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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
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Strong Oualitv Assurance Measures 3
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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 and 88: Table l.b Selected Provisions Relat
- Page 89 and 90: VariiaIioils in rownlr-c1t language
- Page 91: Variations in cbonIlrlcl Is1sgu;age
- Page 95 and 96: ees are more likely to be poor, les
- Page 97 and 98: Finally, relationships with public
- Page 99 and 100: 94 include expedited procedures for
- Page 101 and 102: 96 populations we serve in our <str
- Page 103 and 104: 98 being delivered now, where can i
- Page 105 and 106: 100 Members of the Committe
- Page 107 and 108: 102 3. Managed car
- Page 109 and 110: 104 7. Managed car
- Page 111 and 112: CHAPTER 8 106 Communicating With Vu
- Page 113 and 114: Sooce Medica Health Plant. 108 Comm
- Page 115 and 116: 110 Communicating With Vulnerable P
- Page 117 and 118: 112 Communicating Wits Vulnerable P
- Page 119 and 120: 114 Communicating With Vulnerable P
- Page 121 and 122: 116 Communicating With Vulnerable P
- Page 123 and 124: 118 Communicating With Vulnerable P
- Page 125 and 126: 120 DISCUSSION Ms. CHRISTENSEN. Don
- Page 127 and 128: 122 QUESTION. The risk corridor see
- Page 129 and 130: 124 Ms. RILEY. I think that what yo
- Page 131 and 132: 126 er than a judgmental context, b
- Page 133 and 134: QUALITY AND OUTCOME MEASURES TUESDA
- Page 135 and 136: 131 [Note: Due to recording difficu
- Page 137 and 138: 133 care organizations, we need to
- Page 139 and 140: 135 context of enrolling people who
- Page 141 and 142: 137 I think it is a positive step t
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139 rente.r for Health Program Deve
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141 Center for Health Program Devel
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143 Center for Health Program Devel
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145 MONITORING HEALTH OUTCOMES FOR
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147 MEDICAL OUTCOMES STUDY (MOS) AD
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149 4-Year Physical Health Outcomes
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151 4-Year Physical Health Outcomes
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153 MAJOR FINDINGS - 3 ON AVERAGE,
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44-098 97 - 6 155 NCQA "HEALTH OF S
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Original Contributions 157 Differen
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of change in the metric of the scal
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161 Td b 3 Phy9(005 .- end Men"' Ho
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creased since MOS data collection e
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165 1 Tnrio AR, Ware IE, Creiseld S
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Contracting Options: Monitoring Too
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170 Our first panelist is Bill Scan
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172 are appropriate to bring to thi
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174 STATEMENT OF BARBARA SHIPNUCK,
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176 certified to participate in the
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178 Managed care o
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180 State of Maryland Department of
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182 B. Development of 1115 Waiver -
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184 HealthChoice Fact Sheet On Octo
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186 * MCOs may not solicit or sign
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188 Information in this pamphlet do
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Medicaid is changi
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192 If you do not pick an MCO, the
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194 CHILDREN WITH SPECIAL HEALTH CA
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196 IF YOU HAVE A DEVELOPMENTAL DIS
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198 IF YOU NEED HELP TO GET OFF DRU
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200 Call your Local Health Departme
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202 These principles apply to manag
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204 be adapted to special M
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Tw~hfy G. Tho,,;&O GW~~ Jo- i~.= S-
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208 model to serve the elderly in M
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210 2) Our contract requires each H
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212 the Medicaid p
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214 HMO / Fee-for-Service CO.*PAR&S
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216 aCrildren ages one through five
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QUALITY IMPROVEMENT 218 The Wiconsi
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Program Characterislics __________
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Primary Independent Program for All
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Program AFDC/HS Primary ProvIdar In
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226 An important aspect of the Chil
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* Day Ttesoment Tr=atnt Foster <str
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230 Profile of a Wraparound child F
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232 CCE helps frail elderly keep in
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234 Elder Care Par
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236 Milwaukee County residents with
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238 Ms. CHRISTENSEN. Thank you. I t
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240 low-up and whatever else needs
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242 Other foster care special arran
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244 As of January 1997: 26 States e
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246 Enrollment Carve Out Policies a
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248 Characteristics of Medi
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MS. CHRISTENSEN. Steve. 250 STATEME
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252 I will also just mention that i
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I 254 Forums on Managed</st
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-"' C-- 256 Forums on Manag
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Model Development and Readiness Ass
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260 Ms. CHRISTENSEN. Well, so much
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Physician Payment Review Commission
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265 This chapter presents backgroun
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267 were not enrolled in Me
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269 Figure 20-1. Medicaid</
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271 Figure 20-3. Medicaid</
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Trends in Program Spending 273 In 1
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MEDICAID MANAGED CARE 275 Most <str
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277 Figure 20-5. Status of Section
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279 exercise in purifying bad data.
