Does Medicaid Managed Care Impact Specialty Care Access for Kids?

Medicaid managed care enrollment was not associated with poorer specialty care access for children with special healthcare needs, but it was tied to greater caregiver frustration and reduced mental healthcare access, a study found.

Children with special healthcare needs used to be exempted from Medicaid managed care, but as of 2019, they were mandated to enroll in Medicaid managed care in 33 states.

States generally contract with private managed care organizations that assume financial risk and receive capitated payments from the states. To meet cost containment measures, managed care organizations tend to form narrow provider networks and require prior authorization for specialty services, raising concerns about care access for children with special healthcare needs who require specialty care.

Researchers used data from the 2016 to 2019 National Survey of Children’s Health to assess the connection between Medicaid managed care enrollment and access to specialty care among publicly insured children.

They identified whether children had visits to non-mental health specialists, mental health professionals, or unmet healthcare needs in the past year. Additionally, they assessed if the child’s caregiver reported feeling frustrated accessing services for their child.

Among 20,029 publicly insured children, 7,164 had special healthcare needs and 12,865 did not. Those with special healthcare needs were more likely to visit non-mental health specialists (33 percent versus 7.0 percent) and mental health professionals (36.1 percent versus 4.0 percent) compared to children without special healthcare needs.

However, children with special healthcare needs were more likely to have unmet healthcare needs (10.3 percent versus 2.4 percent). In addition, caregivers of children with special healthcare needs were more than twice as likely to report feeling frustrated with getting services for their children (42.9 percent versus 15.9 percent).

Further analysis indicated no significant association of Medicaid managed care enrollment with visiting non-mental health specialists, mental health professionals, or having any unmet healthcare needs. However, a stratified analysis found that enrollment was negatively associated with visiting mental health professionals.

Meanwhile, Medicaid managed care enrollment was positively associated with caregiver frustration.

Overall, the findings suggest that increasing Medicaid managed care enrollment may have a limited impact on specialty care access for children with special healthcare needs, except for potentially increased caregiver frustration.

This frustration may stem from poor provider availability in Medicaid managed care plans. Furthermore, provider directories may include inaccurate information about specialist availability. Medicaid managed care plans also see high physician turnover, meaning caregivers must often find replacement providers for their child’s ongoing care.

The negative association with visits to mental health professionals identified in the stratified analysis may be due to the low availability of specialty mental health practitioners in Medicaid managed care plans, researchers said.

Additionally, children in certain states may have to use a separate behavioral health managed care plan to receive mental health services, which can lead to administrative burden and more barriers to care.

States can help mitigate these challenges by improving Medicaid managed care plans’ provider directories and administering special needs plans for publicly insured children.

Although Medicaid managed care enrollment was not explicitly correlated with any change in specialty care access and limited mental healthcare access, publicly insured children tend to have difficulty accessing this care regardless of managed care enrollment.

Fee-for-service Medicaid has low specialist participation due to low reimbursement rates, complex billing, delayed reimbursement, and frequent claim denials. States could consider boosting payment rates and improving administrative processes to increase provider participation.