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

The Bazelon Center fur Mental
Health Ltwis the leading sadunal
legal-adoccy organization
represetnstg people sasth mensts
iflneass or metl reasedanot.
Through precedenm-sescng Sciganan,
public-polic' aduducacy and technical
support fo local lauers and other
aduocas, ste center scos to define
and uphold tj nghts of adults and
chldren who rely n public see-vures
and enuare their eqial access to
healh and mental health care,
educanon. hounng and employment.
The Bazele Cent sss founded as
u.o pfit publtc-interest
orgoniztioain 1 9 72;iitosa-eis
A-Wded primarily by prs-ote
foundatians and indiridual detes.
775
HJiamcsn es Psms wenS criwSd lsdHspird, 784 F. Supp. 215, 222-23
(E1. Pa.). fd, 977 F. 2d 568 (3d Cir. 1992); McNrk n % Dvdhkis, 1990 WIL
235439 (D.Mass. 1990). State connsiunions and statutes may also creae etiements
to nental health we.
5. 42 US.C. SSf 1396d(a)(6), 1396d(a)(1 1), 1396d(l(13), 1396d(r)(5).
6. 42 C.F.R 5 440.230(l).
7. 42 C.F S d440230(b).
8. 42C.FL S 440130(c)(1). The US. Supreme Court hus ed a rin r standuad
in defusing the scope of the constitutional 'right to treuten-L' YoUnghesg u
Roranc, 457 US. 307 (1982). See generalty Stefan, Leuing Cmi Righ to the
'Eupemee- Fiom Dqervnce to Adiostion Unie, the PfrfeniaoslJdgmuse Stan-
-4 102 Yale LJ. 639 (1992).
9. The term meding-necessiry is used in other related areas of law. For emple,
se.eral courts have coasidered the meaning of 'edical nrtessity' when it tppears
in preite insurance conracts.
10. The judicial opinions cited here are binding only within the territory orer
which the deciding court has jurisdiction. However, these opinions are likely
to influence other courts. In deciding a lega issue, court review hor other
courts have huandled the matter and often defer to the reasoning of the other
court's decisions. Thus, the opinions cited in this section can he considered as
guidnceu states deedop their polices for seting standards with regard to
* he4 a service is medically necessary.
11. 756 F. Supp. 501, 507 (. Ian. 1990) (internal citations omines9.
12. 432 US. 438, 444 (1977).
13. 886 F.2d 194, 200 (8th Cit. 1919).
14. Pi--eke u Peioer, 623 F.2d 546,550 (8th Cir. 1980). Se lo S. Rep. No. 404,
89th Cong., 1st Sems., repimed in 1965 U i. Code ong. & Admin. Neus 1943,
1986, (the physician is to he the key figure in determining utilization of
health ser-vices'.
15. 42 C.F.R. S 440.23Dh).
16. <strong>Medicaid</strong> Anoged M zal Healtb <strong>Care</strong>, Save, ofthe States, April 1996, Bazelon
Center for Mental Health L.w, Wauhington DC.
17. <strong>Medicaid</strong> <strong>Managed</strong> Mental Health <strong>Care</strong>: Survey of the States (E), March 1997.
bazecon Center for Mental Health Law, Washington DC.
18. Under <strong>Medicaid</strong> law, <strong>Medicaid</strong>. not the school system, mut pay for covered
secr-ices furnished to a child, eren when these scrvices have been found necessay
and included in the child's IEP or IFSP. This language would ensure that
the managed care plan assumes <strong>Medicaid</strong>'s financial responsibilities in these circumstances.
19. This point may have to be ugued, hated on state law. <strong>Managed</strong> cwe entities
will attempt to avoid releasing this information on the bsis that it is propretary.
However, in a public program of benefits, all standards and criteria
should be open to public scruiny.
Defining 'Medically Necessa.y" Ser-ices to Protect Plan Members
a
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LA 41