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

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Medical necessity definitions Variations contract in language: Medical necessity definitions~~~~~ Variations in contract language: Federal law requirement for Medical Necessity: "(b) Each service shall be sufficient in amount duration and scope to reasonably achieve its purpose. (c) The ... agency may not arbitrarily deny or reduce the amount duration or scope of a required service...to [a] recipient solely because of the diagnosis, type of illness or condition (d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures." 42 CFR 440.230 -- '.I! l tI_.../, ........................... _ I i j( .I....Ii. I '"!Iftll* I, I( I .I oisII PtIh .% Reo.I1 ; I ~~~~~~~~~~~~~~~~~~~~~~~~01il,,,,k l,,.
VariiaIioils in rownlr-c1t language: Medical necessily definitions I . W~~~~~~~~~~~~~~~ "The health care services listed below shall be provided by the contractor to enrollees as covered benefits rendered under the terms of this contract. Provision of these services shall be equal in amount, duration and scope as established by the <strong>Medicaid</strong> program, in accordance with medical necessity without any predetermined limits unless specifically stated, and set forth in the <strong>Medicaid</strong> Provider Manuals..." New Jersey Contract I \Vi-.ow -. .: I lI, W i, d IaImI,Pod *an(CoUIV 11i t I 11II le1111. P__It __. i i' Ill I 1-IIjI
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S. HRG. 105-262 MEDICAID MANAGED CA
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CONTENTS PEOPLE WITH SPECIAL NEEDS,
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V Bazelon Center for Mental Health
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2 also apparent that structuring a
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4 through the doors when somebody o
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6 delay the onset of secondary disa
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8 BRIEFING FOR CONGRESSIONAL STAFF
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10 obstetric and gynecological serv
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JlSAes CRi. E CalD5Vilb J~iiiLi uls
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14 people with disabilities and spe
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16 and prospective enrollees the pl
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18 by the disorder. In fact, schizo
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20 r_ 06/23/1997 16: 03 7836845968
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22 Kathy. STATEMENT OF KATHLEEN H.
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24 even lead to an improvement-but
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26 MANAGED CARE AND LONG TERM T h e
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Consortium for C. 20249&Oid Citizen
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30 11 Managed care
Page 37 and 38: Strong Oualitv Assurance Measures 3
Page 39 and 40: NATIONAL ASSOCIATION 34 DEVELOPMENT
Page 41 and 42: 36 Mrs. M.'s care plan is quite com
Page 43 and 44: 38 nurses and social workers be ava
Page 45 and 46: 40 EXPENDITURES FOR NURSING HOMES S
Page 47 and 48: REQUIRES THE SKILL OF A HIGHLY TRAI
Page 49 and 50: 44 ALZHEIMER'S DISEASE AND RELATED
Page 51 and 52: 46 WITHOUT ADEQUATE RESPITE CARE, I
Page 53 and 54: 48 PROBLEM FOR PEOPLE SUFFERING FRO
Page 55 and 56: 50 Ms. CHRISTENSEN. Thank you. Don.
