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

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L DEFINING AND IDENTIFYING CHILDREN WITH SPECIAL HEALTH NEEDS
A. Problem Statement
No operational definition exists for identifying children with special health needs served in
managed care organizations. As a result, these children often are not identified at all and, when
they are, they usually include only those with the most severe and high-cost conditions. In the
case of <strong>Medicaid</strong>, the identification of children with special health needs is usually limited to those
who qualify for the Supplemental Security Income (SSI) program. While this approach offers
some consistency across states, it is limited in that SSI only includes a small subset of children
with chronic conditions. National estimates show that about three to four percent of all
<strong>Medicaid</strong>-enrolled children are receiving SSI cash assistance. However, estimates from the
National Health Interview Survey reveal that as many as ten percent of poor children have a
disabling chronic condition and many more have chronic conditions that are not associated with
disability or activity limitations. Overall, between 20 and 30 percent of all children have chronic
conditions.
In the absence of any widely accepted approach for identifying special-needs children,
plans, pediatric health professionals, Title V agencies, and others are hampered in their ability to:
* target certain families for managed care enrollment assistance,
* assign children to appropriate plans and primary care physicians,
* determine risk-adjusted capitation rates and other risk-sharing mechanisms that
fairly compensate plans,
* design, implement, and monitor quality of care activities, including family
satisfaction surveys appropriate to children with special health care needs, and
conduct ongoing epidemiological and needs assessment studies.
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