Medicaid managed care organizations' experiences with network adequacy.

Abstract

Access to behavioral health care continues to be a challenge in Medicaid, where most enrollees are restricted to networks of providers and facilities contracted with managed care organizations (MCOs). While state and federal regulations have sought to ensure access to care, little is known about how health plans perceive and respond to these network adequacy standards. We interviewed 27 administrators and executives across 19 local, regional, and national Medicaid MCOs to assess their behavioral health networks and perceived barriers and facilitators in these efforts. We purposively sampled MCOs for maximum heterogeneity, with early findings used to refine subsequent recruitment targets until thematic saturation. We used an iterative inductive coding approach with code discrepancies analyzed and reconciled until consensus was reached. Five major themes arose: existing regulations often failed to capture true access gaps; MCOs used supplementary approaches to monitor network adequacy; limited corrective actions were available; access measures were more meaningful when grounded in enrollee experiences; and provider directory accuracy was challenged by logistical barriers. In this first study to examine MCOs' experiences with network adequacy monitoring, our findings suggest key deficiencies with current regulations and opportunities to support MCOs more broadly as policymakers seek to strengthen network adequacy regulations.