Improve Medicaid HMO Provider Networks, Directories

TMA Testimony:  SB 760 – Medicaid HMO Network Adequacy

House Human Services Committee

May 11, 2015

Submitted on behalf of:
Texas Medical Association, Texas Pediatric Society
Texas Academy of Family Physicians, Texas Association of Obstetricians and Gynecologists
American College of Obstetricians and Gynecologists – Texas Chapter,
Federation of Texas Psychiatry  

Thank you for the opportunity to provide comments on Senate Bill 760, which will vastly improve oversight and accountability regarding Medicaid HMO provider networks.  Our organizations strongly support this bill.

Texas’ foray into Medicaid managed care began more than 20 years ago with the promise that such plans would, in part, help improve Medicaid patients’ access to services. Indeed, the state contractually obligates these health plans to establish adequate network of providers, including primary, specialty, and behavioral health physicians. But that contractual requirement has not always been evident to physicians trying to obtain needed care for their patients. 

Of all the complaints our organizations receive about Medicaid managed care, one of the most frequent is that physicians cannot obtain timely, Medicaid HMO in-network specialty care for their patients. In fact, in TMA’s 2014 physician survey, 53 percent of physicians reported it is extremely difficult to find such services. 

While some Medicaid HMOs do a better job than others on network adequacy, the worst-performing plans give the entire program a black eye. Worse, physician frustration with the Medicaid HMOs only further fuels the physician exodus from the HMO networks.

SB 760 will implement several important reforms to improve Medicaid HMO transparency and accountability regarding access to physicians and providers. We particularly support language in the bill directing the Health and Human Services Commission (HHSC) to establish a new network adequacy standard based on the patient’s geographic location and the number and distribution of providers within the region. Such a standard is akin to the standards required of Medicare Advantage plans, and we feel it is better suited to a low-income population. The current Medicaid access standards — 30 miles for primary care and 75 miles for specialty care — were adapted from the Texas Department of Insurance’s standard for commercially insured patients. The standards are easily gamed. For example, our organizations regularly hear about Medicaid patients in San Antonio traveling the 75 miles to Austin for specialty care and vice versa rather than being treated within their own community. Moreover, many Medicaid patients find it difficult to travel these distances because they cannot easily take off from work or do not have reliable transportation.

Another common frustration is that the Medicaid HMO provider directories, including electronic directories, are often outdated and inaccurate. This means physicians and their staff must spend time contacting other practices to find out who is actually accepting new patients. Of the practices that will accept new patients, some have met their limit for the month or cannot see the patient within a reasonable timeframe. Without timely access to specialty care, the primary care physician (PCP) is often put in the uncomfortable position of trying to manage a chronic or complex condition outside his or her expertise. It is not unheard of for physicians to refer more pressing cases to an emergency department in hopes the patient will be seen more quickly by a subspecialist. 

We appreciate that directories will never be completely accurate. But to minimize the burden of PCPs having to locate an in-network specialist (or a patient trying to find a participating physician or provider), we strongly support language within the bill explicitly requiring the HMOs to secure specialty care when the physician’s reasonable efforts to do so have failed. It is time-consuming, frustrating, and costly for PCPs to find a specialist or other provider accepting a plan’s Medicaid patients. This type of service will greatly reduce physician frustration — and expense — while expediting getting care to our patients. 

We also loudly applaud the provision in the bill directing HHSC to conduct direct oversight of health plan networks, such as through “secret shopper” calls to determine whether physicians listed within a plan’s provider directory are actually participating in the plan and accepting new patients. The current review process is largely complaint driven, meaning if patients or providers do not take the time to file a complaint, network limitations may go undetected. At the same time, a variety of stakeholders have been screaming from the rooftops for these last many years that too few providers are accepting Medicaid HMO patients. In our experience, where there is smoke, there’s fire. And direct monitoring will help HHSC better identify and address those fires.

Lastly, we commend the provisions in the bill giving HHSC additional options to penalize HMOs that fail to comply with network adequacy standards.  SB760 specifies that HHSC may suspend the plan’s default enrollment if it fails to meet network access standards for two consecutive quarters. While monetary penalties are important, halting enrollment in a plan is surefire way to get the attention of the HMO CEO regarding network adequacy issues. The bill also will maintain HHSC’s ability to impose liquidated damages or discontinue the plan contract.  We support putting new tools in HHSC’s quiver to ensure plans fulfill their contractual obligations. These proposed statutory changes, along with other provisions of the bill, will help foster a new era of accountability for the substantial taxpayer dollars spent to manage Medicaid patients’ care. 

We ask for your strong support for this important bill. 

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Last Updated On

May 11, 2015