Medicaid Managed Care - U.S. Senate Special Committee on Aging
Medicaid Managed Care - U.S. Senate Special Committee on Aging Medicaid Managed Care - U.S. Senate Special Committee on Aging
- I 412 App-edU I Sw Wd Methodology For each state, we reviewed the contractual and other requirements the states have established with plans for these selected accountability indicators. We also interviewed officials from the state
413 Appendix II Federal and State Oversight Roles of
- 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
- Page 390 and 391: Table 1: Characteristics of <strong
- Page 392 and 393: B-27035 390 numbers of patients. In
- Page 394 and 395: B-270335 392 number of primary care
- Page 396 and 397: B-Z7Oa33 394 developed on the premi
- Page 398 and 399: States Challenged to Develop Effect
- Page 400 and 401: B-270335 398 that beneficiary use o
- Page 402 and 403: B.270335 400 of the care provided a
- Page 404 and 405: States Could Learn More From Improv
- Page 406 and 407: Targeted Analyses of Grievance Data
- Page 408 and 409: Observations Agency Comments and Ou
- Page 410 and 411: B-270335 408 Finally, the experts w
- Page 412 and 413: 410 Appendix I Scope and Methodolog
- Page 416 and 417: 414 AppeAdt U Fedo.I aod Stt. Ove0s
- Page 418 and 419: 416 Appendix III Major Contributors
- Page 420 and 421: GAO July 1996 GAO/HEHS-96-120 418 U
- Page 422 and 423: B-26632 420 family home, rather tha
- Page 424 and 425: Background 1-206320 422 traditional
- Page 426 and 427: States Use Waivers to Expand and Ch
- Page 428 and 429: 84=20 426 Figure 1: Staftes Use of
- Page 430 and 431: B-266320 428 began the 1990s with s
- Page 432 and 433: B26320 430 variety of other service
- Page 434 and 435: Enrollment Caps and Management Prac
- Page 436 and 437: Change in Federal Rule Could Result
- Page 438 and 439: States Are Introducing Innovations
- Page 440 and 441: B-nato 438 offered and the means fo
- Page 442 and 443: 440 We are sending copies of this r
- Page 444 and 445: C-m 442 Table 2: Changes in Number
- Page 446 and 447: 444 App-ar I So-p and Mraodsogo ent
- Page 448 and 449: 446 Appendix H Medicaid</st
- Page 450 and 451: 448 App-di. f M~I Wd., _. So 4 Of0
- Page 452 and 453: 450 App-.i. il _-.1 - Desd s UCFVA'
- Page 454 and 455: 452 Apeadls mn Stadad Seee - Defind
- Page 456 and 457: 454 Appedi. M St.d.ed Se&ee s Dneoe
- Page 458 and 459: Chore 456 Am..& IV LAO n.Gd .Mt. ,
- Page 460 and 461: Occupational Therapy and Assessment
- Page 462 and 463: Psychological Services Provider Typ
413<br />
Appendix II<br />
Federal and State Oversight Roles of<br />
<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> <str<strong>on</strong>g>Managed</str<strong>on</strong>g> <str<strong>on</strong>g>Care</str<strong>on</strong>g><br />
By virtue of the mandated federal-state <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> partnership, states must<br />
meet certain federal requirements when developing their managed care<br />
programs. States may implement managed care programs under <strong>on</strong>e of<br />
three opti<strong>on</strong>s. The first opti<strong>on</strong> is a n<strong>on</strong>walver program that allows states to<br />
c<strong>on</strong>tract with managed care plans to deliver health care services to<br />
<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> beneficiaries who voluntarily participate. Certain c<strong>on</strong>diti<strong>on</strong>s<br />
must be met, such as allowing beneficiaries the freedom to stay in a<br />
traditi<strong>on</strong>al fee-for-service system or enroll with a managed care plan from<br />
which they can disenroll at any time. Plans also must adhere to a -75-25<br />
rule,' which prohibits participating managed care plans from enrolling<br />
75 percent or more <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> and Medicare beneficiaries. The managed<br />
care program in Pennsylvania that we reviewed is a program of this type.<br />
The other two opti<strong>on</strong>s for managed care-program and dem<strong>on</strong>strati<strong>on</strong><br />
waivers-allow HCFA to waive certain provisi<strong>on</strong>s of the <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> statute,<br />
including beneficiaries freedom to choose from am<strong>on</strong>g participating<br />
providers. Under a program waiver, enrollment can be mandatory, but<br />
states are still required to ensure that plan enrollment of <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> and<br />
Medicare beneficiaries does not reach 75 percent and, in most cases, plans<br />
cannot lock in enrollment for more than I m<strong>on</strong>th, Wisc<strong>on</strong>sin operates its<br />
mandatory managed care program under a program waiver. Under a<br />
dem<strong>on</strong>strati<strong>on</strong> waiver, states may be given permissi<strong>on</strong> to c<strong>on</strong>tract with<br />
plans that do not comply with the 75-25 rule and to exclusively enroll<br />
<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> beneficiaries. They also have been permitted to lock in<br />
beneficiary enrollment for up to 12 m<strong>on</strong>ths. The managed care programs<br />
in Ariz<strong>on</strong>a and Tennessee are statewide mandatory programs operated<br />
under dem<strong>on</strong>strati<strong>on</strong> waivers. In additi<strong>on</strong>, some states. such as Tennessee.<br />
have used dem<strong>on</strong>strati<strong>on</strong> waivers to expand eligibility to include<br />
n<strong>on</strong>-<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g>-eligible people who were formerly uninsured.<br />
Certain federal regulati<strong>on</strong>s, requirements, and guidance influence the<br />
development of state managed care programs and state m<strong>on</strong>itoring of<br />
managed care plan performance. The extent of these requirements often<br />
depends <strong>on</strong> waiver type and can vary by state. In general, HCFA m<strong>on</strong>itors<br />
the planning for and implementati<strong>on</strong> of dem<strong>on</strong>strati<strong>on</strong> waivers more than<br />
for program waivers. The initial terms and c<strong>on</strong>diti<strong>on</strong>s of approval for<br />
dem<strong>on</strong>strati<strong>on</strong> waivers are more detailed than for program waivers and<br />
are more specific in the c<strong>on</strong>tent and timing of reporting requirements. For<br />
example, HcFA's terms and c<strong>on</strong>diti<strong>on</strong>s for a dem<strong>on</strong>strati<strong>on</strong> waiver have<br />
required that states specify in their c<strong>on</strong>tracts with plans a specific<br />
patient-to-primary-care-physician ratio that plans must meet. HCFA also<br />
requires that most states establish travel-related requirements for plan<br />
Pat 33<br />
3GADAHE5974 Madi.d Mo.o"d Co A-e*Mafty