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

709
Once a comparison is made between what should be happening in a managed care plan and what aca-
ally is happening it becomes necessary to change practices and procedures. Filing a grievance is one
important way for an individual consumer to address shortcomings in the delivery of their health care.
A grievance is a formal complaint that a beneficiary may file with a managed care organization or with
the state <strong>Medicaid</strong> agency.
For example, if a beneficiary has been told that the managed care organization will not pay for them
to receive viral load testing the beneficiary may argue that this test is necessary to establish a baseline
of their immune functioning from which ti munitur tre piogression of thelr illness and the effec-
tiveness of treatment. They can look for studies to show that such a test is the current state of the act
in asestsing disease progression. Complaining can force the managed care organization to review its
decision not to provide the viral load test In many cases, this can lead to a reversal of the previous
denial of the service.
Another approach to solving problems in the managed care system is to establish an ombuda program.
An ombudsperson is someone either inside or outside of the managed care organization (preferably
outside of the organization so that they are completely independent of the health plan) who re-
ceives grievances and attempts to work with both parties to resolve a grievance. In many models, the
ombudsperson often functions as a benedciary advocate. Many advocates have recently shown a
renewed interest in ombuds programs.
leairwesnoracysdhas a vistort for uAa Mthe
C apito-i Hill for morv, thi a droa.,iti t
on people living with HtV. Og K dteir te needTlm lie-
:doigtopch h ~ rlTt shtld 9:
t paid, hem a he fors navys ninh qulty thaorbr prfe I . die bestwsy ate~s eurliszfsan c
worry ot esrmuc a fr-p t . F V
palkk heB says thnaht % is dthe betsr:yotnutk;i
pe-p! ivitrng with HIV get the raref trneedlbe:
2. Pi tlret "itist, cutegt F The best
heatkh ca system is worthless unttss pepl ngt in
the door, Thereor an imporrc gol of an o
effort 5ust be to ensure tiant thdn Zurnt federal def i.
I 5AKING M MEDICAID rNANADED CARE WODRK AnAisrn A. Adt.. r n f.r o rPleW RS~Riae UWrin ,Itt 11 HIV
I