delivery Checkups after delivery About 2 months
after delivery Comprehensive diabetes care 12 months

Use of appropriate medications for people with asthma 24 months Follow- up
after mental illness hospitalization 1 month after discharge
Antidepressant medication management 12 months Effectiveness of care

Advising smokers to quit 6 months Children*s access to primary care
providers 12 months b Initiation of prenatal care From 1 to 9 months prior
to

delivery c Annual dental visit 12 months Access/ availability of

care Availability of language interpretation services None Frequency of
ongoing prenatal care None Well- child visits in the first 15 months of
life From 1 to 15 months of age d Well- child visits in the third, fourth,
fifth and sixth year of life 12 months

Adolescent well- care visits 12 months Inpatient utilization* general
hospital/ acute care None Ambulatory care None Inpatient utilization*
nonacute care None Discharges and average length of stay* maternity care
None Cesarean section rate None Vaginal birth after cesarean section rate
None Births and average length of stay, newborns None Mental health
utilization* inpatient discharges and average length of stay None Mental
health utilization* percentage of members receiving inpatient, day/ night
care, and ambulatory services None Chemical dependency utilization*
percentage of members receiving inpatient, day/ night care, and ambulatory
services None Use of services Outpatient drug utilization None

Satisfaction with the experience of care Consumer Assessment of Health
Plans (adults and children) 6 months

Source: National Committee for Quality Assurance, HEDIS 2000: Technical
Specifications (Washington, D. C.: 1999). a For measures listed with a
continuous enrollment requirement, HEDIS guidelines indicate that the
managed care entity must assess on a measure- by- measure basis whether
the measure may be reported in the current measurement year. Partial year
reporting for the measures in this table was

considered acceptable or possible by the HEDIS guidelines.

Appendix I: Medicaid HEDIS Measures Related to Service Utilization

Page 52 GAO- 03- 222 Medicaid and SCHIP Access

b Older age groups (7 to 11 years) require 24 months enrollment. c Measure
requires continuous enrollment of at least 43 days prior to delivery but
no more than 279 days. d Measure requires that child is enrolled from 31
days through 15 months of age.

Appendix II: Managed Care Plan Withdrawals from Medicaid in Four States
Page 53 GAO- 03- 222 Medicaid and SCHIP Access

Four states we visited* Massachusetts, Ohio, Tennessee, and Texas* had
varying experiences in terms of the number and impact of managed care plan
withdrawals from their Medicaid managed care programs. In some cases, as
in Massachusetts, the changes occurred early in the states*

implementation of their programs and the number of plans has been stable
in recent years; in other cases, as in Ohio and Tennessee, the changes in
participating plans continued over time and presented ongoing challenges
to the states in managing their programs and ensuring appropriate access
to care for their beneficiaries. The proportion of Medicaid beneficiaries
affected by withdrawals of participating managed care plans ranged from
about 1 percent in Texas to almost 50 percent in Tennessee. Following is a

brief description of managed care plan withdrawals in each of the four
states and examples of some of the measures states took to minimize
disruption to beneficiaries* care as a result of the changes.

Health plan participation in Massachusetts* Medicaid managed care program
has slowly stabilized, with four plans participating in the program since
2000. Earlier fluctuations occurred, however, as the state shaped its
program to limit the number of participating plans and as some health
plans decided to consolidate or leave the market. These early changes in
participating plans affected about 4 percent of the state*s Medicaid
population.