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281 Table 20-3. Enrollment in <stro
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283 Table 20-4. Enrollment In Any <
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285 Excluding PCCM participation re
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287 Table 20-5. Enrollment in <stro
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289 Several states reported annual
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291 For states relying on plans for
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293 services for non-English-speaki
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295 formed by the county government
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297 General Accounting Office, Ariz
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299 Lewin-VHI, States as Payers: <s
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301 Medicaid <stro
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Back- round 303 Medicaid</s
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305 give beneficiaries freedom of c
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307 In addition to shifting the fin
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309 While it is important to set me
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311 The regulation of marketing pra
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313 concerns which may be raised wh
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Conclusion 315 Over the past decade
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GAO July 1996 GAO/HEHIS-96-136 317
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Executive Summary 319 Thim osPrepai
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Principal Findings Few States Have
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Experimentation Is Under Way in Rat
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Contents 325 Executive Summary 2 Ch
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FMgures Coft~ 327 Table 4.3: Massac
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Disabled People Are One of Several
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331 of the Medicaid</strong
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h-r 333 states win need to seek app
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Applying Managed <
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co.w I B.-kgro.w 337 degree of oper
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A8~~~~ 339 ow. A- s .I.ITad M-.d C-
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341 Chap S a A,. M-.9Z T..d - C- Ia
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Most States Exclude the More Vulner
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345 Cu.pt-2 S r MoA-g T--Md li d Ca
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347 t,. Stl- An, U..Iw T.d Maee Crz
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349 cr.yt- I Sty Axe Tuit T-oe tMtd
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351 Chapter 3 Quality Assurance Eff
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353 Ait uuo. fo Focusd - Ce fRa ram
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355 Q.Y A- Efforr Foo.d -Ca 1 . HES
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Requiring Plans to Provide Staff Ad
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359 Ch.pt 3 Qeiiv A x Effru Fe-d -
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361 ckve-. 3 Quilt A- Eare F.-d -m
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363 Ch.ov a Q-ft Apg effft F-d f- D
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TYaditional Rate-Setting Approach D
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367 CkW- 4 RSNA tA d R~o ad WRjk-6.
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Risk Adjustment and Reinsurance Hav
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Table 4.1: Mtisouri Sample Diagnost
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Reinsurance Relieves Financial Pres
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375 Curt- 4 Rkk-.Adjtd at Ed Iexkl,
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377 Chapter 5 Observations, Conclus
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Agency and Other Comments 44-098 97
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381 Appendix I Major Contributors t
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383 G A ^. United States General Ac
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8-27033= 385 A number of these stat
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AgesM 387 coordinate the delivery o
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Difficulties in Monitoring
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Compliance With Primary Car
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BIa70M3s 393 Assessing the availabi
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Systems for Assessing Adequacy of M
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B.c703 397 be changed periodically
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More Targeted Clinical Studies and
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B34l0335 401 plans to submit a one-
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S-270s 403 Statewide Surveys Statew
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States' Analyses of Disenroliment D
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B-270335 407 HealthChoices-a mandat
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Contents 409 Letter I Appendix 1 30
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Tabl. 1,2: Description of the Four
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413 Appendix II Federal and State O
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Table l.: Federal Regulations, Rtqu
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417 Ordering Information The first
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419 ~~~~~~~~~~n AUred St tea J Ge~~
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B-tiMe 421 states have begun to shi
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423 regulations and are subject to
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Table 1: Growth of Developmental Dl
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427 groups have come to believe tha
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aBe_ 429 Are Changing Their In the
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Ba41am 431 Table : Growth In Mediai
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Management of Care
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More Development of Promising Quali
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437 of persons who can observe and
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Agency Comments .2-sagas 439 Determ
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Contents 441 Letter I Appendix I 26
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443 Appendix I Scope and Methodolog
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A I 445 comparisons of data from th
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447 Anp-dh la Notedd WaV Pros S-es
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449 Appendix mI] Standard Services
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451 Agpesd Sd.sAd Seesie e d - fd l
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453 StAshed RSize - Defiss Is ErV.'
