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

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disabled patients and asowing beneficiaries to enroll with providers
outside their geographic service areas.
Although each state makes educational materials available, state staff
familiar with cognitively impaired beneficiaries in two states reported that
written materials wcrc seldom helpful to this population. Instead. for these
beneficiaries, education largely occurs through the one-on-one
relationships between case workers and beneficiaries and their families.
To ensure that needed equipment and supplies are provided without
interruption while a beneficiary's enrollment is processed and a primary
care provider is selected, Oregon also developed a process to inform the
selected plan in advance about an individual's health care needs.
'Continuity of care referral" forms alert prepaid plans to life-sustaining.
ongoing treatment needs of individuals enrolling. Social service agency
case workers, who enroll disabled beneficiaries in the prepaid plans they
select, complete a form for each individual with lifesustaining
needs-such as oxygen supplies-and forward it directly to the plan's care
coordinator. Delaware and Virginia also require plans to either maintain
existing plans of care or develop transition plans for people with ongoing
care needs
Exceptions States with mandatory prepaid plan enrollment face decisions about
whether, or if to allow exceptions for certain beneficiaries to receive
fee-for-service care. Delaware, Tennessee, Utah, and Virginia-four of the
six states with mandatory programs-essentially do not alow exceptions,
though individuals may receive care in a fee-for-service setting for a short
time while eligibility and enrollment forms are processed. In Arizona,
Native Americans living on reservations may elect not to enroll in prepaid
care. Oregon alows case workers, in concert with beneficiaries and their
families, to decide whether prepaid managed care is the best delivery
system. Most exceptions involve an ongoing relationship with a
practitioner who does not participate in any of the managed care
networks, while others are for situations in which the beneficiary is
involved in an ongoing treatment regime or when changing practitioners
could seriously harm the individual.ai Some exceptions are short-lived,
delaying enrollment by up to I year; others may be permanent Oregon
<strong>Medicaid</strong> officials monitor exceptions granted by case workers to
determine, among other things, whether any trends develop.
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