Massachusetts began its current Medicaid managed care program in July 1997
with nine participating health plans. 1 Two of the health plans, created
by hospital systems that had traditionally provided services to lower

income individuals, were formed specifically for this program. Of the
remaining seven plans participating in the state*s Medicaid program, many
were commercially available. Within the first 2 years of the program,
however, the number of participating health plans declined to five. This

reduction was partially a result of the state*s decision to contract with
fewer health plans and to provide each health plan with a greater volume
of beneficiaries. As a result of this decision, contracts were not renewed

with two health plans and approximately 42,000 beneficiaries (about 4 1
Prior to 1997, Massachusetts had a managed care program with voluntary
enrollment for most Medicaid beneficiaries. As many as 13 health plans
participated in the state*s Medicaid managed care program during the early
1990s. However, since enrollment was not mandatory, only a small number of
Medicaid beneficiaries joined health plans. These low enrollment figures,
coupled with health plan consolidations, resulted in some plans leaving
the Medicaid program. Appendix II: Managed Care Plan Withdrawals from
Medicaid in Four States Massachusetts

Appendix II: Managed Care Plan Withdrawals from Medicaid in Four States
Page 54 GAO- 03- 222 Medicaid and SCHIP Access

percent of the state*s Medicaid population) had to select other plans. In
addition, during this period several health plans merged and at least one
plan left the Massachusetts health care market altogether. State officials
reported that some plans lost interest in participating because of
Medicaid*s administrative and reporting requirements. Additionally,
commercial plans found that the Medicaid benefit package included certain
services* such as behavioral health services* that the health plans did
not provide their other members. This meant that health plans had to
establish networks specifically for Medicaid beneficiaries; without a
*critical mass* of Medicaid beneficiaries, however, health plans had
difficulty remaining financially viable in the program. When participating
plans withdrew from the state*s Medicaid program, state officials said
that beneficiaries enrolled in the affected plans were informed that the
plans would no longer be participating in the program and were provided an
opportunity to choose other plans or enroll in the state*s primary care
case manager program. Since the inception of its mandatory managed care
program in 1996, Ohio has faced a large number of health plan withdrawals.
As of January 2002,

10 plans had completely withdrawn from program participation, while 3
additional plans had withdrawn from specific counties in the state. Over
224,000 Medicaid beneficiaries* over 15 percent of the state*s Medicaid
population* were affected by plan withdrawals. As a result of these
withdrawals and providers* growing reluctance to participate in managed
care, Ohio changed from mandatory to voluntary managed care enrollment in
some counties and fee- for- service (FFS) in others. As of April 2002,
Ohio had 7 managed care plans serving Medicaid beneficiaries in 15

counties, with mandatory enrollment in only 4 of the counties. Ohio
Medicaid officials expected to see some fluctuations in plan participation
in the early years of its program. They anticipated that some plans would
withdraw due to the state*s requirement that plans that did not have
significant enrollment* from 10 to 15 percent of the eligible population*
within 2 years of the program*s inception would be required to leave the
program. Several reasons were provided for the number of plans that
eventually withdrew from the program, including voluntary withdrawal and
court- ordered liquidations. In many cases, health plans sold their
Medicaid membership to other plans. State officials acknowledged that the
relatively large number of plan withdrawals affected individuals*
perception of the program and led to changes in the state*s managed care
enrollment policy, with some counties switching from mandatory to
voluntary managed care enrollment. Concerns about Ohio

Appendix II: Managed Care Plan Withdrawals from Medicaid in Four States
Page 55 GAO- 03- 222 Medicaid and SCHIP Access

the program*s viability and stability were increased when the state
insurance department liquidated one Medicaid health plan in 1998 and some
of its network providers did not receive compensation from the plan. State
officials did not believe that beneficiaries* access to care was

affected by these plan withdrawals. In cases where a health plan*s
membership was sold to another plan, the state attempted to ensure
continuity of care by requiring that at least 90 percent of the current
plan*s primary care providers (PCP) were included in the provider network
of the purchasing plan. 2 In other cases, we were told, beneficiaries were
notified of their health plan*s impending withdrawal and provided an
opportunity to select another plan if available. If a beneficiary did not

select a health plan, or there was no alternative plan available, then the
beneficiary returned to the state*s FFS program. In areas with mandatory
managed care enrollment, however, beneficiaries were not allowed to remain
in FFS indefinitely; they were required to select another plan or be
automatically assigned to one.

