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

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338 Chapter 2 States Are Moving Toward <strong>Managed</strong> <strong>Care</strong> for Disabled <strong>Medicaid</strong> Recipients 17 States Have <strong>Medicaid</strong> Prepaid <strong>Managed</strong> <strong>Care</strong> Programs for Disabled Beneficiaries Of the 17 states that enrolled some portion of their disabled <strong>Medicaid</strong> beneficiaries in prepaid managed care plans, enrollment ranged from less than I percent to all of a state's disabled beneficiaries. Six states have programs that are mandatory for some or all disabled beneficiaries. Of the remaining 11 states, 3 operate small-scale, voluntary programs focused specifically on disabled beneficiaries; 7 allow disabled beneficiaries to participate voluntarily wherever prepaid plans for the general <strong>Medicaid</strong> population are available; and I does both. Thirteen states exclude one or both of their more vulnerable disabled populations-those in institutional care and those receiving home and community-based long-term care-from prepaid plan enrollment However, under certain circumstances, all 17 states include one or more groups of 'dually eligible' beneficiaries, who are simultaneously eligible for <strong>Medicaid</strong> and another federally fumded program, such as Medicare. Coordinating enrollment and other requirements for this dually eligible group is difficult, according to state officials. In addition to the 17 states currently enrolling disabled beneficiaries, more states have plans under way to include them in prepaid managed care. Specifically, 10 additional states have waiver proposals either approved or pending; three of these are for pilot programs to gain experience with the approach. As of February 1996, 17 states have implemented prepaid managed care programs for disabled <strong>Medicaid</strong> beneficiaries (see fig. 2.1). Six of 17 mandate prepaid plan enrollment for most or all of their disabled <strong>Medicaid</strong> beneficiaries. Three states designed small-scale programs specifically for disabled individuals in which participation is voluntary. In seven states, disabled beneficiaries may voluntarily enroll wherever prepaid health care plans are available for the general <strong>Medicaid</strong> population The remaining state operates both a small-scale program for disabled individuals and allows beneficiaries to enroll wherever plans are available. Pan 2 C.AesG_'MS-W M.d,.id Era Cu f-r to. rmbled
A8~~~~ 339 ow. A- s .I.ITad M-.d C-e n MdkM ldO oM.MW = WP~W = M VOi o EneaNI C Pi E-EnEmih b4 C Pwa w- NWa: Wmshhgtan. D.C. (ME pnd). has klntod a wargtad vcId5try pWeg-. Table 2.1 shows the available comparative data on enrollment for these programs. Umitations in reporting formats preclude comparisons for two PR& 23 GAGM ^Efl48IN MAdk. M..4pd C cto eh> Dahld
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S. HRG. 105-262 MEDICAID MANAGED CA
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CONTENTS PEOPLE WITH SPECIAL NEEDS,
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V Bazelon Center for Mental Health
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2 also apparent that structuring a
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4 through the doors when somebody o
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6 delay the onset of secondary disa
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8 BRIEFING FOR CONGRESSIONAL STAFF
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10 obstetric and gynecological serv
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JlSAes CRi. E CalD5Vilb J~iiiLi uls
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14 people with disabilities and spe
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16 and prospective enrollees the pl
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18 by the disorder. In fact, schizo
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20 r_ 06/23/1997 16: 03 7836845968
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22 Kathy. STATEMENT OF KATHLEEN H.
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24 even lead to an improvement-but
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26 MANAGED CARE AND LONG TERM T h e
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Consortium for C. 20249&Oid Citizen
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30 11 Managed care
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Strong Oualitv Assurance Measures 3
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NATIONAL ASSOCIATION 34 DEVELOPMENT
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36 Mrs. M.'s care plan is quite com
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38 nurses and social workers be ava
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40 EXPENDITURES FOR NURSING HOMES S
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REQUIRES THE SKILL OF A HIGHLY TRAI
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44 ALZHEIMER'S DISEASE AND RELATED
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46 WITHOUT ADEQUATE RESPITE CARE, I
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48 PROBLEM FOR PEOPLE SUFFERING FRO
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50 Ms. CHRISTENSEN. Thank you. Don.
