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

Significant Efforts Needed
to Ensure Quality
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enrollment for the estimated one-third of disabled individuals who are
'dually eligible' for health care under <strong>Medicaid</strong> and Medicare. Medicare
law guarantees these individuals more freedom in switching providers
than they have under <strong>Medicaid</strong> managed care programs, which require
prepaid plan enrollment The few states wrestling directly with this issue
have taken varying approaches, ranging from adjusting their programs to
conform with Medicare requirements to seeking waivers of Medicare law
that would allow requirements closer to <strong>Medicaid</strong>'s.
States that rely on monitoring the services prepaid care plans provide to
the average enrollee may find that these efforts do not provide enough
specificity for assessing care received by disabled enrollees. For example,
problems in care provided to a very vulnerable disabled category, such as
quadriplegics, might escape general view because few if any cases of
quadriplegia would generally appear in random samples across the entire
population served by a health care plan. Most states recognize a need to
specifically monitor managed care for disabled enrollees and plan to do so
as they expand their programs
Important aspects of states' quality assurance activities can fall into two
main categories: (1) building safeguards into the programs through
adequate planning and consensus-building and (2) tailoring various
aspects of the program (such as enrollment and monitoring) to meet the
specific needs of disabled beneflciaries To date, most of the efforts have
been made by several states with mandatory participation by disabled
individuals or by states with programs targeted exclusively to disabled
beneficiaries on a voluntary basis. The following are examples:
* Oregon's <strong>Medicaid</strong> staff met weekly with health plans, advocates for
disabled individuals, and others for more than a year before the program
was implemented.
. Wisconsin requires the health plan serving participants in its targeted
prepaid care program, which serves only disabled beneficaries, to have a
<strong>Medicaid</strong> advocate on staff who is knowledgeable about disabilities.
Wisconsin also mandates that case managers conduct needs assessments
within 55 days of enrollment in the plan.
* Massachusetts allows specialists to act as primary care providers and uses
a health needs assessment that assists enrollment staff in working with
beneficiaries to select a plan.
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