Page 57 and 58: 52 it will eradicate the virus. Man
Page 59 and 60: I 54 Today I participate in a state
Page 61 and 62: 56 Ms. CHRISTENSEN. Thank you. [Ina
Page 63 and 64: 58 rather than to community-based s
Page 65 and 66: 60 now has to start looking at thin
Page 67 and 68: 62 plan for that matter, can measur
Page 69 and 70: 64 ual is getting state-of-the-art
Page 71 and 72: 66 a larger population of people wi
Page 73 and 74: 68 of recovery or rehabilitation th
Page 75 and 76: 70 are entitled to renew their pres
Page 77 and 78: 72 point and say that Patsy comes f
Page 79 and 80: 74 .The WASHNTND MEDICAL CENTER CEN
Page 81 and 82: 76 exceptions - have largely based
Page 83 and 84: 78 Plans have not shown a willingne
Page 85 and 86: eligible people and for the program
Page 87: Table l.b Selected Provisions Relat
Page 91 and 92: Variations in cbonIlrlcl Is1sgu;age
Page 94 and 95: Executive Summary 1. Setting the Co
Page 96 and 97: age, which pays for those M
Page 98 and 99: This consensus building exercise is
Page 100 and 101: 95 Ms. CHRISTENSEN. I'm going to in
Page 102 and 103: 97 abled population will all need s
Page 104 and 105: 5601 Smetua- Drive PO. r,. 9310 Mmn
Page 106 and 107: 101 Our experience with the AFDC po
Page 108 and 109: 103 I have tried to list both the o
Page 110 and 111: 105 BACKGROUND INFORMATION PATRICIA
Page 112 and 113: 164 Communicating the Quality Messa
Page 124 and 125: 119 Dr. SCANLON. In this series of
Page 126 and 127: 121 lation in managed care in Minne
Page 128 and 129: 123 thing, because you will have va
Page 130 and 131: 125 If we develop them now around e
Page 132 and 133: 127 I think those are the things yo
Page 134 and 135: 130 to use, and they will be collec
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134 unlikely though that these futu
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136 While we are in the midst of th
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138 Center for Health Program Devel
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140 ('enter for Hearlth Proeram Dev
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146 If More is Better, Cost Contain
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148 ANALYSIS OF OUTCOMES SF-36 phys
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150 4-Year Physical Health Outcomes
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152 MAJOR FINDINGS -1 PHYSICAL DECL
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154 INTERPRETATION OF RESULTS * Equ
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156 Additional Information is on th
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order) were followed. Samplingpatie
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AP Ag. 0065(0 og. qP e8 y. d-ftd 04
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162 Tlbb. 5-Plso91 A& MerohJ H89t0
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and chest pain sufficient to requir
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166 Quality Special</strong
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THE STATE OF THE STATES TUESDAY, JU
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171 a little bit about some of the
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173 gatekeeper, and we also wondere
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175 Maryland ought to submit that w
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177 fined by us in our regulations,
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179 To get to that kind of situatio
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181 Outline of Presentation for Dep
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183 B. Approaches to Ensure Quality
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185 * Holds MCOs accountable for qu
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187 HealthChoice and People with <s
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189 HealthChoice and People with <s
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191 Take these three steps to choos
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193 Call 1-800-888-1965 if you are
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IF YOU HAVE HIV/AIDS 195 MCO staff
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197 * Refer you to a medical specia
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*pV 199 SERVICES FOR CHILDREN IN ST
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201 Ms. CHRISTENSEN. Thank you. Go
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203 We implement these QI goals thr
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205 Medicaid recip
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207 My name is Peggy Bartels. I am
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209 At the forefront of Wisconsin's
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211 Finally, we believe that high q
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213 WISCONSIN DEPARTMENT OF HEALTH
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2 SELECTED INDICATORS Access to <st
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Mental Health 217 * HMOs reported f
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'Nisconsin Medicaid</strong
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Program for Program Chareolorletice
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Primary Program AFDC/H8 Provlqar Ch
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225 Children Come First of Dane Cou
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227 Wraparound Milwaukee saving dol
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229 Another positive outcome of the
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231 AltDoughl Nkvie' iniCil costs i
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233 CCE's staff consist of a variet
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235 Al the cturent time, there is n
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237 PACE/Partnership programs guide
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239 necessarily relevant to the AFD
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241 about including these specialty
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EXECUTIVE COMMITTEE Ct-u B.1r- M.mb
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Considerations: 245 Enrolling <stro
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247 Medicaid <stro
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a. some counties 249 b. mandatory e
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251 counties as well-of managed car
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253 In other States devolution is m
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255 /-LCenter for Health Ca
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257 Forums on Managed</stro
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259 Medicaid Carve
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261 So I view Medicaid</str
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264 Medicaid: Spen
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266 a 50 percent match. 2 Since 198
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268 If enrollment of eligible indiv
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270 drugs, ICF services, and optome
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272 Table 20-1. Medicaid</s
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274 The slowdown in spending after
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276 Section 1115 Demonstration Waiv
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278 primary care case management ar
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280 Table 20-2. Enrollment in <stro
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282 / Figure 20-6. Enrollment Growt
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284 Marnaged-care growth at the sta
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286 Figure 20-9. Enrollment in Risk
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288 The extent of problems in repor
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290 plans (PPRC 1996). In other are
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292 There appears to be a clear tre
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Enrollment and Disenrollment Polici
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296 individually with plans over ra
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298 Health Care Fi
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Medicaid M
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Support & Services Office 120 W. Tw