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52 it will eradicate the virus. Man
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I 54 Today I participate in a state
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56 Ms. CHRISTENSEN. Thank you. [Ina
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58 rather than to community-based s
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60 now has to start looking at thin
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62 plan for that matter, can measur
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64 ual is getting state-of-the-art
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66 a larger population of people wi
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68 of recovery or rehabilitation th
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70 are entitled to renew their pres
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72 point and say that Patsy comes f
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74 .The WASHNTND MEDICAL CENTER CEN
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76 exceptions - have largely based
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78 Plans have not shown a willingne
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eligible people and for the program
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Table l.b Selected Provisions Relat
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VariiaIioils in rownlr-c1t language
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Variations in cbonIlrlcl Is1sgu;age
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Executive Summary 1. Setting the Co
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age, which pays for those M
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This consensus building exercise is
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95 Ms. CHRISTENSEN. I'm going to in
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97 abled population will all need s
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5601 Smetua- Drive PO. r,. 9310 Mmn
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101 Our experience with the AFDC po
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103 I have tried to list both the o
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105 BACKGROUND INFORMATION PATRICIA
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164 Communicating the Quality Messa
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119 Dr. SCANLON. In this series of
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121 lation in managed care in Minne
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123 thing, because you will have va
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125 If we develop them now around e
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127 I think those are the things yo
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130 to use, and they will be collec
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134 unlikely though that these futu
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136 While we are in the midst of th
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138 Center for Health Program Devel
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140 ('enter for Hearlth Proeram Dev
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146 If More is Better, Cost Contain
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148 ANALYSIS OF OUTCOMES SF-36 phys
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150 4-Year Physical Health Outcomes
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152 MAJOR FINDINGS -1 PHYSICAL DECL
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154 INTERPRETATION OF RESULTS * Equ
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156 Additional Information is on th
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order) were followed. Samplingpatie
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AP Ag. 0065(0 og. qP e8 y. d-ftd 04
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162 Tlbb. 5-Plso91 A& MerohJ H89t0
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and chest pain sufficient to requir
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166 Quality Special</strong
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THE STATE OF THE STATES TUESDAY, JU
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171 a little bit about some of the
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173 gatekeeper, and we also wondere
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175 Maryland ought to submit that w
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177 fined by us in our regulations,
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179 To get to that kind of situatio
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181 Outline of Presentation for Dep
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183 B. Approaches to Ensure Quality
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185 * Holds MCOs accountable for qu
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187 HealthChoice and People with <s
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189 HealthChoice and People with <s
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191 Take these three steps to choos
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193 Call 1-800-888-1965 if you are
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IF YOU HAVE HIV/AIDS 195 MCO staff
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197 * Refer you to a medical specia
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*pV 199 SERVICES FOR CHILDREN IN ST
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201 Ms. CHRISTENSEN. Thank you. Go
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203 We implement these QI goals thr
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205 Medicaid recip
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207 My name is Peggy Bartels. I am
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209 At the forefront of Wisconsin's
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211 Finally, we believe that high q
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213 WISCONSIN DEPARTMENT OF HEALTH
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2 SELECTED INDICATORS Access to <st
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Mental Health 217 * HMOs reported f
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'Nisconsin Medicaid</strong
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Program for Program Chareolorletice
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Primary Program AFDC/H8 Provlqar Ch
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225 Children Come First of Dane Cou
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227 Wraparound Milwaukee saving dol
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229 Another positive outcome of the
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231 AltDoughl Nkvie' iniCil costs i
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233 CCE's staff consist of a variet
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235 Al the cturent time, there is n
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237 PACE/Partnership programs guide
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239 necessarily relevant to the AFD
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241 about including these specialty
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EXECUTIVE COMMITTEE Ct-u B.1r- M.mb
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Considerations: 245 Enrolling <stro
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247 Medicaid <stro
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a. some counties 249 b. mandatory e
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251 counties as well-of managed car
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253 In other States devolution is m
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255 /-LCenter for Health Ca
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257 Forums on Managed</stro
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259 Medicaid Carve
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261 So I view Medicaid</str
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264 Medicaid: Spen
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266 a 50 percent match. 2 Since 198