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455 Appendix IV Licensure, Certific
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Environmental Modifications 457 Li-
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Personal Emergency Response System
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461 Ai tY Up, Af-t I a_ adon. Nuses
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463 App.di. rV Lee, Ce-tfcdd., d O-
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Related GAO Products (IOIJ1U) P.S.
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467 G OWebbingion, n-r- 2lS4 GAOUni
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469 managed care options and enroll
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B- 27601 471 The Two-Plan Model Cal
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B-2760e7 473 contracted with the lo
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Figure 1:12 Counties Pawltrtsfng hi
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Education and Enrollment Problems C
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3-t7fU78 479 to respond. Dois remai
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5.27601 481 and some beneficiaries
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B-27607S 483 as the cause of initia
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W276z 485 operations to ensure the
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Enrollment Brokets Cite Operating C
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B-2787U 489 'proportionately' assig
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Recommendation Agency Comments and
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493 administrative control of the b
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495 Appendix _ _ _ ___ _ _ _ _ __ _
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497 Medicaid <stro
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499 Medicaid <stro
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501 Addressing Continuity . .......
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503 Chapter One Program Design Issu
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505 independent research is growing
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507 precisely what beneficiaries ne
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509 that voluntary programs are mor
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511 contrast, a state that excludes
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513 What Services will the Program
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515 for Medicaid c
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517 is moving in this direction now
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519 Medicaid syste
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521 recent legislation provides for
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523 Chapter Two Care</stron
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525 * the state should develop corr
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527 Chart B National Academy for St
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529 Allowing beneficiaries to conti
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531 Some states use other strategie
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533 In particular, plans without an
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535 Responsibility for most home he
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537 Medicare. Long term care accoun
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539 spending will exceed the capita
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541 Care Coordinat
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543 State Medicaid
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545 coordinate community supportive
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547 medical case management. Health
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549 determining when to contact the
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551 and therefore have greater abil
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553 Beyond identifying and contacti
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555 The next level of decision maki
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557 member with complex needs might
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559 Materials explaining the Oregon
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561 As of June 30, 1996, only four
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563 and Medicare is billed fee-for-
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565 * Striking a balance between st
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567 demographics of the population
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569 . 0 r. I c E a. E __ . t e s V
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571 Those states that use managed c
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573 who have a disability. Finally,
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575 assess compliance with minimum
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577 attained this ability through u
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579 review systems in place to dete
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581 Chapter Three Medicaid<
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583 is a pure 'model,' for purposes
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585 Goals of Managed</stron
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587 Coordinating services remains a
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589 Plan and Provider Issues The ca
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591 uninsured, but more impact on "
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593 * The 'outcomes", both short-an
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595 - Client improvements on pre/po
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597 collected by the mental health
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599 Washington conducts 20-minute i
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601 planning process and had a rela
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603 available in the network and is
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605 Department of Health and Human
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PURPOSE 607 EXECUTIVE SUMMARY To id
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609 program, can encourage and help
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EXECUTIVE SUMMARY 611 TABLE OF CONT
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THIS INQUIRY 613 This inspection fo
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615 In Stage I, the Medicai
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617 > For the most part, the core s
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619 TABLE 2 PARADIGM SHIFT FOR MINN
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621 expanded the scope of managed c
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623 relations staff could (and some
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625 the program, agency nurses work
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627 RECOMMENDATIONS Our review indi
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629 and how to address them. Most r
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631 APPENDIX A BACKGROUND ON MEDICA
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633 APPENDIX B COMPLETE COMMENTS ON
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635 Comments of the Health
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JUL 1 5 97 637 DEPARTMENT OF HEALTH
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639 and family members, patient adv
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641 Reform for Tennessee," Journal
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643 20. This was a particular probl
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645 CHILDREN WITH SPECIAL HEALTH CA
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647 TABLE OF CONTENTS Preface .,...