In establishing its mandatory managed care program in January 1994,
Tennessee expanded Medicaid eligibility to hundreds of thousands of
previously uninsured individuals and enrolled them into 1 of 12 capitated
managed care plans. Four plans left the program or were sold from 1994
through 1999. 3 Since 2001, plan withdrawals have increasingly been an
area of concern, with large numbers of Medicaid beneficiaries affected by
changes to the state*s 2 largest health plans. For example, in 2001,
almost

580,000 beneficiaries, or 41 percent of the state*s Medicaid population,
were affected when 1 plan withdrew from the western and central portions
of the state and a second plan*s contract was terminated due to solvency
issues. In response to the first of these two withdrawals, the state took
two actions: (1) it recruited two new health plans to join the market and
(2) it created a self- insured plan to serve as a backup in areas of the
state where beneficiaries could not be adequately served by other health
plans.

2 Of the beneficiaries affected by plan withdrawals in Ohio from 1996 to
January 2002, nearly half were involved in withdrawals that were the
result of a plan selling its membership to another plan.

3 Plan withdrawals during this period affected approximately 105,000
beneficiaries, about 7 percent of the state*s Medicaid population.
Tennessee

Appendix II: Managed Care Plan Withdrawals from Medicaid in Four States
Page 56 GAO- 03- 222 Medicaid and SCHIP Access

As of April 2002, 10 health plans were participating in Tennessee*s
Medicaid managed care program although 2 plans, covering 21 percent of the
state*s Medicaid beneficiaries, were considered to be at financial risk.

The state announced its intention in March 2002 to terminate its contract
with 1 health plan, which would necessitate the transfer of approximately
135,000 beneficiaries to other health plans. 4 A second plan, with over
160,000 beneficiaries, was under rehabilitation by the state*s insurance
department.

In view of the instability of the program and participating plans,
Tennessee has taken several steps to help ensure continuous access to care
for Medicaid beneficiaries. In order to provide time to plan ahead in the
event of plan withdrawals, the state*s contract with participating plans
requires 6

months of advance notice of an intended withdrawal and a transition plan
to assure uninterrupted care to beneficiaries. When plans stopped
participating in the program, beneficiaries were either provided the
option to select new health plans or were assigned to health plans. Texas
began its capitated Medicaid managed care program in1996 in four areas of
the state. Since 1996, managed care was expanded to three

additional service areas and now exists in 46 of the state*s 254 counties.
Since the rollout of managed care began, only three plans have withdrawn
from participation in Texas* Medicaid managed care program, affecting less
than 20,000 beneficiaries, or approximately 1 percent of the state*s
Medicaid population. 5 Two of these withdrawals were from the same service
delivery area, leaving three plans participating in that area. 6 However,
the state contends that prior to the withdrawals there was a

saturation of health plans in that service delivery area. As of July 2002,
11 plans were participating in the Medicaid managed care program. 4
According to the state, the decision to terminate the contract was based
on problems including the plan*s financial solvency and failure to pay
accurate and timely claims. As of

May 1, 2002, the state was working with the health plan in an attempt to
resolve these problems.

5 Over 50, 000 additional beneficiaries were affected when their health
plan was acquired by another participating health plan. 6 There are seven
service areas, each consisting of multiple counties, in Texas* Medicaid
capitated managed care program. Health plans are contracted by service
area, with some health plans having contracts in multiple service areas.
Texas

Appendix II: Managed Care Plan Withdrawals from Medicaid in Four States
Page 57 GAO- 03- 222 Medicaid and SCHIP Access

In one instance, a participating plan gave the state less than 3 weeks*
notice of its intent to leave the program. Because of the limited notice,
beneficiaries were automatically assigned to other plans in order to
minimize disruption in their access to care. Although these assignments
were initially made without direct input from the affected beneficiaries,
their prior PCP and specialist utilization patterns were taken into
account during this assignment process and beneficiaries were later given
an

opportunity to change plans. The state paid particular attention to the
number of complaints during these transition periods and did not see a
dramatic change. As such, state officials believe that the transitions
went smoothly. Texas has a number of other measures in place to facilitate
beneficiaries* enrollment in alternative plans when their plans leave the
program, as illustrated in table 9 along with additional examples from
other states we visited.