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INTRODUCTION 304 Presently, nearly
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306 more mandatory services. Full-r
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308 the ability of beneficiaries to
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310 managed care also requires the
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312 condition period. Such requirem
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314 If a state contracts with or in
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Appendix A State Activity* 316 Many
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GA { I ~United States (3 Mu General
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Results in Brief E.. - 320
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Significant Efforts Needed to Ensur
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Recommendations Agency Comments E-d
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cow 326 Chapter 4 Traditional Rate-
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Chapter I Background 328 Me
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ovapt I 330 the option of extending
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Federal Requirements Govern State U
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Table 1.2: Comparison of Ma
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Objectives, Scope, and Methodology
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338 Chapter 2 States Are Moving Tow
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Table 21 nEnollmen of Disabled Bene
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342 chona Se. As To~ed Id C"fn, Dai
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Table a& Eabent to Which 17 State I
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346 So A- hbydf TSo -d Cam fo DIbbi
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Table 2.5: Extent to Which 17 State
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350 8t" Age Bowi T-Mar 11 Cue fRa D
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352 C".Pt a Q...itA- Efl~t. . - C f
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Addressing Concerns Through Enrollm
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Assignment Active Management of a D
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358 fo.V D Axd B ref .Ak,.d - CC-e
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Targeted Quality-of-Care</s
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Encounter Data Analysis Shows Poten
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364 Chapter 4 Risk-Adjusted Rates a
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366 Cu.pd 4 Rk-A4tAjLd Row Ad RIASW
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States Could Experience Adverse Sel
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370 Ckspt. 4 JUek-Mtod Rate Wd HIa
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372 Ch.piWr 4 JU-i.k.d Row md RJAk-
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374 Coob,, 4 RkikAdjned Rtr -d Rub-
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376 rued R.I. . 2".shBd c- provider
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378 c-5 Obh- .. I, Co.eWda, ad CHe
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380 Ob-e-eU-o, Co-ded, end C-ost pr
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382 United States General Accountin
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Results in Brief B-Z70335 384 manag
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B-2Kn0 386 assess service utilizati
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Table 1: Characteristics of <strong
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B-27035 390 numbers of patients. In
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B-270335 392 number of primary care
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B-Z7Oa33 394 developed on the premi
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States Challenged to Develop Effect
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B-270335 398 that beneficiary use o
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B.270335 400 of the care provided a
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States Could Learn More From Improv
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Targeted Analyses of Grievance Data
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Observations Agency Comments and Ou
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B-270335 408 Finally, the experts w
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410 Appendix I Scope and Methodolog
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- I 412 App-edU I Sw Wd Methodology
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414 AppeAdt U Fedo.I aod Stt. Ove0s
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416 Appendix III Major Contributors
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GAO July 1996 GAO/HEHS-96-120 418 U
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B-26632 420 family home, rather tha
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Background 1-206320 422 traditional
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States Use Waivers to Expand and Ch
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84=20 426 Figure 1: Staftes Use of
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B-266320 428 began the 1990s with s
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B26320 430 variety of other service
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Enrollment Caps and Management Prac
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Change in Federal Rule Could Result
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States Are Introducing Innovations
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B-nato 438 offered and the means fo
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440 We are sending copies of this r
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C-m 442 Table 2: Changes in Number
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444 App-ar I So-p and Mraodsogo ent
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446 Appendix H Medicaid</st
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448 App-di. f M~I Wd., _. So 4 Of0
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450 App-.i. il _-.1 - Desd s UCFVA'
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452 Apeadls mn Stadad Seee - Defind
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454 Appedi. M St.d.ed Se&ee s Dneoe
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Chore 456 Am..& IV LAO n.Gd .Mt. ,
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Occupational Therapy and Assessment
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Psychological Services Provider Typ
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462 AWppdi IV U-e, Cotfi-, E d Othe
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Licensure/Registration Other Standa
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466 United States General Accountin
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Results in Brief B-276078 468 care
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B-270078 470 Medi-Cal was implement
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_.27_7 Tab 1: Mad-C Eiglbli and Enr
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~~- - o~~BZ760?S 474 I J I the enro
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B.276078 476 delaying the contracti
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State's Education Process Has Not R
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B.276078 480 and thereby supplement
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Weaknesses in State Management of t
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B-276078 484 standards can provide
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Insufficient Communication and Invo
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Some Safety-Net Providers Are Encou
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Conclusions B-276D78 490 Safety-net
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B-270078 492 current enrollment bro
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Contents Letter 494 Appendix 30 Sco
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(1115) oPP. -.M.taoy 496 oversight
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498 ACKNOWLEDGEMENTS This Volume of
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500 Is Lock-in to a Managed
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502 Plan and Provider Issues ......
