How Medicaid Network Adequacy Rules Affect Children with Special Needs

Children with special health care needs (CSHCN) may experience access to care barriers as a result of new quantitative Medicaid network adequacy standards, a study published in Health Affairs found.

“Compared to their peers without special health care needs, CSHCN have been found to be more likely to report having difficulty in accessing specialty care. When specialty care is delayed or forgone, these children may experience negative health consequences and incur higher treatment costs,” the study explained.

More states are requiring CSHCN to transition from fee-for-service Medicaid to Medicaid managed care plans, but the managed care plans often have narrower specialty networks.

To combat the flaws in this design, in 2018 the federal government implemented quantitative standards on Medicaid managed care networks to improve CSHCN access to specialty care. As of 2020, states can select which quantitative standards they apply from a list of standards.

The researchers used 2016–19 National Survey of Children’s Health data for over 8,600 children between the ages of three and seventeen in 18 states with network adequacy standards available. Of this sample, almost 3,160 children were CSHCN.

The most significant finding was that CSHCN caregivers in states that implemented the new network adequacy standards had a higher likelihood of expressing frustration with access to care. This trend was particularly noticeable among CSHCN who visited non-mental health specialists in the past year.

Otherwise, the results did not reveal strong trends in access to care associated with the new network adequacy standards. The researchers noted that studies among adult Medicaid beneficiaries regarding the effects of such standards on access to specialty care yielded similar results.

Instead of cultivating greater access to specialty care or decreasing unmet healthcare needs, the new network adequacy standards may have maintained the status quo while making it more difficult for CSHCN caregivers to connect children with specialists.

The researchers suggested that these findings might indicate a lack of compliance among Medicaid managed care plans regarding provider directory accuracy.

Regarding caregivers’ frustration around access to specialty care under new network adequacy standards, the study considered a couple of causes. The new standards might interrupt ongoing care or states whose pre-existing policies exceeded the new network adequacy standards might have adjusted their networks to a lower bar that was still compliant.

“Our findings suggest that without additional policy interventions, the current federal requirement of setting quantitative network adequacy standards might not be sufficient to improve specialty care access for Medicaid-enrolled children,” the study concluded.

The researchers suggested two policies that could help reform the network adequacy standards to make them more amenable for CSHCN enrollees and their families. States could bolster the enforcement of their standards or they might offer enrollees better patient navigation support. They also noted that medical homes could reduce unmet needs among CSHCN.

“As states are increasingly enrolling children, including those with special health care needs, in Medicaid managed care, additional policy efforts are needed to ensure adequate specialty care access for them,” the researchers underscored.

These findings are particularly important in light of the higher Medicaid and Children’s Health Insurance Program (CHIP) enrollment trends among children. Between February 2020 and October 2022, children’s enrollment in these programs grew by 28.5 percent with 20.2 million new enrollees.