Administrative Oversight of State Medicaid Payment Policies: Giving Teeth to the Equal Access Provision

Article excerpt

Introduction   I. Deconstructing Medicaid      A. The History and Development of Medicaid      B. The Operation of Medicaid: A Federal and State         Partnership         1. State Medicaid Plans         2. Provider Payment Rates            a. The Equal Access Provision            b. Enforcing the Equal Access Provision  II. Assessing the Administrative Enforcement Scheme with      Respect to the Equal Access Provision      A. SPA Process      B. Compliance Action III. Strengthening CMS' Oversight of States' Medicaid      Provider Payment Rates      A. Require and Enforce Prior Approval of Medicaid         Rate Cuts      B. Benchmark Medicaid Rates to Medicare Conclusion 

INTRODUCTION

After enrolling in the Illinois Medicaid program, the public health insurance program for poor and disabled Americans, Tessinia Rodriguez and Elissa Bassler both sought a physician referral from the Medicaid hotline. (1) The hotline gave Rodriguez the names of approximately ten doctors, all of whom practiced more than thirty miles from her home; not one accepted Medicaid. (2) Bassler received the names of eight doctors, none of whom accepted Medicaid. (3) Benita Branch had difficulty finding a doctor to treat her children on Medicaid, and when she finally did, the doctor did not schedule appointments. (4) Branch had to bring her children into the doctor's office and take a number, often waiting more than an hour--and sometimes several hours--before being seen. (5) Sara Mauk was able to find a doctor that would see her daughter; however, the doctor required Medicaid patients to wait until after all privately insured patients had been seen. (6)

Over sixty million low-income individuals rely on Medicaid for their health insurance coverage. (7) The majority of Medicaid beneficiaries are parents and children. (8) The most medically needy and costly are the elderly and disabled. (9) For both groups, however, Medicaid is intended to be a lifeline to essential health and medical care. (10) Although Medicaid patients have freedom of choice to select among participating providers, (11) physicians also have freedom of choice to participate in Medicaid. (12) Congress has recognized that "without adequate payment levels, it is simply unrealistic to expect physicians to participate in the [Medicaid] program." (13) In fact, low reimbursement rates have led many physicians and particularly specialists to stop treating Medicaid patients. (14)

Despite the well-established correlation between Medicaid provider payments and physicians' willingness to treat Medicaid recipients, states continue to make budget-driven cuts to their Medicaid provider reimbursement rates. (15) Although the economy is improving slowly, states still face a dire fiscal situation and growing Medicaid costs are a key contributor to state budget gaps. (16) As a result, nearly every state has proposed or implemented cuts to Medicaid in their 2011-2012 budget year, reducing payments to doctors, hospitals and other health care providers that treat Medicaid patients. (17) As the stories of Tessinia Rodriguez, Elissa Bassler, Benita Branch, and Sara Mauk exemplify, cuts to state Medicaid programs can make it difficult, and sometimes impossible, for Medicaid patients to find a doctor who will see them. (18) Cuts in reimbursement rates for providers can and have resulted in dramatic consequences for Medicaid patients. (19) For example, in a highly publicized case, a hospital in Clare, Michigan closed its obstetrical unit in direct response to the state's inadequate Medicaid payments. (20)

Congress enacted Medicaid in 1965 to ensure that poor and disabled Americans had access to "mainstream" and often life-saving medical services. (21) The goal was to provide beneficiaries with meaningful access to medical services, not merely a Medicaid card. (22) Title XIX of the Social Security Act, 42 U.S.C. [section] 1396 (Medicaid Act) gives individuals who meet Medicaid eligibility requirements a legal right to have payments made to their providers for their needed medical services. …