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Improving Health Care Access and Stability for Medicaid-Eligible Americans


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Published on Jun 16, 2022

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Medicaid is an essential part of American health care. It helps improve the health and financial security of millions of Americans every day, including more than 2 million veterans. Medicaid managed care organizations (MCOs) are committed to ensuring that Medicaid is effective, affordable, and accountable.

AHIP recommends several policy solutions that together will enhance Americans’ access to Medicaid coverage and services, the stability of Medicaid enrollment and the services provided, and health equity through the program.

Improve Medicaid Eligibility and Enrollment Processes

Solutions that would improve and streamline eligibility and enrollment for Medicaid-eligible people and families include:

  • Enhance real-time and cross-program eligibility processes. These include, for example, “no wrong door” eligibility and enrollment systems, as well as real-time eligibility verification.
  • Approve state waivers allowing continuous coverage. CMS should further accelerate approvals of state requests to extend coverage for populations like children and postpartum women, in circumstances in which they would otherwise lose coverage.
  • Increase program accessibility for diverse and minority populations. CMS could create a workgroup with states to develop template materials that would inform people of the benefits they qualify for and the essential resources that Medicaid coverage provides. These materials should be appropriately targeted, culturally sensitive, and inclusive for under-represented and underserved communities.
  • Address specific social barriers that impact Americans’ ability to apply for or maintain coverage. CMS should collaborate and coordinate with other federal and state agencies to provide resources and strategies that overcome social barriers for access and care. Solutions could include providing access to technologies such as internet access, computers, printers, and scanners; providing childcare resources to allow people to apply for Medicaid, and providing transportation to help people get to and from a Medicaid application office.
  • Leverage MCOs to help Medicaid enrollees retain the coverage for which they are eligible. States should be encouraged to provide MCOs with monthly lists of members at risk of disenrollment, and to allow MCOs to communicate with and assist members in maintaining coverage. CMS could also offer states a waiver template for additional processes that allow MCOs to partner with states in facilitating enrollments and renewals.
  • Improve the use of data matching to streamline processing. CMS should continue to help states (e.g., through grants and technical assistance) to improve their use of “ex parte” processes that allow them to use data in other government programs so that eligibility determinations can be made without additional paperwork from individuals.
  • Monitoring state performance. CMS’ monitoring of states’ eligibility and enrollment process measures (e.g., decision timelines and approval rates), including specific attention to applications for individuals with disabilities, can help to identify states that need technical assistance and process improvements.

Improve Access to Services for Medicaid Enrollees

CMS should adopt several strategies to complement states’ and MCOs’ efforts to enhance access to services, including:

  • Issue guidance to facilitate MCO services addressing Social Determinants of Health (SDOH). Additional clarity is needed from CMS on the medically related SDOH services and interventions eligible for federal matching funds, and to understand how their eligibility would be counted for Medical Loss Ratio (MLR) purposes.
  • Increase access to mental health support. Mental health is an essential part of overall health. A multipronged approach is required to improve access to mental health support, including growing the number of mental health practitioners serving Medicaid enrollees, integrating of mental health support into primary care settings, expanding the use of telehealth, and creating mental health centers of excellence for patients with complex needs. CMS can support these strategies by facilitating state waivers that expand the capacity for treating mental health conditions, including substance use disorders.
  • Augment the existing provider workforce by addressing state-based licensure restrictions. CMS should strongly support efforts to allow providers to practice across state lines when they hold the appropriate medical licensure.

Maintain State Flexibility When Measuring Availability of Care

In general, AHIP supports CMS continuing to rely on states’ oversight of the availability of care given their unique geographic and other considerations, and avoid rigid national standards (such as provider time and distance standards) or new data demands on states or MCOs. At the same time, some new requirements from CMS may help improve access to care for Medicaid enrollees:

  • Support the role of telehealth. Standards should recognize the critical role of telehealth, self-service, and digital care.
  • Recognize the unique nature of long-term services and supports (LTSS). There are several additional challenges in developing a standardized monitoring approach to LTSS, given the nature of services and the locations in which they are provided. If CMS were to impose new monitoring requirements, those requirements should include measures that differ for home-based LTSS (e.g., late or missed visits) compared to LTSS provided outside the home (e.g., provider enrollee ratios).
  • Allow/facilitate value-based arrangements. MCOs should have the flexibility to negotiate constructive and quality-focused arrangements with network providers. Value-based arrangements are also well-suited to supporting whole person care across the major dimensions of physical and behavioral health, LTSS, and social needs when such arrangements include performance measures of the extent to which the needs of individual enrollees are met through care management activities of providers and MCOs.