Table 9: Examples of Plan Withdrawal Transition Activities Conducted by
Four State Medicaid Programs Type of action Examples of action

Contractual requirements of managed care plans

 Massachusetts takes responsibility for notifying beneficiaries of the
health plan*s withdrawal from the program and the process beneficiaries
must undergo to continue to receive services; however, health plans must
continue to provide services until the beneficiary is disenrolled and
participating in another plan.

 Ohio*s contract requires the collection of monetary assurance or the
withholding of payments from withdrawing health plans until all contract
requirements are completed.

 Texas requires health plans to provide the state 90 days notice of their
intention to terminate participation, Ohio requires 75 days notice, and
Tennessee requires 6 months advanced notice.

 Tennessee*s contract requires withdrawing health plans to submit
transition plans to ensure uninterrupted care to beneficiaries.
Notification of beneficiaries and other stakeholders

 Ohio, Tennessee and Texas send letters to beneficiaries informing them
of the health plan*s withdrawal. The letters may include a list of the
other health plans, important telephone numbers, and actions beneficiaries
must take.

 Texas notifies stakeholders, including the enrollment broker and other
health plans, of the impending withdrawal. Remaining health plans in the
area are provided with a list of PCPs that are only participating with the
exiting plan. Additionally, the state or health plan notifies providers of
the plan*s intention to withdraw from the program. Coordination between
plans  In Texas, the withdrawing plan identifies individuals with special
needs and a dialogue

between the current and future case managers begins. In addition, the
withdrawing health plan provides instructions for providers on seeking
authorization for continued services from new health plan. Source: GAO
analysis of states* data, December 2001.

Appendix III: Analysis of Medicaid FFS Payment Rates in Selected States

Page 58 GAO- 03- 222 Medicaid and SCHIP Access

Nationally, low Medicaid physician fees have been a long- standing area of
concern because they can affect the degree to which physicians participate
in Medicaid, and thereby affect beneficiaries* access to care. The
relative fees paid by different insurers* Medicare, Medicaid, and SCHIP*
can also affect providers* willingness to participate in these programs.
Since many children in Medicaid remain in fee- for- service (FFS)- based
programs, we compared Medicaid fees for selected office visit and
pediatric preventive medical care services to the corresponding Medicare
fees. While Medicare is a federal health insurance program primarily for
the elderly and persons with disabilities, some children do

receive Medicare benefits and thus its fee schedule includes fees for
pediatric medical services. Among the 13 states we reviewed that used FFS-
based delivery systems as a key care delivery system for Medicaid
children, 1 Medicaid fees for primary and preventive care ranged from 32
percent to 89 percent of what Medicare would pay for similar services.
(See table 10.) Concerns with the adequacy of Medicaid physician payment
levels were also identified in studies of Medicaid physician payment in
California, Washington, and Maryland. 2 1 Tennessee enrolls nearly all
beneficiaries in managed care; therefore, we did not collect a Medicaid
FFS payment schedule that can be compared to Medicare rates.

2 See PriceWaterhouseCoopers, Comparing CPT Code Payments for Medi- Cal
and Other California Payers (Oakland, Calif.: June 2001) and University of
Washington, State Primary Care Provider Study, Health Policy Analysis
Program (Seattle, Wash.: February 2001). A study was also conducted in
Maryland because, even though most beneficiaries are served through
managed care, the state Medicaid program*s FFS payment rates for some
groups of beneficiaries are considered to affect what managed care plans
pay physicians. See State of Maryland Department of Health and Mental
Hygiene, Report on the Maryland Medical Assistance Program and Maryland
Children*s Health Program * Reimbursement Rates Fairness Act (Baltimore,
Md.: September 2001). Appendix III: Analysis of Medicaid FFS

