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

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* Strategies for measuring network adequacy include:
- requiring the plan to demonstrate that it has enough providers
to meet state established provider/enrollee ratios for specific
provider types;
- require plans to demonstrate their ability to meet state measured
community standards that reflect the distribution or availability
of providers for the population of the area, adjusted by the
characteristics of the population to be served;
- allow the plan to demonstrate how the network is appropriate to
the population served.
* Plans may need to contract with community based organizations to
meet some of the needs of special populations.
* Ensuring that plans contract with providers who have knowledge and
experience that enable them to best meet the needs of special
populations is important for program success.
* Plans may need the flexibility to assign specialist as primary care
providers for some members of special populations or use standing
referral to ensure that enrollees can have the access to specialist they
may need.
* States should consider establishing plan contracting requirements that
allow or encourage plans to build linkages with the existing network of
home and community based providers rather than building a separate
network.
Long Term <strong>Care</strong> Services
Enrolling vulnerable populations in managed care programs requires more
attention to long term care than healthier populations. In federal fiscal year 1994,
long term care services accounted for 35% of all <strong>Medicaid</strong> spending. 7 Spending on
children and adults averaged $1,360 and $1,974 respectively while spending for
blind/disabled adults averaged $8,421 and $9,437 for elderly beneficiaries. With few
exceptions, elderly beneficiaries use more long term care than any other eligibility
group. <strong>Medicaid</strong> acute care costs for elderly beneficiaries are lower than costs for
blind/disabled beneficiaries since more elderly beneficiaries also participate in
7 The Kaiser Commission on the Future of <strong>Medicaid</strong>, <strong>Medicaid</strong> Expenditures and
Beneticianes: National and State Profiles and Trends 1984-1994, (Washington, DC: Kaiser Commission,
1996).
The National Academy for State Health Policy * 0 8/97
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