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

Therefore, states are faced with the challenge of first trying to define what services and
structures are needed and then trying to translate these definitions into a contract. The limited
experience of plans in caring for these types of populations - in contrast with the traditional
77
medical system who has cared for them almost exclusively - would indicate that these standards
should not simply be left to plan discretion.
The early stage of evolution for this process is clearly reflected in the contracts
themselves. For example, even where diabled beneficiaries are technically eligible, we can see in
the attached table that language on inclusion of specialists in the provider networks is provided in
only a minority of state contracts. Indeed, network requirements tend to focus on primary care
providers, pediatricians, and maternity care providers - providers appropriate for the AFDC
population. Similarly, provisions dealing with transition arrangements for people in on-going
treatment, access to specialists, or special communication services for diabled people are
relatively rare. Virtually all contracts specifically exclude long-term nursing home care from
plan services.
It is important to note that these problems do not affect only dual eligibles but affect all
people with complex health care needs. A disabled child enrolled in a <strong>Medicaid</strong> managed care
plan who is not eligible for Medicare needs the same network sophistication as-a-dually eligible
adult.
Our initial review of 1996 contracts indicates that some states are moving more
aggressively to enroll disabled populations. Florida, for example, now specifically incorporates
a frail elderly program in its managed care system. Massachusetts and Minnesota are also
engaged in a targeted effort to include the chronically ill into their managed care programs.
However, these states are the exception, not the rule.