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

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Of the 17 states, only the District of Columbia includes long-term care in
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the set of services covered by capitation payments to health plans.
However, a few such programs have existed on a small scale since the
1980s, and HCFA is currently reviewing Colorado's request to implement a
pilot program in one county. Integrating primary and acute care into a
single prepaid contract with long-term care presents certain challenges.
Among them are the lack of generally accepted standards regarding the
use of various long-term care services; prepaid plans' lack of experience
providing long-term care; the potential for the demise of existing
commnunity-based providers with experience in delivering such care; and
the difficulty in establishing adequate rates for the combined set of
services. Concerns about integrating the two types of care include the
potential for medically based prepaid plans to emphasize medical
technology or institutional care over the social and supportive services
that many beneficiaries prefer. In addition, integration raises concerns
about who should perform care needs assessments and case management
services-state or prepaid plan staff-given the lack of recognized
standards for appropriate long-term care and the fact that in such
integrated arrangements a single provider is responsible for major
portions of an individual's life needs.
Enrollment of Dually Another consideration for states with <strong>Medicaid</strong> managed care initiatives is
whether to include beneficiaries who are also eligible for medical services
Eligible Individuals or supplies through another federal program. For <strong>Medicaid</strong> beneficiaries,
Creates Challenges these programs fall into two categories-Medicare and title V and related
school-based programs.
Medicare is a federal health insurance program that covers, among others,
alt people who have received Social Security disability benefits for 24
months or longer. Medicare and <strong>Medicaid</strong> provide essential and
complementary services to dually eligible beneficiaries. For example,
Medicare is the primary provider of inpatient and physician care, while
<strong>Medicaid</strong> generally provides prescription drugs. Some estimate that about
one-third of disabled <strong>Medicaid</strong> beneficiaries nationally are also covered by
Medicare, but proportions will vary from state to state. For example,
Oregon officials estimate that 45 percent of disabled beneficiaries are also
covered by Medicare.
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