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
554 beneficiaries that belong to the population served by the program may choose a health plan or remain in the fee-for-service system. (3) States may implement a mandatory managed care program under which beneficiaries must select a health plan or a primary care case management provider. 2 3 As shown by Chart C,24 states appear to be divided as to which of the options to select-even within the same state. For example, some states may have a voluntary HMO program and a mandatory mental health carve-out program. Or, as in Utah, a program may be voluntary in the rural areas of the state and mandatory in the urban areas. 90% 82% n-31 23 As previously discussed states may currently establish voluntary programs without need of a waiver. Also, Title IV-H of the Balanced Budget Act of 1997 will, as of October 1997, enable states to establish mandatory programs without need of a federal waiver for all
555 The next level of decision making is National Arsdemy for State Health Poticy which members of Mnmitment Policies populations that are Rsk-Bad Ct otherwise eligible from El AFDC C1 SSI * Elddy the program will Il 0 5 1 _UssI either be given the S Nopportunity to opt out . _e s_ of a mandatory adult. program or be excluded from 4-% enrollment (Chart D). X For example, states shr t tfi I , frequently allow people who are u A- i, currently under treatment to delay - Medc.d I C% l i enrollment until after the treatment is completed or until the L Z-P as". provider can transition t.. the beneficiary to a plan provider (short term medical). R c a g losty4 . b g 0s Another group that is frequently carved out M..&-aboo '. s -5. 0 5-25 are those who are 0M 1o% 20% 30M 40 50% 00% 50% 50% 90% 100% receiving institutional Percent of States care. States may decide to carve-out these individuals because p td unK - t mood populd- 3150 h 0=.. 30 por atApl . W the state feels that the individual's care is already being coordinated by the institution. Many states also carve-out dual eligibles (those eligible for both
- Page 506 and 507: 504 Chapter 1 Program Design Issues
- Page 508 and 509: 506 Other studies attest to improve
- Page 510 and 511: 508 Will the Program Be Voluntary o
- Page 512 and 513: 510 additional option for people wi
- Page 514 and 515: 512 contractor collect spenddown pa
- Page 516 and 517: 514 Option A is still quite rare. P
- Page 518 and 519: 516 experience with special populat
- Page 520 and 521: 518 particularly on a full risk bas
- Page 522 and 523: 520 Dual eligibility raises a disti
- Page 524 and 525: 522 special populations, and states
- Page 526 and 527: 524 Chapter 2 Care
- Page 528 and 529: 526 settings. Finally, plans that s
- Page 530 and 531: 5281 needs. For example, women who
- Page 532 and 533: 530 Oregon's rules require that pla
- Page 534 and 535: 532 beneficiaries on July 1, 1997.
- Page 536 and 537: 534 facility's delivery, dosage, an
- Page 538 and 539: 536 * Strategies for measuring netw
- Page 540 and 541: 538. arrangements with traditional
- Page 542 and 543: 540 community based or well elders.
- Page 544 and 545: 542 Finally, coordination for vulne
- Page 546 and 547: 544 Care Coordinat
- Page 548 and 549: 546 home health agency developed a
- Page 550 and 551: 548 develop a case management syste
- Page 552 and 553: 550 Coordinating services is compli
- Page 554 and 555: Highlights 552 Effective care coord
- Page 558 and 559: 556 services when needed. This is t
- Page 560 and 561: 558 federal government and not at s
- Page 562 and 563: 560 cannot enroll a person in a Med
- Page 564 and 565: 562 Medicare members are not typica
- Page 566 and 567: 564 Regence HMO Oregon staff noted
- Page 568 and 569: 566 community based organizations t
- Page 570 and 571: 568 Although technical advice for c
- Page 572 and 573: 570 Risk pools are usually used to
- Page 574 and 575: 572 Internal Quality Program Standa
- Page 576 and 577: 574 enrollee utilization patterns,
- Page 578 and 579: 576 that the overall prevalence of
- Page 580 and 581: 578 HMOs with risk contracts must h
- Page 582 and 583: 580 Summary As Medicaid</st
- Page 584 and 585: 582 Chapter 3 Medicaid</str
- Page 586 and 587: 584 carve-out approach: - improves
- Page 588 and 589: 586 Coordinating Medical and Non-Me
- Page 590 and 591: 588 Oregon,8 program planners origi
- Page 592 and 593: 590 Medicaid syste
- Page 594 and 595: 592 Oversight/Monitoring Quality De
- Page 596 and 597: 594 with family and friends, contac
- Page 598 and 599: 596 * The type(s) of data necessary
- Page 600 and 601: 598 * Specificity of desired result
- Page 602 and 603: 600 Initiatives under way may prove
- Page 604 and 605: 602 a estring the services authoriz
555<br />
The next level of<br />
decisi<strong>on</strong> making is Nati<strong>on</strong>al Arsdemy for State Health Poticy<br />
which members of Mnmitment Policies<br />
populati<strong>on</strong>s that are Rsk-Bad Ct<br />
otherwise eligible from El AFDC C1 SSI * Elddy<br />
the program will Il 0 5 1<br />
_UssI<br />
either be given the S Nopportunity<br />
to opt out . _e s_<br />
of a mandatory adult.<br />
program or be<br />
excluded from 4-%<br />
enrollment (Chart D). X<br />
For example, states shr t tfi I ,<br />
frequently allow<br />
people who are u A- i,<br />
currently under<br />
treatment to delay -<br />
Medc.d I C% l i<br />
enrollment until after<br />
the treatment is<br />
completed or until the<br />
L Z-P as".<br />
provider can transiti<strong>on</strong> t..<br />
the beneficiary to a<br />
plan provider (short<br />
term medical).<br />
R<br />
c<br />
a g<br />
losty4 .<br />
b g 0s<br />
Another group that is<br />
frequently carved out<br />
M..&-aboo '. s -5. 0 5-25<br />
are those who are 0M 1o% 20% 30M 40 50% 00% 50% 50% 90% 100%<br />
receiving instituti<strong>on</strong>al Percent of States<br />
care. States may decide<br />
to carve-out these<br />
individuals because<br />
p td unK - t<br />
mood populd- 3150<br />
h<br />
0=.. 30<br />
por<br />
atApl .<br />
W<br />
the state feels that the individual's care is already being coordinated by the<br />
instituti<strong>on</strong>. Many states also carve-out dual eligibles (those eligible for both<br />
<str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> and Medicare) due to the administrative difficulties of coordinating the<br />
two programs described throughout this volume.<br />
Enrollment Process<br />
The process of enrolling beneficiaries into <str<strong>on</strong>g>Medicaid</str<strong>on</strong>g> managed care plans is a critical<br />
comp<strong>on</strong>ent of providing access to quality health care services. States have built<br />
their systems with the expectati<strong>on</strong> that beneficiaries who know what they need and<br />
prefer and who voluntarily select a plan that meets those needs are more likely to be<br />
satisfied with the plan and to use services as they are needed. Beneficiaries need a<br />
process that fully informs them about the availability of plans and their networks,<br />
the implicati<strong>on</strong>s of managed care and the procedures for effectively accessing<br />
The Nati<strong>on</strong>al Academy for State Health Policy * 08/97 IV-52