Poster #80 - Navigating the Maze: Medicaid Managed Care and Patient Access Barriers

• In Event: Saturday Poster Luncheon

Abstract

Research Objective: Managed care has become the dominant Medicaid delivery system and now finances a majority of Medicaid-covered births in many states. Managed care was introduced to reduce healthcare costs and enhance access and quality. Although some evidence points to such positive effects, other studies suggest that managed care may increase administrative burdens, creating barriers to healthcare access. This qualitative study examines the potential administrative hurdles pregnant and postpartum Medicaid enrollees face under managed care.

Study Design:  We conducted in-depth interviews with 72 patients with births insured by Medicaid, policy experts, healthcare providers, and health navigators across four states (Texas, New York, and New Jersey) to learn how patients navigate their Medicaid pregnancy benefits. Interviews were conducted from November 2022 to November 2024 during and after a time when the Medicaid continuous coverage requirement was in effect, enabling postpartum patients to remain on Medicaid for an extended period. States were selected due to their adoption of managed care and varying Medicaid policy environments. Using open coding and thematic analysis, multiple coders analyzed the data using Atlas.ti. The study interviewed four groups: (1) postpartum Medicaid enrollees, (2) state Medicaid stakeholders (e.g., policy advocates, state legislators, and FQHC directors), (3) patient-facing providers (e.g., obstetricians, nurse practitioners, midwives), and (4) health navigators working in community organizations or clinics to assist with Medicaid enrollment.

Findings: We identified four major themes, each representing one of the participants groups.

1) Patients struggled to understand plan coverage and complex rules about what was covered and what was not. Uncertainty about coverage led patients to avoid seeking care that in fact was covered. 

2) Stakeholders noted that role confusion created by contracting-out impedes eligibility communication. Different managed care plans varied in the extent to which they communicated eligibility with patients, and there was a lack of clarity about whether it was the state’s responsibility to communicate eligibility changes or MCOs’ responsibility.

3) Clinicians reported low awareness of pregnancy and postpartum benefits that were covered and a desire to focus on clinical recommendations, leaving eligibility questions to other support staff (e.g., social workers) and patients to navigate.

4) Navigators assisted Medicaid enrollees with provider navigation and switching MCO plans, but confusion about benefits and networks persists. Provider dropouts from insurance networks often force patients to either find new providers or switch their MCO plans.

Conclusions: While introduced partially to improve patient access to care, managed care can generate additional barriers to Medicaid enrollees due to administrative complexities, limited communication about coverage, and inconsistent benefits/provider networks, magnifying problems under traditional Medicaid. These challenges can adversely impact patients’ access to eligible benefits and lead to delays, disruptions, and confusion for both patients and providers. Enhanced communication efforts are needed from state governments and managed care organizations (MCOs) to convey benefit eligibility. Strengthening community-based support systems, such as health navigators and community organizations, can help enrollees navigate systems and access timely care but is not a panacea for the complexity generated by third-party administration.

 

Authors

• Soyun Jeong, University of Hawaii
  Presenting Author

• Ashley M Fox
  Non-Presenting Co-Author

• Ellerie Weber, Icahn School of Medicine at Mount Sinai
  Non-Presenting Co-Author

• Teresa Janevic, Columbia University
  Non-Presenting Co-Author