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

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2) Our contract requires each HMO to hire at least one full-time <strong>Medicaid</strong> advocate to help
enrollees navigate the managed care system and learn how to use their HMO effectively.
3) We contract with two ombudsmen to help managed care enrollees with more systemic
complaints and grievances about managed care.
4) We allow voluntary HMO participation for children who qualify for the federal 'Birthto-Three"
program - a program targeted for children with special health care needs.
Most parents and caregivers opt to keep their children in the HMO program.
Specific, targeted contract requirements for the elderly and disabled also incl the following:
each managed care organization must have a Board of Dectrs including <strong>Medicaid</strong> consumer
representatives; our plans must have working Memoranda of Understanding with affected
counties (in Wisconsin, many behavioral health and supportive home case services are county
based); and required quality studies must reflect some subjects of importance to consumers.
All of our special managed care programs are undergoing extensive quality evaluations by
outside evaluators. This has been the Wisconsin way: we start slowly, evaluate and-improve.
then expand to larger mmbers of covered persons.
Another critical aspect of our multi-pronged QI approach is public accountability. We use an
extensive network of community-based forums as vehicles for public input on an aspects of
managed care. Examples of these meetings include: a Statewide Advisory Group, quarterly
rneetngs wit HMO technicnl staff, monthly meetings with EMO contract administrators,quarterly
regional forums and workgroups (statewide or regional) to address specific areas of
concerns (e.g., behavioral health). We foster and encourage proactive advocacy and
community involvement as part of our public/private partnerhip.
Every year Wisconsin produces an MO/Fee-For-Service Comparison Report for the lowincome
women and children managed care enrollees. This report is based on a combination of
survey and encounter data submitted and processed by HMOs. The rxport is always made
public with the results discussed in public forums. Areas needing improvement may be further
studied by workgroups and audited. We will be producing similar reports for our other
programs also.
Wisconsin has a strong audit and utilization reporting component to its multi-pronged QI
approach. We target specific areas of oncern, such as behavioral health and dcntal services.
We also regularly conduct comprehensive medical chart reviews of both fC0-for-service and
managed care recipients through an independent peer review organization. We review twice
as many charts for <strong>Medicaid</strong> managed care enrollees as for those on <strong>Medicaid</strong> fee-for-service.
AU of these strategies - contract requirements, enrollment codactorm, advocates, public
forums, public reporting of data, audits and chart reviews - can be adapted to all special
<strong>Medicaid</strong> populations, including persons with special health care needs.
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