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504 Chapter 1 Program Design Issues
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506 Other studies attest to improve
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508 Will the Program Be Voluntary o
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510 additional option for people wi
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512 contractor collect spenddown pa
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514 Option A is still quite rare. P
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516 experience with special populat
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518 particularly on a full risk bas
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520 Dual eligibility raises a disti
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522 special populations, and states
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524 Chapter 2 Care
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526 settings. Finally, plans that s
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5281 needs. For example, women who
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530 Oregon's rules require that pla
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532 beneficiaries on July 1, 1997.
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534 facility's delivery, dosage, an
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536 * Strategies for measuring netw
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538. arrangements with traditional
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540 community based or well elders.
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542 Finally, coordination for vulne
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544 Care Coordinat
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546 home health agency developed a
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548 develop a case management syste
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550 Coordinating services is compli
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Highlights 552 Effective care coord
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554 beneficiaries that belong to th
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556 services when needed. This is t
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558 federal government and not at s
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560 cannot enroll a person in a Med
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562 Medicare members are not typica
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564 Regence HMO Oregon staff noted
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566 community based organizations t
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568 Although technical advice for c
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570 Risk pools are usually used to
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572 Internal Quality Program Standa
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574 enrollee utilization patterns,
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576 that the overall prevalence of
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578 HMOs with risk contracts must h
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580 Summary As Medicaid</st
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582 Chapter 3 Medicaid</str
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584 carve-out approach: - improves
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586 Coordinating Medical and Non-Me
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588 Oregon,8 program planners origi
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590 Medicaid syste
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592 Oversight/Monitoring Quality De
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594 with family and friends, contac
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596 * The type(s) of data necessary
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598 * Specificity of desired result
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600 Initiatives under way may prove
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602 a estring the services authoriz
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604 Development of appropriate plan
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606 OFFICE OF INSPECTOR GENERAL The
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Establishing core developmental tea
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610 taken into account considerable
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PURPOSE 612 INTRODUCTION Our purpos
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614 MANAGED CARE PENETRATION The de
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616 CHALLENGES AND RESPONSES Our re
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618 > In building up and maintainin
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620 * For the most part, the agenci
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622 beginning to look for associate
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624 challenge will be to ensure tha
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626 RETOOLING AS AN ISSUE Retooling
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628 finding effective ways of deali
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630 COMMENTS ON THE DRAFT REPORT We
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Defining Managed <
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DATE: JU 27 1997 TO: June Gibbs Bro
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636 protocols will be enhanced thro
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638 Broad and explicit state health
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640 APPENDIX C ENDNOTES 1. See, for
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642 The First Biannual Report of th
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644 30. In Massachusetts, for examp
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646 CHILDREN WITH SPECIAL HEALTH CA
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Prface 648 The U.S. Maternal and Ch
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650 L DEFINING AND IDENTIFYING CHIL
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2. Child Health Questionnaire (CHQ)
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654 Limits * This approach identifi
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656 To what extent does the definit
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658 II. FAMILY PARTICIPATION IN MAN
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660 Description This is an integrat
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12. American Academy of Pediatries
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664 knowledge of a child's conditio
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666 though only the NACHRI approach
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668 Sources Ash A, Porell F, Gruenb
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C. Recommended Adivities 670 With t
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672 B. Examples of Current Research
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674 The Practice Parameters Project
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076 -Administrative Survey: Enrollm
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678 Description This guide provides
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680 APPENDIX 1: PARTICIPANT LIST MA
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682 MANAGED CARE EXPERT WORK GROUP
