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

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11 <strong>Managed</strong> care systems/plans must be structured in a manner that decentralizes decisionmaking
and promotes innovation in providing appropriate services and supports to people with
disabilities.
@ <strong>Managed</strong> care systems/plans must provide enrollees with a choice of plans or offer an affordable
point of service option. However, the availability of a point of service option must not mean that
managed care plans do not have the responsibility to provide appropriate care or pay for an outof-network
referral if the managed care plan cannot provide a service.
Appropriate Definition of Medical Necessity
*M For individuals with disabilities, the term "medical necessity" must be defined in the broadest
manner possibleto ensure access to all appropriate services and supports that can enable a person
with a disability to function in the community as independently as possible.
Equitable Financine Mechanisms
II Any financing mechanism that may directly or indirectly constrain access to appropriate services
must be prohibited.
I <strong>Managed</strong> care systems/plans must not include financial incentive procedures that directly or
indirectly restrict access or deny adequate and appropriate services. Systems/plans that contain
incentives for individual providers regarding utilization of services must not link financial
rewards/penalties with individual treatment decisions.
19 <strong>Managed</strong> care systems/plans must have "stop-loss" provisions or limits to risk that are mutually
agreed upon by providers and plan sponsors when provider groups (particularly small groups)
assume financial risk for the. cost of specialty care, ancillary services, and/or hospital care.
*1 Additional amounts of provider time or effort required by people with disabilities or chronic
illness must be compensated commensurate with the additional effort required, either as a
component in the capitation agreement- or thr-ugjsome mutually agreeable financial
* arrangement.
* <strong>Managed</strong> care systems/plans must collect utilization data over periods of time sufficient to
identify patterns of risk. Risk sharing arrangements across a group of providers must also be
based on the performance of the provider group over periods of time.