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New Medicaid populations being integrated into managed care
For Medicaid programs that have good relationships with managed care contractors already in place, it's a "natural development" to add the population of seniors and people with disabilities, says Alice R. Lind, RN, MPH, senior clinical officer at the Center for Health Care Strategies (CHCS) in Hamilton, NJ. "The timing is right now, because budgets are tight."
Over time, states have had to add in a lot of requirements for the high-needs population anyway, Ms. Lind explains. "Even in the relatively healthy mom and kid population, there are children with mental health needs, and women with high-risk pregnancies," she says. "So most state managed care programs have been dealing with the disabled and chronically ill population for a number of years anyway."
Gradual phase in
CHCS provided technical assistance for California in developing its 1115 waiver, says Ms. Lind, which included a component for moving its Seniors and Persons with Disabilities (SPD) population, known as Aged, Blind and Disabled in other states, into managed care.
During the early planning for the waiver proposal, Ms. Lind says that key informant interviews were done with stakeholders to gather input on the best approaches to ensure a medical home for the SPD population. "We also looked at performance measures," she says. "The state is planning to look at changes in utilization, and how beneficiaries interact with health plans after managed care is implemented."
In June 2011, managed care will be implemented for the SPD population in California's Medicaid program, rolled out by the birth date of the beneficiaries, reports Ms. Lind. "They are planning on a one-year gradual phase-in, done by groups of beneficiaries as opposed to geographically," she says.
In most plans, the addition of the SPD population means that health plan services must meet new requirements, says Ms. Lind. For example, there is a requirement to determine whether the beneficiary is high or low risk, she says, and any high-risk member must have a Health Risk Assessment completed within a certain number of days.
"The plan must be well aware of what the beneficiary's needs are, and any deteriorating conditions," says Ms. Lind. The reason for the gradual phase-in, she explains, is so the health plans can meet the needs of the newly enrolled.
ID future care needs
"You don't want to give the plans 100,000 clients on the first day. They have a hard time staffing up to deal with a huge wave of people getting enrolled at once," says Ms. Lind. "They much prefer California's incremental method of rolling enrollment by birth month."
California had a voluntary enrollment option for managed care for the disabled population in place, says Ms. Lind, and this will now become mandatory. "They are making sure they have the right set of consumer protections in place," she says.
While there were existing requirements for provider's offices to be accessible, a facility site assessment will now be done, says Ms. Lind. "They are going from office to office to see whether it is accessible by a person with a wheelchair," she says. "Those findings are going to be made public on the health plan's website."
Previously, case managers helped members to find accessible offices, says Ms. Lind, but now this information needs to be readily available to a much larger group of people.
The state will share prior utilization about new members with the plan shortly after the person becomes an enrollee, reports Ms. Lind. "The health plans have gotten really good at using data to identify folks at high risk," she says. "Now they will have a year or two of historical data. It helps them identify future care needs, so they can do more active outreach."
Contact Ms. Lind at (609) 528-8400 or firstname.lastname@example.org.