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

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Risk Adjustment - A statistical
method of paying managed care organizations
different capitated payments
based on the composition and relative
healthiness of their benefidaries. This
proedure would generally compensate
providers of HIV services with a higher
capitated payment than providen of
other (often less costly) health carc services.
Risk Cotrldor - A financial arrangement
between a payer of health care
services, such as a state <strong>Medicaid</strong>
agency, and a provider, sudh as a man.
aged care organization that spreads the
risk for providing health care services.
Risk corridors protect the provider from
excessive care costs for individual beneficiaries
by instituting stop-los pro.
tecdons and they protect the payer by
limiting the profits that the provider
may earn.
Risk Sbhrlng - A financial arrangement
between health care providers,
managed care organizations and another
entity sudh as a state <strong>Medicaid</strong>
program in oeder to spread the risk of
providing health care services. This type
of arrangement is often employed to
protect providters and managed care
organizations serving chronically ill
individuals (such as people living with
HMv)
from financial insolvency.
Spedalty Gatekeeper - A health care
provider within a managed care organization
with expertise in HIV care (or
a specific area of medidne) who makes
decisions regarding referrals to other
providers and when it is necessary to
provide specific health care services. For
persons living with HIV, it is particularly
important to have the designated
care coordinator experienced and
knowledgeable in treating HIV.
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Staff Model HMO -A type of managed
care organization that hires its
own doctors as salaried employees, and
generally owns its own clinics and
health care facilities.
Utilization Review - A management
technique designed to reduce unnecessary
health care costs or to ensure that
the least costly care option is provided.
Utilization review can include. pre-certification
which requires the approval
of a managed care organization
beforea tpedfic health care service is
provided; case management whidh involves
designating a nurse or other
employee to monitor and coordinate
the care that a patient receives; or imposing
second opinion requirements in
whidh a second specialist must agree
that a specific health care procedure is
necessary before the managed care organization
will agree to approve the
expense. Various utilization review
tedhniques can take place at different
stages in the delivery process (i.e. before
during and after a service is provided).
Walver - Approval that the Health
<strong>Care</strong> FinandingAdministration (HCFA.
the federal agency that administers the
<strong>Medicaid</strong> program) may grant to state
<strong>Medicaid</strong> programs to exempt them
Standing Referral - A referral
from
to
specific
a
aspects of Tide XJX. the
specialist provider
federal
that coven
<strong>Medicaid</strong>
routine
law. Most federal
visits to that provider.
waivers
It
involve
is a common
loss of freedom of
practice to permit the gatekeeper
choice regarding
to
whidh providers ben-
make referrals for only a limited
eficiariesnum-
may use, exemption from reber
of visit (often 3 or fewer). In cases
quirements that all <strong>Medicaid</strong> programs
where the medical condition requires
be operated throughout an endre state,
regular visits to a specialist,
or
this
exemption
type of
from requirements that
referral eliminates the need to
any
return
benefit must be available to all
to the gatekeeper endh time the initial
classes of beneficiaries (whidh enables
referral expires.
states to experiment with programs
only available to special populations).
Stop-Loss Insurance - A type of The federal government has only
insurance that managed care organiza- granted waivers in cases where the pubdons
purdhase to protect against exceslic has had an opportunity to provide
sive costs associated with a few high- input, and where the waivers are decost
beneficiaries.
signed to protect both access to andquality
of care
<strong>Medicaid</strong> waivers have been used
to allow states to mandatorily enroll
<strong>Medicaid</strong> beneficiaries into managed
care. Some of these waivers have used
mandatory enrollment into managed
care as a means of expanding <strong>Medicaid</strong>
coverage to uninsured groups of
individuals.
I MAKNG MEICAIDMANAGD CAR WORKA. An.Utisn PIr ns -pil. ULiv9 .ith HIV