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

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medical case management. Health plans advise any plan to implement an ENCC
position even if it is not required. "Health conditions can't be isolated and primary
care alone will not make a person well when they are poor, have communication
and housing problems and other traumas. A broader approach is needed to pull all
components together."
Plans also conduct medical case management which may be combined with the
ENCC function or handled separately. Regence HMO Oregon has established twelve
criteria for case management referrals. They include long term ventilator
dependency, members whose anticipated and/or cumulative claims exceed $50,000 a
year, members with a pattern of repeated hospital admissions for the same or like
diagnosis, three emergency room visits in three months, members with multiple
providers and resources use, all transplant activity, DME purchases over $5,000,
requests for private or two intermittent home visits per day, convenience
ambulance transports, medically necessary services for members without benefits or
whose benefits are nearly exhausted, requests for services that are not least costly,
and out of state non-contracted services.
<strong>Care</strong> Coordination in CalOPTIMA
Another approach was described by CalOPTIMA, which administers the <strong>Medicaid</strong>
program in Orange County, California through contracts with multiple health
plans. CalOPTIMA staff indicated that case management procedures'8 should be
developed at the beginning of a program because of their value. Initially, some
CalOPTIMA plans equated case management with utilization review. CalOPTIMA
mailed a survey to each of its members to identify beneficiaries receiving home
health services, awaiting scheduled surgery, or members receiving supplies.
Smaller, less experienced Physician Hospital Consortiums were not sure what to do
with the information initially. The survey also increased expectations from
members who expected follow up. CalOPTIMA officials reported that over time,
plans saw the need for and benefit of coordination.
CalOPTIMA case management staff provide coordination for the elderly and
persons with disabilities. The coordination function includes trouble shooting,
liaison to carved out services (mental health, dental) and specific activities for high
risk members which includes facilitating access to services, monitoring medications,
home safety, compliance with treatment plans and coordination with long term care
providers. CalOPTIMA uses registered nurses as case managers and they are
assigned to specialty areas. The role also includes resolving operational problems
and developing memoranda of understanding. CalOPTIMA requires that plans
18 Cal6PTIMA and the Arizona Long Term <strong>Care</strong> Cost Containment System both use the
term case management' to mean what has previously been described in this Guide as care coordination.
Therefore, these two sections also use the term in the same way.
The National Academy for State Health Policy * @ 8/97 IV-44