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

240
low-up and whatever else needs to get done to make sure that
these children are accessing medically appropriate services. Also,
that nurse case manager coordinates the rest of the services that
the children need and receive. The nurse case management role is
being extended to include all the mental health services as well. I
think that's a very interesting idea of taking it out of the HMO.
The other issue that becomes significant in program design, is
the <strong>Medicaid</strong> funding and who is responsible for what. It has been
a real eye-opener for the <strong>Medicaid</strong> sister agencies in many States
to learn or realize, extent to which they are reliant on <strong>Medicaid</strong>
funding for their services, including Part H, IDEA, mental health
system and what it may mean. It really becomes a real threat if
<strong>Medicaid</strong> includes that funding in an MCO capitation and moves
those services outside to an MCO. How this funding/capitation
issue is handled is typically through negotiation. <strong>Medicaid</strong> agencies
need to be very sensitive to the potential effect of pulling all of
these service dollars out of different agencies and handing them
over to the HMO.
I am going to turn next to the issue of physical access which becomes
a big issue in the context of special needs populations with
disabilities. States have learned-Massachusetts springs to mind
right away-that they really ought to make sure their HMOs or
their MCOs meet physical access standards for the doctors' offices
in their network. In Massachusetts I believe physical access is actually
part of their quality assurance and their onsite monitoring.
They go out and check for physical access now that they are enrolling
special needs populations.
Network composition can be different when you enroll special
needs groups. There is the standard issue of number and type specialists,
but also States can consider if there are generalists experienced
with treating the populations being enrolled. Pediatricians
who are familiar with the foster care caseload, for instance, come
to mind. Children in foster care are different than non-foster care
population of AFDC children. Even though you need pediatricians
in any network, you may need or want providers who are familiar
with the foster care caseload and how to treat them if you enroll
this group. So network composition standards may change.
Wisconsin has some contract language around this composition
issue, and I think States are evolving in their thinking. Maryland,
I understand, has some very good regulations on what they are expecting
of their contractors in terms of provided expertise-and not
necessarily specialization, but expertise and familiarity in treating
the foster care caseload.
In regard to covered services, I think a definition of medically
necessary and appropriate services becomes far more important
when you are talking about enrolling these populations than it
heretofore has been for States. There are a lot more potential gray
areas than with the AFDC/TANF population. The fundamental
issue is who is responsible for providing and paying for what.
I also wanted to just say, too, one way states have sought to address
issues of network composition, assuring access, and provider
expertise or specialty in certain conditions is to encourage formation
of MCOs which are the traditional providers for this population
of people with special health care needs. William talked