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THE STATE OF AMERICA'S CHILDREN YEARBOOK 199..8 ..1 The 1997 Balanced Budget Act made major changes in these rules-the most significant changes pertaining to managed care in Medicaid history. Medicaid managed care will now operate with much less oversight by HCFA and more state autonomy, although it will be governed by far more specific federal statutes. Whether children receive good care depends, now more than ever, on state officials and advocates. Under the new law, states no longer need federal waivers to force most Medicaid beneficiaries to enroll in managed care, and the 75/25 rule is repealed. Waivers are still required, however, for children with disabilities, children in foster care or other out-of-home placements, children receiving adoption assistance under title IV-E of the Social Security Act, people eligible for both Medicaid and Medicare, and certain Native Americans. Two types of managed care entities-managed care organizations (MCOs) and primary care case managers (PCCMs)-are permitted under the new law. MCOs provide a range of services from a closed network of providers in exchange for a set fee per beneficiary (a capitated payment). PCCMs locate, coordinate, and monitor an enrolled beneficiary's receipt ofservices and function as gatekeepers. A PCCM may be a physician, a physician group practice, a physician assistant, or a nurse practitioner. Both types of managed care entities may be responsible for either all Medicaid-covered services or only some, in which case beneficiaries are free to choose providers for services not subject to managed care. In an effort to protect consumers, the new law sets forth detailed rules for Medicaid managed care programs. Features include: • Choice of health plans. As a general rule, states must give beneficiaries a choice of at least two managed care entities, although options may be more limited for some beneficiaries (those in rural areas, for example). Beneficiaries may change managed care entities at any time for good cause, any time within the first 90 days after initial enrollment, or annually thereafter. Beneficiaries who fail to choose a managed care entity are assigned one by the state, according to established criteria that take into account prior relationships with particular providers. • Adequate access to care. MCOs must demonstrate the capacity to serve expected enrollment by offering an appropriate range of services, access to preventive and primary care, and a sufficient number and mix of providers. In situations considered medical emergencies (in the judgment of an ordinary, prudent person, not a health professional), diagnosis and stabilizing treatment must be covered without requiring prior approval or limiting beneficiaries to a specified network of providers. • Access to information. Providers are required to give beneficiaries clear information on a variety of topics, including their rights and responsibilities, covered services, benefits available outside the managed care entity, costs, participating health care providers, service area, quality and performance indicators, and grievance and appeal procedures. In addition, MCOs generally may not impose "gag rules" that prevent network providers from discussing medical options with enrollees. • Regulation and oversight. By August 5, 1998, HCFA must issue quality assessment and improvement standards that states must follow. States likewise must establish and periodically review quality standards and monitoring procedures for MCOs. States must ensure annual, external, independent review of the care furnished under each MCO contract and make the results publicly available. Strict rules also apply to the marketing of managed care entities. For example, marketing materials must be approved by the states and may not contain false or misleading information. Potential changes for private managed care. In 1997 state legislatures remained deeply involved in managed care issues. More than 1,000 bills were introduced, with more than 200 enacted. However, federal law (ERISA) forbids states from regulating managed care for employers who "self-insure"-that 32 CHILDREN'S DEFENSE FUND
CHILO HEALTH is, for those who assume the legal responsibility of paying for their workers' health care (although many such employers use insurance companies to administer health coverage). Forty percent of Americans with coverage through work have employers who self-insure. These workers and their families are not protected by state statutes regulating managed care; only the federal government can give them the protection ofconsumer safeguards. Toward the end of 1997, several events foreshadowed a major congressional struggle in 1998 over managed care safeguards. In November 1997 the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry recommended enforceable, national standards to strengthen consumers' rights. The President called for federal legislation to imple. ment these recommendations. However, while consumers and others were pushing for stronger patient protections, opposition began to form among some insurers, employers, and other interest groups. Newspapers reported meetings between such interest groups and the majority leadership in Congress to plan strategy for blocking enactment of managed care safeguards. These events were accompanied by the intrcr duction of major managed care legislation with considerable bipartisan cosponsorship in the House and Senate. More than 70 health care quality bills were introduced in Congress in 1997, and advocates of managed care reform promised vigorous action in 1998. Progress in Maternal and Child Health According to data released in 1997 by the National Center for Health Statistics (NCHS), fewer women died of complications during childbirth in 1995 than in 1994, a higher percentage of babies were born to mothers receiving early prenatal care, and fewer babies died before their flISt birthday. At the same time, however, the percentage of babies born at low birthweight (5.5 pounds or less) remained at its highest level in 20 years. Other newly released data from NCHS show modest health gains for Black children and pregnant women in 1995. Infant mortality and low birthweight were down and prenatal care rates were up, continuing their improvement since 1990. This has been a welcome trend after nearly a decade of stagnant or worsening indicators in low birthweight and prenatal care during the 1980s. Improvement in Black infant mortality in particular accelerated after the Medicaid expansion in 1989, which was accompanied by a broad range of community-based efforts to reduce infant deaths among Blacks. The five years before 1989 saw only a 3.1 percent reduction in Black infant mortality, while the mortality rate dropped more than 16 percent between 1990 and 1995. Following are some key statistics. The appendices present additional data on rates of early prenatal care, low birthweight, and infant mortality. • The overall infant mortality rate has been falling for decades, reaching a record low in 1995 (the latest year for which frnal data are available). In that year, 29,583 babies died before their first birthday, putting the rate at 7.6 deaths per 1,000 live births-far below the infant mortality rate of 17.7 two decades earlier (see table 2.3). Put differently, had infant mortality remained at its 1973 level in 1995, nearly 40,000 more American babies would have died before their flISt birthday. • Although infant mortality declined among White, Black, and Hispanic infants in 1995, a disproportionate number ofBlack babies died. In 1995 the mortality rate for Black infants was 15.1 per 1,000 live births-more than twice that for Whites (6.3 per 1,000 live births). Hispanics had an even lower rate (6.1 per 1,000 live births), although the r,ates for different groups ofHispanics vary widely. • In 1995, 81.3 percent of babies were born to mothers who received early prenatal care, up from 80.2 percent in 1994. Good news is also emerging in the battle against childhood AIDS. Between 1992 and 1996 CHI LOR E 'S 0 E FEN S E FUN 0 33
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About CDF he Children's Defense Fun
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Copyright © 1998 by Children's Def
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THE STATE OF AMERICA'S CHILDRE YEAR
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THE STATE OF AMERICA'S HILDREN YEAR
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