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Advocates Should Take Advantage of Opportunities to Participate in Developing and Implementing Managed Care Programs for Medicaid
May 10, 2012 | David Heymsfeld
By David Heymsfeld, AAPD Policy Advisor
On May 4th, AAPD President and CEO wrote to emphasize the importance of full participation by the disability community to ensure that the on-going shift to managed care for Medicaid services does not impair any health or support services that are vital for people with disabilities. If managed-care programs offer comprehensive health and support services, they hold promise of improving the coordination and the quality of the services we receive.
As health care costs spiral upward, states are moving toward creating managed-care Medicaid programs to address the financing and delivery of services to beneficiaries with serious disabilities and multiple chronic conditions, a population that has not previously been covered under traditional managed care programs. In most cases the transition to managed care will have to be approved by the Department of Health and Human Services as a new or amended “waiver” from the regular Medicaid requirements. In addition, HHS is considering state demonstration projects that propose to apply managed care approaches to so-called “dual eligibles,” who are eligible for both Medicare and Medicaid.
Under existing HHS regulations, advocates have the right to file comments with a state as the state develops a managed care proposal. After the state submits a proposal for approval by HHS there is a further right to file comments with HHS.
Advocates should be aware that each state will design its own proposal, and set its own schedule for comments. There are some excellent web sites that enable advocates to determine what each State is proposing, and the schedule for comments. For proposals for dual eligibles, see the site of the National Senior Citizens Law Center. For waiver proposals, see the site of the Center for Medicare and Medicaid Services. The requirements for public participation in waiver applications at the State and federal levels are summarized in a CMS Guidance letter.
There are many features of a State’s program that advocates should evaluate. Mark’s blog links to an excellent detailed summary of issues prepared by the National Disability Leadership Alliance.
Major issues include
- A managed care plan must give enrollees access to an adequate network of providers furnishing health care, behavioral health services and long term care services. There must be a sufficient number of providers in each specialty so that beneficiaries will be able to get needed care and services without excessive travel or delays in getting appointments.
- Managed care programs must provide a comprehensive range of services and supports across the health care continuum and lifespan.
- Programs must provide services and supports that are at least at the level of current programs.
- Enrollees must have access to appropriate durable medical equipment, prosthetics, orthotics, supplies and assistive technologies that allow daily function and the capacity for employment where possible.
- Enrollees with disabilities who are capable of working should have “Medicaid buy-in” opportunities that will foster independence.
- Managed care programs must emphasize patient individual choice, person-centered planning, and self-directed care. Beneficiaries in managed care must have choices in selecting service and support options, providers, and care settings. Beneficiaries and their representatives must be given the right to self direct their care if they choose to do so.
- Medicaid enrollees with disabilities, who are higher-need, higher-risk enrollees, should have the choice to opt in or out of new managed care programs while the states are experimenting with and refining their approaches.
- A managed care plan should emphasize home- and community-based services and supports. The majority of beneficiaries prefer to live in their homes, not in nursing homes. In addition, home and community-based services are less expensive than institutionalized care. Plans should include incentives for home- and community-based services and reduced admission rates to higher-cost long-term care institutions. Managed care programs must also include a transition out process for enrollees already in nursing homes.
- There must be full participation of stakeholders, including persons with disabilities, in the initial design of the program, and in oversight of the program.
- There must be strong and continuing oversight of the program by State and federal officials, with the necessary authority and expert knowledge. Managed care organizations must be required to implement reporting systems that permit an evaluation of the quality of services they are providing.
- The State must provide qualified advisors to help beneficiaries understand and deal with a managed care system. There must be a State agency with authority to overrule unjustified decisions by a managed care organization to deny coverage.
- There must be accommodations and assistance to ensure that persons with disabilities have full access to the system.
Finally, advocates should bear in mind that this is not a theoretical, long term problem. Many states are now in the process of developing managed care proposals, and receiving comments.
