Managed Care & Persons with Disabilities & Chronic Illnesses

Quality Assurance/Consumer Protection

State Issues, Strategies, & Experiences

This session began with Trish Riley identifying a set of key issues that States must address in developing a quality assurance/consumer protection strategy for persons with disabilities who are enrolled in managed care plans. They included:

• What do you want to achieve for these populations? What special expectations do you have for health plans?
• How do you translate your expectations to health plans?
• How do you assist plans in meeting your expectations?
• How do you know if plans are meeting your expectations and what do you do if you don't?

In discussing these questions, Ms. Riley shared with participants information on the activities being pursued by individual States, as well as several federally sponsored quality assurance and improvement initiatives.

Ms. Riley's overview was followed by several presentations on individual States' efforts. Tina Kitchin began by describing Oregon's approach to ensuring that the needs of persons with disabilities were met by managed care plans as part of the State's Oregon Health Plan initiative, which included the enrollment of the Supplemental Security Income (SSI)-related Medicaid population into managed care. These efforts included:

• The heavy involvement of persons with disabilities in the planning of the initiative.
• The establishment of Exceptional Needs Care Coordinators within health plans.
• The requirement for the provision of medically appropriate, rather than medically necessary, services by plans.
• Differential capitated rates across eligibility categories.
• A heavy emphasis placed on communication.
• The establishment of other safeguards, including an ombudsman program and mechanisms to ensure continuity of care.

Stephanie Davis then discussed the quality assurance and consumer protection efforts undertaken by the Arizona Health Care Cost Containment System (AHCCCS). These included:

• Risk adjusted capitation rates paid across eligibility classes and reinsurance provisions.
• The establishment of network requirements concerning specialty providers and case management.
• The conduct of monitoring activities and member surveys.

Betsy Laitinen returned to describe the features of the Community Medical Alliance (CMA), a managed care program specifically designed to care for persons with disabilities that is under contract with Massachusetts Medicaid. She described the nurse practitioner/physician care management model used by the program and its emphasis on providing care in the most appropriate setting, including the home.

In emphasizing CMA's flexibility in meeting patients' needs in as appropriate a manner as possible, Ms. Laitinen also described a number of the services that it provides on an as-needed basis that may not be included in standard managed care plan benefit packages. These included:

• Home modifications.
• Non-emergency transportation.
• Assisted living.
• Adaptive equipment.
• Nutritional supplements.

The last panelist, Janet Freeze, discussed the consumer protection and quality assurance provisions being put in place as part of Maryland's new Health Choice Medicaid managed care initiative, many of them based upon consumer input received during the program design phase. They include:

• Specific definitions developed for special needs populations.
• Special health plan access, network, and service requirements established for these populations.
• A special case management program created for "rare and expensive" conditions.
• Monitoring activities targeted to ensure plans are meeting the needs of these special populations.

References

Booth M. Look Before You Leap. Assuring the Quality of Care of Managed Care Programs Serving Older Persons and Persons with Disabilities. Maine: National Academy for State Health Policy, 1996.

State of Oregon, Department of Human Resources. Office of Medical Assistance Programs 1997. "Oregon Health Plan Adult Satisfaction Survey."

Ancillary Services Work Group, OMAP. "Ancillary Services Criteria for OHP." January 1995.

Oregon Advocacy Center and Oregon Developmental Disabilities Council. To Your Health: Choosing the Health Care That is Right for You. pp. 6-8, 19-21.

Maryland Register. Emergency Action Regulations. Title 10: Department of Health and Hygiene. Vol. 23, Issue 25, December 6, 1996.

Sofaer S. Consumer Satisfaction and Quality Standards: An Overview of Research and Policy Issues Relevant to How Managed Care Responds to the Needs of Persons with Disabilities. Reproduced for Beyond the Water's Edge: Charting the Course of Managed Care for People with Disabilities: November 1996. pp. 1-26.

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