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684 APPENDIX H: BIBLIOGRAPHY MANAGE
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686 MANAGED CARE EXPERT WORK GROUP
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688 MAKING MEDICAID MANAGED CARE PR
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690 On Saturday, July 13, 1996 and
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INTRODUCTION Medicaid</stro
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694 INTRODUCTION People living with
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696 |CONSENSUS FOR ATO of many of o
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- 698 There is a huge need to educa
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700 People fiving with HIV, and the
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702 The HIV epidemic disproportiona
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NATIONAL ASSOCIATION OF PEOPLE WITH
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706 People living with HIV must be
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708 CONSENSUS FOR ACTION service Fo
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710 E . | CONSENSUS FORACTION Peopl
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712 CONSENSUS FOR ACTION _ Under Cr
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714 PNDX Aj MedIcaId -A health care
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Resources 716 NAPWAserves as the vo
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Medicaid Working G
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Background 720 FAMILY"7OICES A nati
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722 was included. A telephone numbe
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724 provider to ask questions. fami
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726 * Families were twice as likely
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728 carefully to explain why they a
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Table I Family Voices Survey on <st
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Table 2 (continued) Family Voices S
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Table 4 Family Voices Survey on <st
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736 Table 7 Family Voices Survey on
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738 Table 8 Family Voices Survey on
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740 Table 10 Family Voices Survey o
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al 742 Table II Family Voices Surve
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744 Tn Uvman 1usoUU - Ya..e. PeMh i
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746 Tihe b d. - Yc'.n-e-aPcopb bith
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748 UT1, W L= 1. - Y g o. ith ,Pb M
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750 o As with the rest of the <stro
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752 Mlbe 1 Mediaid Benefici7 ibtas
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754 9: Office of the Assistant Secr
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The research for this paper Was sup
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Definitions of "Medically Necessary
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Who Should Define What Is Necessary
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762 contract. In that situation, th
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764 sannes and for certain conditio
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Defining Elements of a Definition o
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768 (6J identify and evaluate a men
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770 This paper highlights children'
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772 din resulut in inadequate or in
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774 dividual under public-sector ma
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BAZELON CENTER RESOURCES ON MANAGED
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ivn58ffR1eL_ 778 THF VARIAI LITY OF
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_4 What are the essential benefits
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WHAT PUBLIC PURCHASERS CAN DO - Oen
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ASSESSMENT OF STANDARDS - Quality M
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Accessibility, Availability, Referr
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- Credentialing and Recredtentialin
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Standards for Members' Rights and R
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Preventive Behavioral Health Servic
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9b4 etfJovrk9imut July 16, 1997 794
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hel,4Neipaork SEmi July 16, 1997 79
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798 Principles for Accountable <str
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800 The Coalition for Accountable <
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802 Principles for Accountable <str
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Im. Community 804 Health plans shou
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806 4. participating in community p
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808 5. give patients opportunities
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810 aRve New Children With Disabili
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Table of Contents 812 Executive Sum
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814 combination of HealthPartners d
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Introduction 816 F amilies whose ch
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818 Of the 24 families asked, 13 pa
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820 Shriner's Hospital, or claims s
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822 Major Child and Family Concerns
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Services and Funding Sources 824 Nu
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Physician Survey 826 M ost physicia
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828 Discussion and Recommendations
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830 * Claims and billing informatio
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832 El Advocate for a safety net of
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834 :i:PTNG F'AITH SYMThMr -"r W, M
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836 We recognize that managed care
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due to a host of complex demographi
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affect many different facets of an
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state agencies, must be held accoun
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In selecting managed care entities
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Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
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plans were virtually identical in b
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to chronically i persons has been t
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Managed Risk Medic
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the lead. Large purchasers might wo
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ISBN 0-16-055952-9 9 [ 10111111 155
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Medicaid Managed Care - U.S. Senate Special Committee on Aging

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