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Medicaid Managed Care for Older Persons and Persons with Disabilities: National Overview
PRESENTATION BY PAUL SAUCIER
at the NATIONAL ACADEMY FOR STATE HEALTH POLICY 24TH ANNUAL CONFERENCE, KANSAS CITY, MISSOURI
OCTOBER 4, 2011
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NATIONAL MEDICAID MANAGED CARE ENROLLMENT, 2009
14.3
36.2
0
5
10
15
20
25
30
35
40
Original Medicaid Managed Care
millions
CMS: “Medicaid Managed Care Enrollment as of June, 2009”
https://www.cms.gov/MedicaidDataSourcesGenInfo/04_MdManCrEnrllRep.asp
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TYPES OF MEDICAID MANAGED CARE
• Comprehensive risk contracts: capitation for a wide range of services (e.g., primary, acute, behavioral, dental)
• Carve-out risk contracts: capitation for one type of service (most common are behavioral, dental, transportation)
• Primary Care Case Management: PCP receives monthly PMPM payment for care management; services are reimbursed FFS
• Medical/health home can occur within risk or PCCM arrangements
4
RISK-BASED MMC IS THE DOMINANT FORM
7.2
23.5
19.2
0
5
10
15
20
25
PCCM Risk MCO Risk Other
millions
CMS: Derived from “Number of Managed Care Entity Enrollees by State as of June, 2009”
https://www.cms.gov/MedicaidDataSourcesGenInfo/04_MdManCrEnrllRep.asp
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ENROLLMENT OF OLDER PERSONS OR PERSONS WITH DISABILITIES• National enrollment is not reported by eligibility
category.
• CMS does publish the National Summary of State Medicaid Managed Care Programs which lists all MMC programs and the populations they serve.
• The 2009 Summary identified 48 states that enrolled older persons or persons with disabilities.
• Only West Virginia and Wyoming did not.
• In many states, adults with disabilities are enrolled in more than one program.
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IN 2009, ALL BUT 2 STATES ENROLLED OLDER PERSONS OR PERSONS WITH DISABILITIES IN MANAGED CARE
Enroll Do Not Enroll0
10
20
30
40
50
48
2
CMS: National Summary of State Medicaid Managed Care Programs, June, 2009
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38 OF THE 48 INCLUDED OLDER PERSONS AND PERSONS WITH DISABILITIES IN RISK-BASED MANAGED CARE
Include in Risk-Based Plans
PCCM Only05
10152025303540
38
10
CMS: National Summary of State Medicaid Managed Care Programs, June, 2009
8
28 OF THE 38 INCLUDED OLDER PERSONS AND PERSONS WITH DISABILITIES IN COMPREHENSIVE PLANS
Comp. Plans BH/SA, Transporta-tion, Dental or Dis-ease Management
Only
0
5
10
15
20
25
30
28
10
CMS: National Summary of State Medicaid Managed Care Programs, June, 2009
OCTOBER 2010 KFF SURVEY
“A majority of states reported that, for at least one Medicaid managed care program and/or
geographic area, they also mandate enrollment in managed care for children with disabilities receiving Supplemental Security Income (SSI), children with special health care needs, and seniors and people
with disabilities who are not dually eligible for Medicare and Medicaid.”
Gifford et al., A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey. Kaiser Commission on Medicaid and the Uninsured, September, 2011.
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10
POTENTIAL BENEFITS OF MANAGED CARE FOR OLDER PERSONS AND PERSONS WITH DISABILITIES
• Better access to primary care/medical home
• Better management of chronic conditions
• Diversion from emergency rooms
• Better management of hospital stays and prevention of readmissions
• Better care coordination
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CONCERNS ABOUT MMC AMONG OLDER PERSONS AND PERSONS WITH DISABILITIES
• Inadequate specialty capacity
• Loss of relationships with existing providers
• Restrictions on DME and supplies
• Loss of control, particularly among persons who self-direct services
• Medical model
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LESSONS LEARNED
• Cultivate long term collaborative relationships with contractors
• Measure performance, which requires early attention to data gathering and analysis
• Engage stakeholders early and continuously
• Build effective administrative infrastructure
• Adapt to local conditions(Hurley & McCue, 2000; Verdier & Hurley, 2004; Schneider et al., 2004;
Barth 2007; Bella et al., 2006 )