Payment Rates in Selected States

Appendix III: Analysis of Medicaid FFS Payment Rates in Selected States

Page 59 GAO- 03- 222 Medicaid and SCHIP Access

Table 10: Medicaid FFS Payment Rates, Expressed as a Percentage of
Medicare Payments, in 13 States with Traditional FFS or Primary Care Case
Manager Delivery Systems That Serve Children

State a Medicaid FFS payments as a percentage of Medicare FFS payments
(weighted)

Massachusetts b 89 Arkansas 71 Florida 71 Texas 71 Nevada 66 Ohio 64
Illinois b 61 Washington 60 Colorado 57 Louisiana 57 New York b 54
California 48 Pennsylvania 32

Source: GAO analysis of Medicare data and states* data, as of December
2001. a Other study states not shown on this table include the following:
Tennessee enrolls nearly all

beneficiaries in capitated managed care, and therefore, we did not collect
a Medicaid FFS payment schedule that can be compared to Medicare rates.
Maryland uses a FFS- based delivery system for less than 5 percent of
children and includes only those children requiring case management for
rare and expensive conditions, or who are technology dependent. Michigan
uses FFS- based care only for children in an eligibility category for
special needs. b Illinois, Massachusetts, and New York provide payment
enhancements for some services, in addition to the regular fee for the
service; where appropriate, these enhancements were included in the

analysis.

For our comparative analysis of Medicaid and Medicare FFS payments, we
obtained fee schedules from 13 of the 16 states we reviewed, compiling
fees for 12 medical services using selected codes from a commonly used
procedural coding system* the standard Physicians Current Procedural
Terminology, 4th edition (CPT 4). (See table 11.) For each state, we
weighted the Medicaid and corresponding lowest Medicare fees 3 for that
state by the relative utilization of the service among pediatricians,
identified from a 1999 American Academy of Pediatrics survey. 4 The sum

3 States can have more than one Medicare payment rate for a service,
varying by locality. 4 Monique Morris and Suk- fong Tang, Pediatric
Service Utilization, Fees and Managed Care Arrangements: 2001 Report Based
on 1999 Data (Elk Grove Village, Ill.: American Academy of Pediatrics,
2001). Methodology for

Comparison of FFS Payment Rates

Appendix III: Analysis of Medicaid FFS Payment Rates in Selected States

Page 60 GAO- 03- 222 Medicaid and SCHIP Access

of the weighted Medicaid fees was then expressed as a percentage of the
sum of the Medicare payments in order to develop a single, weighted
payment rate.

Table 11: CPT 4 Codes Used in Comparing Medicaid and Medicare Fees CPT 4
code Description Office or other outpatient visit 99201 New patient, 10
minute visit

99202 New patient, 20 minute visit 99203 New patient, 30 minute visit
99213 Established patient, 15 minute visit 99214 Established patient, 25
minute visit

Preventive medical services 99381 New patient, under 1 year 99382 New
patient, 1 to 4 years 99383 New patient, 5 to 11 years 99391 Established
patient, under 1 year 99392 Established patient, 1 to 4 years 99393
Established patient, 5 to 11 years 99394 Established patient, 12 to 17
years

Source: CPT 4.

Appendix IV: Comments from the Department of Health and Human Services

Page 61 GAO- 03- 222 Medicaid and SCHIP Access

Appendix IV: Comments from the Department of Health and Human Services

Appendix IV: Comments from the Department of Health and Human Services

Page 62 GAO- 03- 222 Medicaid and SCHIP Access

Appendix IV: Comments from the Department of Health and Human Services

Page 63 GAO- 03- 222 Medicaid and SCHIP Access

Appendix IV: Comments from the Department of Health and Human Services

Page 64 GAO- 03- 222 Medicaid and SCHIP Access

Appendix V: GAO Contact and Staff Acknowledgments

Page 65 GAO- 03- 222 Medicaid and SCHIP Access

Carolyn L. Yocom, (202) 512- 4931 Catina Bradley, Karen Doran, Laura
Sutton Elsberg, Mary Giffin, Michelle Rosenberg, and Ann Tynan made key
contributions to this report. Appendix V: GAO Contact and Staff

Acknowledgments GAO Contact Acknowledgments

Related GAO Products Page 66 GAO- 03- 222 Medicaid and SCHIP Access

Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-
02- 813. Washington, D. C.: August 22, 2002.