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268 If enrollment of eligible indiv
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270 drugs, ICF services, and optome
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272 Table 20-1. Medicaid</s
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274 The slowdown in spending after
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276 Section 1115 Demonstration Waiv
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278 primary care case management ar
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280 Table 20-2. Enrollment in <stro
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282 / Figure 20-6. Enrollment Growt
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284 Marnaged-care growth at the sta
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286 Figure 20-9. Enrollment in Risk
Page 290 and 291: 288 The extent of problems in repor
Page 292 and 293: 290 plans (PPRC 1996). In other are
Page 294 and 295: 292 There appears to be a clear tre
Page 296 and 297: Enrollment and Disenrollment Polici
Page 298 and 299: 296 individually with plans over ra
Page 300 and 301: 298 Health Care Fi
Page 302 and 303: Medicaid M
Page 304 and 305: Support & Services Office 120 W. Tw
Page 306 and 307: INTRODUCTION 304 Presently, nearly
Page 308 and 309: 306 more mandatory services. Full-r
Page 310 and 311: 308 the ability of beneficiaries to
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Page 316 and 317: 314 If a state contracts with or in
Page 318 and 319: Appendix A State Activity* 316 Many
Page 320 and 321: GA { I ~United States (3 Mu General
Page 322 and 323: Results in Brief E.. - 320
Page 324 and 325: Significant Efforts Needed to Ensur
Page 326 and 327: Recommendations Agency Comments E-d
Page 328 and 329: cow 326 Chapter 4 Traditional Rate-
Page 330 and 331: Chapter I Background 328 Me
Page 332 and 333: ovapt I 330 the option of extending
Page 334 and 335: Federal Requirements Govern State U
Page 336 and 337: Table 1.2: Comparison of Ma
Page 338 and 339: Objectives, Scope, and Methodology
Page 342 and 343: Table 21 nEnollmen of Disabled Bene
Page 344 and 345: 342 chona Se. As To~ed Id C"fn, Dai
Page 346 and 347: Table a& Eabent to Which 17 State I
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Page 350 and 351: Table 2.5: Extent to Which 17 State
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Page 354 and 355: 352 C".Pt a Q...itA- Efl~t. . - C f
Page 356 and 357: Addressing Concerns Through Enrollm
Page 358 and 359: Assignment Active Management of a D
Page 360 and 361: 358 fo.V D Axd B ref .Ak,.d - CC-e
Page 362 and 363: Targeted Quality-of-Care</s
Page 364 and 365: Encounter Data Analysis Shows Poten
Page 366 and 367: 364 Chapter 4 Risk-Adjusted Rates a
Page 368 and 369: 366 Cu.pd 4 Rk-A4tAjLd Row Ad RIASW
Page 370 and 371: States Could Experience Adverse Sel
Page 372 and 373: 370 Ckspt. 4 JUek-Mtod Rate Wd HIa
Page 374 and 375: 372 Ch.piWr 4 JU-i.k.d Row md RJAk-
Page 376 and 377: 374 Coob,, 4 RkikAdjned Rtr -d Rub-
Page 378 and 379: 376 rued R.I. . 2".shBd c- provider
Page 380 and 381: 378 c-5 Obh- .. I, Co.eWda, ad CHe
Page 382 and 383: 380 Ob-e-eU-o, Co-ded, end C-ost pr
Page 384 and 385: 382 United States General Accountin
Page 386 and 387: Results in Brief B-Z70335 384 manag
Page 388 and 389: B-2Kn0 386 assess service utilizati
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Table 1: Characteristics of <strong
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B-27035 390 numbers of patients. In
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B-270335 392 number of primary care
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B-Z7Oa33 394 developed on the premi
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States Challenged to Develop Effect
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B-270335 398 that beneficiary use o
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B.270335 400 of the care provided a
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States Could Learn More From Improv
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Targeted Analyses of Grievance Data
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Observations Agency Comments and Ou
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B-270335 408 Finally, the experts w
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410 Appendix I Scope and Methodolog
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- I 412 App-edU I Sw Wd Methodology
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414 AppeAdt U Fedo.I aod Stt. Ove0s
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416 Appendix III Major Contributors
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GAO July 1996 GAO/HEHS-96-120 418 U
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B-26632 420 family home, rather tha
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Background 1-206320 422 traditional
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States Use Waivers to Expand and Ch
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84=20 426 Figure 1: Staftes Use of
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B-266320 428 began the 1990s with s
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B26320 430 variety of other service
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Enrollment Caps and Management Prac
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Change in Federal Rule Could Result
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States Are Introducing Innovations
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B-nato 438 offered and the means fo
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440 We are sending copies of this r
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C-m 442 Table 2: Changes in Number
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444 App-ar I So-p and Mraodsogo ent
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446 Appendix H Medicaid</st
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448 App-di. f M~I Wd., _. So 4 Of0
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450 App-.i. il _-.1 - Desd s UCFVA'
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452 Apeadls mn Stadad Seee - Defind
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454 Appedi. M St.d.ed Se&ee s Dneoe
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Chore 456 Am..& IV LAO n.Gd .Mt. ,
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Occupational Therapy and Assessment
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Psychological Services Provider Typ
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462 AWppdi IV U-e, Cotfi-, E d Othe
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Licensure/Registration Other Standa
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466 United States General Accountin
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Results in Brief B-276078 468 care
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B-270078 470 Medi-Cal was implement
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_.27_7 Tab 1: Mad-C Eiglbli and Enr
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~~- - o~~BZ760?S 474 I J I the enro
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B.276078 476 delaying the contracti
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State's Education Process Has Not R
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B.276078 480 and thereby supplement
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Weaknesses in State Management of t
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B-276078 484 standards can provide
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Insufficient Communication and Invo
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Some Safety-Net Providers Are Encou
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Conclusions B-276D78 490 Safety-net
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B-270078 492 current enrollment bro
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Contents Letter 494 Appendix 30 Sco
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(1115) oPP. -.M.taoy 496 oversight
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498 ACKNOWLEDGEMENTS This Volume of
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500 Is Lock-in to a Managed
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502 Plan and Provider Issues ......
