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

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Tablb 2A: Example. of Barrier States Face In Including Dunlgy Eligible Baneficieries In <strong>Medicaid</strong> Prepaid <strong>Managed</strong> <strong>Care</strong>
Programs
Program Barer
Medicare Plans may be unwilting to participate in <strong>Medicaid</strong> Prepaid programs if the additi of dually eligible
beneficiaries threatens to raose their Percentage of publicly tunded enrollees above 50 percent, which
would disqualdy them from Medicare participation.
Medicare ules regarding surrogate decisionmalkers-those allowed to make decisions for people not
able to make their own-are more restrictive than those of <strong>Medicaid</strong>, thereby complicating prepaid plan
enroltnent of dually eligible individuals and affecting who may aid them in selecting a plan.
Title V programs
If individuals want to poin the same prepaid plan for both their Medicare- and <strong>Medicaid</strong>-covered
services, timing differences between the two programs may require them to remain in Medicare
fee-for-senrce care for up to 2 months after they have enrolled in the <strong>Medicaid</strong> prepaid plan.
These programs for children with special health care needs are typically administered in states by
departments of health. which are often separate irom <strong>Medicaid</strong> agences. Including these children
requires significant interagency coordination.
School-based programs Conflicts surrounding medical equipment such as wheelchairs or devices to help overcome
communicational imparments arise when children receive services through prepaid pians and through
school-based programs. In some cases, schools and plans cannot eanily agree on whether the
equipment is 'medically or *educationally' necessary. In others, schools or plans restrict the use of the
equipment to either the classroom or the home. potentially leading to the need to duplicate services.
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The nature and extent of coordination barriers between Medicare and
<strong>Medicaid</strong> vary depending on the extent to which states require prepaid
plan enrollment and thse extent to which Medicare prepaid plans are
available. Coordination issues are lessened when dually eligible
beneficiaries remain in Medicare fee-for-service care and join a <strong>Medicaid</strong>
prepaid plan for services not covered by Medicare. But coordination issues
increase in states where beneficiaries are required to enroll in <strong>Medicaid</strong>
prepaid plans and are to be 'locked in" for specified periods. Chief among
these are Medicare's requirement that beneficiaries are free to choose a
prepaid plan or to use fee-for-service care and, when in a prepaid plan, are
allowed to disenroll at will. As a result, in states restructuring their
<strong>Medicaid</strong> programs under waivers, the potential benefits of coordinated
care may elude <strong>Medicaid</strong> beneficiaries dually eligible for Medicare who
may not be enrolled in a single managed care plan for both sets of services
or have a single primary care provider-which undermines one goal of a
prepaid program.
Although many of the state and federal officials we interviewed described
coordination of these programs as a difficrult process, most states with
prepaid programs for disabled <strong>Medicaid</strong> beneficiaries are extending
enrollment to the dually eligible. In all 17 states, one or both of these
groups of dually eigible individuals may elect to enroll in prepaid plans
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