When Joseph DeMarco’s mental health issues began at the age of 19, his family’s change in insurance plans revealed significant challenges in accessing care. Transitioning from TRICARE to Mercy Care, under Arizona’s Medicaid program, posed unexpected hurdles in finding mental health providers.
Joseph’s mother, Seetha DeMarco, noted the ease of finding providers with TRICARE, describing it as a straightforward process with a comprehensive list of active providers. However, after switching to Mercy Care, the situation became more complex.
“Each and every time I’ve contacted Mercy Care to identify a provider in the network, they direct you to a website with a list,” she said. “It would take days to go through that list and find a provider that is active and enrolled with Mercy.”
It took almost a decade to secure a competent provider. This delay in accessing care can lead to severe consequences for individuals with serious mental health conditions, including worsening symptoms and repeated crises.
DeMarco’s experience is a prime example of what federal investigators term “ghost networks.” According to a recent report from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), these networks are directories filled with providers who are either unreachable or not accepting new patients.
The report highlighted issues with private Medicare Advantage and Medicaid managed care plans listing inactive or unavailable mental health providers. This practice violates federal requirements for current and accurate provider directories. Plans are obligated to update directories quarterly or within 30 days of any provider status changes.
Arizona, a pioneer in the Medicaid managed care model, contracts with private insurers to deliver most health services. AHCCCS, Arizona’s Medicaid program, has a proposed budget of $22.3 billion for fiscal 2025. These funds pay insurers per-member capitation payments to cover eligible residents’ health services.
Meridith Seife, deputy regional inspector general, commented on the report’s findings: “There was a significant percentage of providers that were inactive, meaning they had not provided a single service throughout an entire year… Almost three-quarters of them should not have been listed in those network directories.”
The HHS-OIG reviewed plans in 10 counties across five states, including Arizona’s Maricopa and Santa Cruz counties. Findings showed that 55% of behavioral health providers listed in Medicare Advantage plans were inactive, along with 28% in Medicaid managed care plans.
Providers reported that the demanding administrative workload and insufficient reimbursement rates contributed to their decision to stop participating in these networks. Seife noted the burden: “Keeping up with them (administrative requirements) is nearly impossible and clinical staff feel like they are just cogs in a wheel versus clinicians.”
To address these issues, HHS-OIG recommends reducing administrative burdens and establishing a centralized national directory for providers to list their insurance participation details accurately.
In response, AHCCCS acknowledged the challenges and outlined efforts to improve access to behavioral health services. The agency is enhancing network monitoring, reducing provider administrative barriers, and investing in workforce development. It also aims to improve provider search tools for the public.
Seetha DeMarco emphasizes the need for tangible improvements beyond policy statements, expressing concern for future generations’ access to care. “There’s going to be a time where I’m not going to be there to advocate for (my children) and for the level of care and support that they need. … This is a human crisis,” she said. “We’ve got great laws (in Arizona), we’ve got great policy, it just hasn’t been implemented.”
Cronkite News reached out to private insurance companies in Arizona for comments, but none responded before publication.
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