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504 Chapter 1 Program Design Issues
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506 Other studies attest to improve
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508 Will the Program Be Voluntary o
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510 additional option for people wi
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512 contractor collect spenddown pa
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514 Option A is still quite rare. P
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516 experience with special populat
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518 particularly on a full risk bas
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520 Dual eligibility raises a disti
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522 special populations, and states
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524 Chapter 2 Care
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526 settings. Finally, plans that s
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5281 needs. For example, women who
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530 Oregon's rules require that pla
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532 beneficiaries on July 1, 1997.
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534 facility's delivery, dosage, an
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536 * Strategies for measuring netw
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538. arrangements with traditional
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540 community based or well elders.
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542 Finally, coordination for vulne
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544 Care Coordinat
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546 home health agency developed a
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548 develop a case management syste
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550 Coordinating services is compli
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Highlights 552 Effective care coord
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554 beneficiaries that belong to th
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556 services when needed. This is t
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558 federal government and not at s
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560 cannot enroll a person in a Med
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562 Medicare members are not typica
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564 Regence HMO Oregon staff noted
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566 community based organizations t
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568 Although technical advice for c
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570 Risk pools are usually used to
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572 Internal Quality Program Standa
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574 enrollee utilization patterns,
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576 that the overall prevalence of
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578 HMOs with risk contracts must h
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580 Summary As Medicaid</st
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582 Chapter 3 Medicaid</str
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584 carve-out approach: - improves
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586 Coordinating Medical and Non-Me
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588 Oregon,8 program planners origi
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590 Medicaid syste
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592 Oversight/Monitoring Quality De
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594 with family and friends, contac
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596 * The type(s) of data necessary
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598 * Specificity of desired result
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600 Initiatives under way may prove
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602 a estring the services authoriz
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604 Development of appropriate plan
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606 OFFICE OF INSPECTOR GENERAL The
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Establishing core developmental tea
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610 taken into account considerable
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PURPOSE 612 INTRODUCTION Our purpos
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614 MANAGED CARE PENETRATION The de
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616 CHALLENGES AND RESPONSES Our re
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618 > In building up and maintainin
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620 * For the most part, the agenci
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622 beginning to look for associate
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624 challenge will be to ensure tha
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626 RETOOLING AS AN ISSUE Retooling
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628 finding effective ways of deali
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630 COMMENTS ON THE DRAFT REPORT We
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Defining Managed <
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DATE: JU 27 1997 TO: June Gibbs Bro
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636 protocols will be enhanced thro
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638 Broad and explicit state health
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640 APPENDIX C ENDNOTES 1. See, for
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642 The First Biannual Report of th
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644 30. In Massachusetts, for examp
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646 CHILDREN WITH SPECIAL HEALTH CA
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Prface 648 The U.S. Maternal and Ch
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650 L DEFINING AND IDENTIFYING CHIL
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2. Child Health Questionnaire (CHQ)
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654 Limits * This approach identifi
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656 To what extent does the definit
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658 II. FAMILY PARTICIPATION IN MAN
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660 Description This is an integrat
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12. American Academy of Pediatries
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664 knowledge of a child's conditio
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666 though only the NACHRI approach
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668 Sources Ash A, Porell F, Gruenb
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C. Recommended Adivities 670 With t
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672 B. Examples of Current Research
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674 The Practice Parameters Project
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076 -Administrative Survey: Enrollm
