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

state agencies, must be held accountable
for plan perfomance. The
DDSA also must be equipped with the
authority and the resources to manage
the system, including the enforcement of
contractual requirements, evaluation of
system performance and outcomes,
protection of consumer rights, and the
assurance/improvement of service
quality;
The managed care plan must clearly
define: (a) eligibility;(b) the services and
supports to be furnished to eligible
individuals; (c) the obligations of managed
care entities in ensuring the timely,
effective delivery of benefits defined
in the plan; (d) standards for the procurement
of managed care entities; (e)
consumer rights (including prompt resolution
of consumer grievances); (t)
service provider credentialing standards;
(g) the methods to be used in collecting
and employing performance and outcome
data; and (h) risk sharing arrangements;
* The plan should seek to provide all
eligible individuals with access to
needed and desired supports. To the
extent that resources are inadequate to
support the delivery of necessary services
to all enrollees, the plan also
should specify the strategies for achieving
universal access to supports within
legitimate time frames, including methods
of redeploying the savings resulting
from productivity improvements;
, Service decisions should be based on
person- and family-centered assessments
and planning processes anchored
in the fundamental public policy aims
that frame the system;
* The plan must provide for consumerdirected
options that enable individuals
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and families to self-managed supports.
These options may include vouchers,
individual budgets, cash and counseling
approaches, and other recognized and
accepted models of support that will
enable individuals and families to
excercise self-determination, encourage
the development of consumer collaboratives
that make it possible for individuals
and families to work together as a 'purchasing
block, and expand the network
of supports beyond traditional service
providers. The use of these options must
be subject to appropriate safeguards.
Accountability for the use of public funds
must be retained;
The plan should be based on decentralized
decision-making and communitybased
management in order to foster
effective interaction with natural and
other community supports;
Individuals and families must have bona
fide choices among service agencies,
including non-traditional vendors. <strong>Managed</strong>
care organization procurement
policies should foster comprehensive
provider networks/panels;
Capitation methods must be risk-adjusted
to ensure that funding is adequate
and, consequently eligible individuals,
regardless of the severity of
their disability, are able to access
needed services and supports;
Risk bearing arrangements should be
phased-in gradually. Provisions should
be made for the use of stop-loss, reinsurance,
and other risk sharing arrangements
in order to reduce potential conflicts
of-interests in meeting the needs of
individuals who require intensive
services and supports;