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

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additional option for people with disabilities, it does not result in
disparate treatment, but if people with disabilities are required to join a
specialty managed care program separate from the program developed
for TANF beneficiaries, the state may be subject to legal challenges,
even if the state believes the specialty program is more comprehensive
or otherwise better than the one serving TANF beneficiaries;
Constituent Support. Older people and people with disabilities tend to
be more effective than TANF beneficiaries in expressing their
opposition to state initiatives in legislative and other forums. States
may find it easier to gather constituent support for voluntary
programs.
Who Will the Program Serve?
At the broadest level, the term "special populations" is generally broken into two
distinct groupings: the elderly, who are defined as being 65 years of age or older for
<strong>Medicaid</strong> purposes; and adults with disabilities. Many elderly qualify for <strong>Medicaid</strong>
through Supplemental Security Income (SSI), a needs based program available to
anyone 65 years old or older who meets income and asset tests. Although many
older SSI beneficiaries have disabilities, they need not be determined disabled to
qualify for SSI. Thus, the group of older people with SSI in any given state includes
individuals with a broad range of health and social needs, with poverty being their
common characteristic. States with medically needy programs extend <strong>Medicaid</strong>
eligibility to older people with income above SSI limits who have significant health
care costs. Most older medically needy beneficiaries are nursing home residents,
making them a more homogeneous group than SSI beneficiaries.
In order to qualify for SSI, people under 65 must be poor and have a disability. Yet
the under 65 SSI population is also a diverse group, including three major
categories: physical disability, mental illness and developmental disability. Within
these disability categories, a wide range of conditions and diagnoses are represented,
including AIDS, cardiovascular disease, cancer, cerebral palsy, mental retardation,
schizophrenia, paraplegia, multiple sclerosis, stroke and spina bifida.10
As a state develops its target group for managed care, the diversity of needs among
subgroups of special populations must be considered. The needs of the target group
will determine a state's criteria for network adequacy as it chooses managed care
contractors. For example, a state that includes all populations in a single managed
care program must assess whether all of the disabilities and conditions listed above
can be adequately addressed by or through individual managed care networks. By
10 Mard-Lynn Drainoni, Carol Tobias, and Tony Dreyfus, <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong>
for People with Disabilities: Overview of the Population, (Boston: <strong>Medicaid</strong> Working Group, 1995).
The National Academy for State Health Policy 0 @ 8/97 IV-7