U.S. Senator Bob Casey (D-PA) has requested that the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) open a review of managed care organizations (MCOs) that manage Medicaid services. ANCOR is flagging this issue because states and MCOs are increasingly becoming interested in transitioning Medicaid supports for people with intellectual / developmental disabilities (I/DD) to managed care systems. I/DD supports have traditionally kept out of managed care because of the unique needs of the individuals who receive these benefits.
As written in the letter sent by Senator Casey’s office:
“Reports from across the country have surfaced alleging that some Medicaid managed care companies (MCOs) continuously deny care to patients sorely in need of care. In some cases, patients have experienced entirely preventable life-altering harms. Due to concerns that some MCOs are putting their bottom line ahead of patient health and safety, I am requesting that you open an investigation into this industry to shed light on whether all patients enrolled in Medicaid managed care can successfully access the services to which they are entitled. I am also requesting that the investigation review the Centers for Medicare & Medicaid Services’ (CMS) role in providing sufficient and appropriate oversight to ensure that people with Medicaid are receiving the care that they are entitled to.
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As states turn to MCOs to manage their Medicaid portfolios, we have a sacred responsibility to ensure that patients, like D’ashon and Betty, have access to the care they need. Given these concerns, I request that you conduct a review of the Medicaid MCO industry to determine whether these companies are meeting their obligations to serve children, older adults, people with disabilities and their families. Specifically, I encourage the Office of Inspector General to address the following questions:
1. Have Medicaid MCOs knowingly denied care to enrollees that should have been covered?
2. Do Medicaid MCOs systemically deny care to patients? Further, do parent companies develop care denial protocol and distribute that protocol to subsidiaries?
3. Are people enrolled in Medicaid MCOs able to successfully navigate the appeals process? Further, do Medicaid MCOs respond in an adequate and timely manner to appeal requests?
4. Are people enrolled in Medicaid MCOs able to successfully issue grievances? Further, do Medicaid MCOs respond diligently and substantively to grievances brought forward by their enrollees?
5. Are children, people with disabilities, older adults and other individuals with complex conditions, who were historically not covered by managed care companies, adequately served by Medicaid MCOs?
6. Do children, people with disabilities, older adults or individuals with complex or chronic conditions face additional hurdles in gaining access to care from Medicaid MCOs? Are these individuals denied access to care at higher rates than other people enrolled in Medicaid MCOs?
7. Has CMS conducted sufficient oversight of to ensure that Medicaid MCOs are adequately meeting their obligations to provide access to care for people enrolled in Medicaid MCOs?
8. What type of data should CMS ensure states collect and analyze to ensure that patients are not inappropriately denied care?”