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649 During the past year, expert wo
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651 B. Examples of Current Research
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Approach Service based 653 Testing
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655 Source Stein REX. Westbrook LE,
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C. Recommnended Atihitles 657 While
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659 B. Examples of Current Research
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661 Description This survey is desi
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663 Description This project is des
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665 III. CAPITATION AND RISK ADJUST
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667 Sources Smith NS, Weiner J: App
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669 Sources Kronick R, Dreyfus T. L
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IV. QUALITY OF CARE A. Problem Stat
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673 2. - .Agency forHealth
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S. Otber Relevant Quality Initiativ
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677 Source Maternal and Child Healt
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C. Recommended Activities 679 The m
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681 MANAGED CARE EXPERT WORK GROUP
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683 MANAGED CARE EXPERT WORK GROUP
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685 MANAGED CARE EXPERT WORK GROUP
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687 MANAGED CARE EXPERT WORK GROUP
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*689 NAPWA wishes to adknowledge th
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691 6. People living with H1V and t
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693 M anaged care it a way ofprovid
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ENSUS FOR ACON In examining issues
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697 Some managed care organizations
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CONSENSUS FOR ACION 699 works and h
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CONSENSUS FOR ACTION 701 4. Develop
- Page 705 and 706:
ICONSENSUS FOR ACTION] 703 ILISTENI
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[ 705 [6 People living with HIV, an
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707 Clinical guidelines are specifi
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709 Once a comparison is made betwe
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9, 711 People lving with HIV, and t
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713 I~ Glossary of Terms Benefidary
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APE ;I Risk Adjustment - A statisti
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APEDI_ Amerleass Psychological Asao
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G rn-ge BOARD OF DIRE( CTRS| 719 Ch
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721 their children and to participa
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723 families responding had childre
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725 improve family satisfaction by
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Implications 727 most unmet needs i
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729 Family Voices will use lessons
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Table 2 1 Family Voices Survey on <
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I Table 3 Family Voices Survey on <
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Table 5 Family Voices Survey on <st
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737 Table 7 (continued) Family Voic
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739 Table 9 Family Voices Survey on
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741 Table 10 (continued) Family Voi
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743 Table 12 Family Voices Survey o
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2of II 745 acute care, while 43 per
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4 of II 747 state-only programs pro
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Cost Shfting mnd Medicaid</
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751 MsliC20 EV tUres for mgerl Bmda
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hot33 753 tam beiacn 34 261.3 39.3
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755 Protecting Consumer Rights in P
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-WHAT IS "MEDICALLY NECESSARY" IN M
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759 only to those for whom they are
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761 requirements or oversight, who
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763 disturbance who depend upon the
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765 the appeal system can then be s
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767 legally binding requirement on
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769 - ewrise satisfies the standard
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771 odic screens on a regular hasis
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773 quest, am awilablefor review by
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The Bazelon Center fur Mental Healt
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777 MANAGED CARF & V , AMER VUI.FRA
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* Unk the child with a primary care
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781 Protecting Consumer Rights in P
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783 dress this issue and omits requ
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785 groups, ombudsman programs hot
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787 b) Utilization-Review Criteria
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789 ual practitioners who work in s
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791 member for failure to 'follow p
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793 BAZELON CENTER T he following m
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lose their jobs. 795 "Governor Pata
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797 Raske, who is on far better ter
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799 PREAMBLE Over the past decade,
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801 standards for managed care. The
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II. Quality 803 Managed</st
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805 2. advocating publicly for comm
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807 * appeals and grievance policie
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809 VII. Financial Responsibility T
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Acknowledgments Sponsors: k publica
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Executive Summary The political con
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Page 6 815 need habilitation and th
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Objectives & Methods Brian Ashby an
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The Pediatrician Foilig say the p-i
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Family Perceptions & Needs Page 12
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Trips to Courage Center WhilMkphysi
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825 Cost & Utilization Analysis Cos
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827 Community Advisory Council n In
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Page 20 829 What Can HealthPartners
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Page 22 831 What Can Communities Do
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Collaborators Advisory Board Barbar
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835 Over the past two years, the Na
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837 CURRENT POLICYMAKING ENVIRONMEN
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Fee-for-service payment systems pen
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841 Managed <stron
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* Plans must contain adequate provi
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845 participate in the redesign pro
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Summnary: Premium adjustors to neut
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* Discouraging the use of specific
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actuarially manageable service pack
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individual case or for an individua
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8. For a recent review of this and