Children*s Health Insurance: Inspector General Reviews Should Be Expanded
to Further Inform the Congress. GAO- 02- 512. Washington, D. C.: March 29,
2002.

Medicaid and SCHIP: States* Enrollment and Payment Policies Can Affect
Children*s Access to Care. GAO- 01- 883. Washington, D. C.: September 10,
2001.

Medicaid: Stronger Efforts Needed to Ensure Children*s Access to Health
Screening Services. GAO- 01- 749. Washington, D. C.: July 13, 2001.

Medicaid Managed Care: States* Safeguards for Children With Special Needs
Vary Significantly. GAO/ HEHS- 00- 169. Washington, D. C.: September 29,
2000.

Oral Health: Factors Contributing to Low Use of Dental Services by
LowIncome Populations. GAO/ HEHS- 00- 149. Washington, D. C.: September
11, 2000.

Medicaid and SCHIP: Comparisons of Outreach, Enrollment Practices, and
Benefits. GAO/ HEHS- 00- 86. Washington, D. C.: April 14, 2000.

Oral Health: Dental Disease Is a Chronic Problem Among Low- Income
Populations. GAO/ HEHS- 00- 72. Washington, D. C.: April 12, 2000.

Children*s Health Insurance Program: State Implementation Approaches Are
Evolving. GAO/ HEHS- 99- 65. Washington, D. C.: May 14, 1999.

Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort. GAO/ HEHS- 97- 86. Washington, D. C.: May 16, 1997.
Related GAO Products

(290046)

The General Accounting Office, the investigative arm of Congress, exists
to support Congress in meeting its constitutional responsibilities and to
help improve the performance and accountability of the federal government
for the American people. GAO examines the use of public funds; evaluates
federal programs and policies; and provides analyses, recommendations, and
other assistance to help Congress make informed oversight, policy, and
funding decisions. GAO*s commitment to good government is reflected in its
core values of accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no cost
is through the Internet. GAO*s Web site (www. gao. gov) contains abstracts
and fulltext files of current reports and testimony and an expanding
archive of older products. The Web site features a search engine to help
you locate documents using key words and phrases. You can print these
documents in their entirety, including charts and other graphics.

Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as *Today*s Reports,* on its
Web site daily. The list contains links to the full- text document files.
To have GAO e- mail

this list to you every afternoon, go to www. gao. gov and select
*Subscribe to daily E- mail alert for newly released products* under the
GAO Reports heading.

The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent of
Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
copies mailed to a single address are discounted 25 percent. Orders should
be sent to: U. S. General Accounting Office 441 G Street NW, Room LM
Washington, D. C. 20548 To order by Phone: Voice: (202) 512- 6000

TDD: (202) 512- 2537 Fax: (202) 512- 6061

Contact: Web site: www. gao. gov/ fraudnet/ fraudnet. htm E- mail:
fraudnet@ gao. gov Automated answering system: (800) 424- 5454 or (202)
512- 7470 Jeff Nelligan, managing director, NelliganJ@ gao. gov (202) 512-
4800

U. S. General Accounting Office, 441 G Street NW, Room 7149 Washington, D.
C. 20548 GAO*s Mission Obtaining Copies of

GAO Reports and Testimony

Order by Mail or Phone To Report Fraud, Waste, and Abuse in Federal
Programs Public Affairs
*** End of document. ***