The Gap Between Health Care Coverage and Access
disability benefits
Public Benefits
Social Security
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In 2013, the Social Security Administration told Ms. Andrews,* a 31-year-old woman with intellectual and cognitive disabilities, that her disability benefits would be terminated because she needed to provide medical evidence that she remained disabled. Shortly thereafter, Legal Aid began representing Ms. Andrews to show that she still suffered from intellectual and cognitive disabilities and thus remained entitled to disability benefits. To do this, we needed to submit updated medical evidence and find a doctor who would administer an IQ test for Ms. Andrews. Since Ms. Andrews is a Medicaid recipient enrolled in a managed care organization (MCO), she needed a specialist within the Medicaid MCO’s network of providers who could perform the test. We worked with Ms. Andrew’s doctors for nearly a year to secure a referral to an appropriate professional. We were repeatedly told, however, that there was no specialist within her MCO who could provide the services we needed. Ultimately, we had to resort to a non-Medicaid agency to provide the required IQ testing.

Ms. Andrews’ situation exemplifies a persistent and growing problem in the Medicaid program: the gap between having health insurance and having meaningful access to health care services. Last week, an article in the New York Times highlighted the difficulties new Medicaid enrollees face in finding doctors that accept their insurance. The article focused on a forthcoming report by the Inspector General of the U.S. Department of Health and Human Services concluding that State standards for ensuring that Medicaid beneficiaries are able to access health care services “vary widely and are rarely enforced.” The result, according to the New York Times, is that Medicaid beneficiaries experience long waits or travel long distances to get services. With Medicaid enrollment increasing, these problems will multiply if left unaddressed.

Over the last few years, Legal Aid has focused on issues of network adequacy in the District’s Medicaid program. In July 2013, Legal Aid issued a Freedom of Information Act (FOIA) request to the District of Columbia Department of Health Care Finance (DHCF), the District’s Medicaid agency, for information on DHCF’s policies regarding network adequacy. In response, DHCF produced no documents on the policies, procedures, practices and standards that it uses to determine whether Medicaid managed care organizations have sufficient provider networks. What DHCF did provide us included inaccurate lists of doctors and specialists within MCO networks. DHCF’s responses revealed that the agency lacked a firm grasp on its MCO networks.

However, that may be changing. In February 2014, DHCF presented its first Managed Care Quarterly Performance Report, which included information about DHCF’s network adequacy standards and MCO compliance with those standards. The second report was issued in June 2014, and the agency promises that additional reports will be forthcoming.

The success of health care reform in the District depends in part on the ability of agencies like DHCF to ensure that coverage and access go hand-in-hand. Legal Aid will continue advocating for more robust data collection and oversight of MCOs, so that people like Ms. Andrews will have access to meaningful health care.

* The client’s name and other identifying characteristics have been changed to preserve confidentiality.

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