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

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MedIcaId -A health care program that Medicare - Atederal
health care OpenSeason-Period(generallyonce
is jointly operated between the federal program providirig
benefits to elderly per year) when persons who have a
and state governments to provide health retirees and peol ae with disabilities choice among more than one health
care to specificcategories of low-income who have a workk
history that makes plan are permitted to switch enrollment
residents - cash assistance recipients, them eligible fo f benefits. Persons to another plan.
persons with disabilities, and the eld- under age 65 mu
erly who require long term care.
yrs beisafed hr a Out-of-Network
period of two
Provider - A health
<strong>Medicaid</strong> provides health care qualify for benefi tsa. While this 2-year care provider with whom a inanaged
benefits to more than 50% of all requirement has traditionally
limited core organization does not have a onn.
adults with AIDS in the United States access to Medico
. . tract to provide health core services. Be-
vwho generally qualify on the basis of AIDS, Medicire
nrowpay fo emo r with re thebenefidarymustpayeidtherall
x
disability). Additionally, more than AIDS care than th
se payn fhr moRE of the costs of care from an out-of-net-
90% of all children with HIV disease Act Additionally, as new treatents work provider or their oast-sharing re-
depend on <strong>Medicaid</strong> for their health
care. Most of these children and their
and other changem
increase our ability
to manage Hi Vdisease, Medicr
quirements are greatly increased, depending
on the partiaslar plan a ben-
parents qualify for coverage because
they also receive cash assistance.
Please note that federal welfare
will increase in importance as a eficiary is in, out-of-network providers
source of health scare
for people with are generally not financially accessible
AIDS.
to <strong>Medicaid</strong> beneficiaries.
reform legislation was recently enacted
that eliminates the Aid to Families
with Dependent Children (AFDC)
program and replaces it with a new
type of cash assistance program, called
Temporary Assistance for Needy Families
(TANF). Nonetheless, children
and their parents who would have
qualified for benefits under the old
AFDC program remain eligible for
<strong>Medicaid</strong> benefits.
Another important source of <strong>Medicaid</strong>
coverage for people with AIDS is
the medically needy program. Medically
Some people are dually eligible Out-of-Pocket Expense - Payments
for <strong>Medicaid</strong> and Medicare. that the benefidary mustpay at the time
Network=-A list :of physians, hospi- that they access a particular health care
tals and other prcwviders
who provide service
health care services
to the beneficiaries Primary <strong>Care</strong> Provider - A type of
of a specific managed
care organiza- health care provider who is trained to
don.
recognize and treat a broad range.of
Omhudegserson - A person within a medical problems. Primary care physi-
managed care organization
th
ora
care
person ~~medicine
cians are
or
frequently
intemnal trained
medicine.
in family
outside of the heal tcoesy~stem (such In the context of managed corm the
as an appointee ctf
the tate) who is
an .ve investigate
designated to rea
primary care provider ofterserveras the
complaints from beneficiaries about gatekeeper who must approve all refer-
needy persons are those individuals
who meet the disability requirements
for <strong>Medicaid</strong>, but whose income is too
high to automatically qualify for coverage.
Persons may also spend down into
the medically needy category whereby
they spend their own resources to pay
for medical care until their income minus
their medical expenses would make
them eligible for coverage. Although
states are not required to opeate medically
needy programs, 36 states currently
do.
quality of care. insability
to access ' rals to spedialist providers.
discrimination, and
other problems Private Insurance-Health insurance
that beneficiaries nnay
experience with thatis operated bythe private sector.Any
their managed car e organization. This health insurance plan not operated by
individual often functions as the federal, state or local governments.
beneficiary's advocate
in pursuing Re-Insurance - A method of limiting
grievances or corn plaintt about deni- theriskthataproviderormanagedcare
ala of care or inapiaropeate
care. organization assumes by purchasing in-
Not all states, or health plans cur- surance that becomes effective after set
ren&yoperate omb uds programs. These amont ofhealth cre sevices have ben
programs increasir
ined by consumregr
advocategs as a provided This insurance is intended to
mechanism for prc r tectthes i s protect a provider from the extraordi-
of beneficiaries wi
ething masaed aerses nary' health care costs that just a few
*thin managed care beneficiaries with extremely extensive
organizations.
health care needs may incur. (See also
stop-loss insurance).
NATIONAL ASSOCIATION OF PEOPLE WITH AIDS