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

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Chapter 1
Program Design Issues
Overview of <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> for <strong>Special</strong> Populations
Risk-based <strong>Medicaid</strong> managed care for older persons and persons with disabilities
continues to grow. By January 1997, 25 states plus the District of Columbia were
enrolling older people, people with disabilities or both into plans with some degree
of provider risk, up from 20 states in May, 1995.1 In many of these states, actual
enrollment is very low, reflecting decisions to proceed slowly with small, voluntary
pilot programs, but other states (notably Arizona, Minnesota, Oregon, and
Tennessee) have mandatory programs with significant numbers of elderly people or
people with disabilities or both enrolled. Many states report plans to expand their
efforts in the near future. Twenty-three of the 26 states currently enrolling the
elderly or people with disabilities reported impending.changes in their programs,
with most planning expansion of risk-based care in one manner or another. Forms
of planned expansion include: covering a specific population for the first time;
expanding an existing program geographically; moving from voluntary to
mandatory; including a particular service (such as long term care) in the capitation
for the first time; and phasing out primary care case management (PCCM) or
partially capitated programs in favor of full risk arrangements.
Despite the growth and evolution of individual programs, the states are not yet
converging on key program design decisions. The 26 states are about evenly divided
on whether to have mandatory or voluntary programs, and on whether to create
specialty programs or include special populations with Transitional Assistance for
Needy Families (TANF) beneficiaries. The subpopulations included in programs
covers a broad spectrum of conditions, including developmental disability, physical
disability and mental iliness. 2
The variety of approaches reflects the diversity of the states themselves, but also
points out <strong>Medicaid</strong> managed care's lack of experience in this area. The body of
l Joanne Rawlings-Sekunda, Directory of Risk-Based <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> Programs
Enrolling Elderly Persons or Persons with Disabilities (Update: January 1997), (Portland, ME: Center for
Vulnerable Populations, 1997).
2 It is important to note that Title IV-H of the Balanced Budget Act of 1997 will allow states,
effective October 1997, to mandate enrollment of all <strong>Medicaid</strong> beneficiaries into managed care without
need of a federal waiver except: dual eligibles (those receiving both <strong>Medicaid</strong> and Medicare), certain
children with special needs, and (in most circumstances) American Indians. States will still need to obtain
waivers before mandating enrollment of these three groups into managed care.
The National Academy for State Health Policy * 0 8/97
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