Medicaid Managed Care - U.S. Senate Special Committee on Aging

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fined by us in our regulations, so there is no equivocating about
whether you have responsibility for case management for special
needs populations in Maryland.
The seven populations that we defined were: the physically disabled;
pregnant and post partum women; people diagnosed with
HIV/AIDS; children with special health care needs; the developmentally
disabled; the homeless, and persons in need of substance
abuse treatment. So all of those populations are called out
for additional services and responsibilities to the managed care organization.
Our approach to ensuring quality medical care for these special
needs populations has several components to it. The first is around
the way in which we do capitation. As you all know, often, managed
care organizations claim that they cannot afford to take care
of people with special needs because of the way capitation is defined,
and so they self-select or they cause people to disenroll. That
was actually the experience in Maryland in our voluntary program
where our managed care organization and an individual could
disenroll-a managed care organization could urge an individual to
disenroll. Currently in Maryland, an individual selects a managed
care organization, and that managed care organization must accept
the patient. They have no right to refuse someone because of their
prior physical condition or their known medical history.
What we have tried to do to make that feasible across our MCOs
is that we have built into our capitations the cost of care based on
previous medical history. So we actually have two sets of capitation
rates. Where we do not have a medical history for an individual,
we base the capitation on age, gender, eligibility categories-so
there is a difference between SSI and other eligibility categoriesand
for the city of Baltimore, we have a geographic adjuster because
the cost of care is higher. For those individuals-and currently
that is more than one-third of our population and will grow
over time as we have experience-for more than one-third of our
population, we use ambulatory care groupings, which was designed
b Professor Jonathan Weiner at Johns Hopkins School of Public
Health, someone whom we are familiar with and have been able to
work closely with, and that rate adjustment is based on what the
expected use of care is for a specific individual. So that when that
individual chooses a managed care organization, the dollars that
should be able to support that individual's medical care go to that
organization. It is a way of making certain that more dollars flow
to an organization taking care of people with greater health care
needs than to one that does not. We have done that.
In addition, we did design a stop-loss program to make it feasible
for managed care organizations to take care of individuals even at
the early part of the program. I would be happy if we have time
at the end to go into this a little bit more extensively, because I
know our time is limited for presentations.
Our managed care organizations must provide the full range of
medically necessary services, from primary care to specialist care
to ancillary care to case management, and our local health departments
have been given specific grants to help with transportation
so that people can get to there appointments and get their appropriately.