Oregon’s Oversight Did Not Ensure That Four Coordinated-Care Organizations Complied With Selected Medicaid Requirements Related to Access to Care and Quality of Care

The Medicaid Program and the State Agency’s Waiver The Medicaid program provides medical assistance to low-income individuals and individuals with disabilities.  The Federal and State Governments jointly fund and administer the Medicaid program.  At the Federal level, CMS administers the program.  Generally, States administer their Medicaid programs in accordance with a CMS-approved State plan.  However, section 1115 of the Social Security Act authorizes the Secretary of Health and Human Services to approve demonstration projects, under a waiver to the State plan, to assist in promoting the objectives of the Medicaid program.  These waivers give States flexibility to design and improve their programs to better serve Medicaid populations. The State agency administers Oregon’s Medicaid program through a waiver initially approved by CMS in 1994.  The goal of the waiver was to expand eligibility and contain costs through managed care.  Initially, various types of managed-care organizations, such as those providing physical, mental, and dental health care, contracted directly with the State agency.  However, in a 2012 waiver amendment, with the establishment of CCOs, the State agency integrated those lines of care under the CCO umbrella. Coordinated Care Organizations A CCO is a network of different types of participating providers (e.g., physical, mental, and dental health-care providers and those that provide addiction treatment) that have agreed to work together in their local communities to serve low-income beneficiaries who receive health care coverage through Medicaid.  CCOs are similar to traditional managed-care organizations but have some key differences, such as more active roles by providers and community members in governance.  CCOs are also accountable for health care access and quality.  In addition to the goal of improving access to care and quality of care, CCOs focus on prevention and helping people manage chronic conditions, such as diabetes, to help reduce unnecessary emergency-room visits and give people support to be healthy.  In 2016 and 2017, 16 CCOs operated in Oregon.