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

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disturbance who depend upon the public sector have been provided under
<strong>Medicaid</strong>.
Especially disturbing is language in several contracts that services
need not be provided if the member fails to comply fully with the medical
regime established by a physician or other provider of services. This
not only limits choice, but can divert attention from issues that reflect
problems of the service system, rather than being the fault of the individual
member. In addition, this language can be interpreted as overruling
the plan's requirement to provide services when needed.
Problematic language in some contracts permits plans to use communiry,
rather than national, standards of practice in making decisions.
This languad may be used to deny services that are not available within
the community, even though that service may be the most appropriate
choice. This is especially likely to occur in rural communities, where
services are currently more sparse.
TAKING A M anaged care plans define 'medically necessary' services in a
very concise and limited way. These definitions are typically only a few
DIFFERENT lines long, making it impossible to take more than a very limited approach.
In the public sector, on the other hand, definitions of what con-
APPROACH stitutes an appropriate service for reimbursement, although not termed
'medically necessary," are much longer and more detailed. They encompass
considerably more than 'medical' services in the strict definition of
the term, and they address a host of service-delivery issues, such as requiring
care be furnished in the least restrictive setting and in a culturally
competent manner.
As managed care techniques are adopted for the public sector, it is
neither appropriate nor advisable for public agencies to take traditional
managed care definitions as their model. They have no reason to limit
their definition of medically necessary services to a few lines, perforce
omitting essential elements of good public-sector care. -
States should instead use the 'medically necessary' definition to protect
consumers' choice and access to high-qualiry services, furthering the
overall goals of their mental health system. To achieve this, states need
to design detailed definitions of medically necessary services.
A wide array of commonly used treatments and rehabilitation approaches
is effective for individuals with mental illness-in some circum-
Defining Medically Necessary" Services in Protect Plan Members
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALT .LAW 9
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