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678 Description This guide provides
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680 APPENDIX 1: PARTICIPANT LIST MA
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682 MANAGED CARE EXPERT WORK GROUP
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684 APPENDIX H: BIBLIOGRAPHY MANAGE
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686 MANAGED CARE EXPERT WORK GROUP
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688 MAKING MEDICAID MANAGED CARE PR
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690 On Saturday, July 13, 1996 and
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INTRODUCTION Medicaid</stro
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694 INTRODUCTION People living with
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696 |CONSENSUS FOR ATO of many of o
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- 698 There is a huge need to educa
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700 People fiving with HIV, and the
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702 The HIV epidemic disproportiona
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NATIONAL ASSOCIATION OF PEOPLE WITH
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706 People living with HIV must be
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708 CONSENSUS FOR ACTION service Fo
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710 E . | CONSENSUS FORACTION Peopl
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712 CONSENSUS FOR ACTION _ Under Cr
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714 PNDX Aj MedIcaId -A health care
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Resources 716 NAPWAserves as the vo
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Medicaid Working G
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Background 720 FAMILY"7OICES A nati
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722 was included. A telephone numbe
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724 provider to ask questions. fami
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726 * Families were twice as likely
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728 carefully to explain why they a
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Table I Family Voices Survey on <st
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Table 2 (continued) Family Voices S
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Table 4 Family Voices Survey on <st
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736 Table 7 Family Voices Survey on
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738 Table 8 Family Voices Survey on
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740 Table 10 Family Voices Survey o
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al 742 Table II Family Voices Surve
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744 Tn Uvman 1usoUU - Ya..e. PeMh i
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746 Tihe b d. - Yc'.n-e-aPcopb bith
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748 UT1, W L= 1. - Y g o. ith ,Pb M
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750 o As with the rest of the <stro
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752 Mlbe 1 Mediaid Benefici7 ibtas
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754 9: Office of the Assistant Secr
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The research for this paper Was sup
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Definitions of "Medically Necessary
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Who Should Define What Is Necessary
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762 contract. In that situation, th
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764 sannes and for certain conditio
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Defining Elements of a Definition o
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768 (6J identify and evaluate a men
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770 This paper highlights children'
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772 din resulut in inadequate or in
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774 dividual under public-sector ma
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BAZELON CENTER RESOURCES ON MANAGED
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ivn58ffR1eL_ 778 THF VARIAI LITY OF
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_4 What are the essential benefits
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WHAT PUBLIC PURCHASERS CAN DO - Oen
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ASSESSMENT OF STANDARDS - Quality M
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Accessibility, Availability, Referr
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- Credentialing and Recredtentialin
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Standards for Members' Rights and R
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Preventive Behavioral Health Servic
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9b4 etfJovrk9imut July 16, 1997 794
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hel,4Neipaork SEmi July 16, 1997 79
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798 Principles for Accountable <str
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800 The Coalition for Accountable <
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802 Principles for Accountable <str
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Im. Community 804 Health plans shou
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806 4. participating in community p
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808 5. give patients opportunities
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810 aRve New Children With Disabili
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Table of Contents 812 Executive Sum
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814 combination of HealthPartners d
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Introduction 816 F amilies whose ch
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818 Of the 24 families asked, 13 pa
Page 822 and 823:
820 Shriner's Hospital, or claims s
Page 824 and 825:
822 Major Child and Family Concerns
Page 826 and 827:
Services and Funding Sources 824 Nu
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Physician Survey 826 M ost physicia
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828 Discussion and Recommendations
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830 * Claims and billing informatio
Page 834 and 835:
832 El Advocate for a safety net of
Page 836 and 837:
834 :i:PTNG F'AITH SYMThMr -"r W, M
Page 838 and 839:
836 We recognize that managed care
Page 840 and 841:
due to a host of complex demographi
Page 842 and 843:
affect many different facets of an
Page 844 and 845:
state agencies, must be held accoun
Page 846 and 847:
In selecting managed care entities
Page 848 and 849:
Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
Page 850 and 851:
plans were virtually identical in b
Page 852 and 853:
to chronically i persons has been t
Page 854 and 855:
Managed Risk Medic
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the lead. Large purchasers might wo
Page 858:
ISBN 0-16-055952-9 9 [ 10111111 155
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Medicaid Managed Care - U.S. Senate Special Committee on Aging

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