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

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a estring the services authorized were actually delivered. In managed care,
<strong>Medicaid</strong> agencies do not receive claims information directly from providers, but
instead from the plans, making this information more difficult to come by.
Problems arise even when data is available since plans', providers', and states'
different systems are difficult to coordinate, and definitions and outcome measures
are not standardized. Many states reported difficulties setting up data systems, but
agreed that it is worth the effort.
In Connecticut, lack of time and support were barriers to setting up a data system.
They also encountered problems such as the claim system not being linked to the
eligibility system, creating problems determining the number of clients to pay
capitation to the BHO on a monthly basis. Other states expressed concern about
eligibility management issues and how to handle retroactive eligibility in paying
plans.
Delaware's Division of Child Mental Health Services has established a data system
that provides immediate and accurate information on every child in the system. It
allows the Division to track: service demand, rates of referral, unduplicated number
of clients served in the month, service loads at the various levels of care, and
psychiatric hospital days. However, the state is having trouble tracking clients across
systems.
Contracting
States were not in agreement on what format the contract should take. Some felt it
should be very specific with services listed, with the desired outcomes and
stipulations if the outcomes are not met. Those in disagreement felt that stringent
contracting confined MCOs, not allowing them to be creative in developing costeffective
approaches to care.
Colorado establishes a minimum package of benefits MCOs must provide, but
provides no ceiling or limits. Washington is reluctant to have all measures and
outcomes specified in their contracts for fear BHOs will only perform to those
standards. They believe the contract needs to be flexible depending on the
organization and population, since many outcomes vary by population. Finally,
Massachusetts requires aggressive purchasing specifications to assure services
provided are designed for the population being served and not carried over from a
general MCO's contract. All MCOs are granted financial incentives if quality
standards are met in their 6-month reviews. The state often increases standards,
striving for continuous quality improvement.
States can require plans to include specific services appropriate to a consumer's
diagnosis in the benefit package. In Wisconsin, if the state finds that it is an
unrealistic expectation for the network to provide a service, the state allows
beneficiaries to disenroll and the state pays fee-for-service. If the service should be
The National Academy for State Health Policy 0 8/97 lV-99