Beyond the Water's Edge: Charting the Course of Managed Care for People with Disabilities - Conference Resource Book. State Medicaid Managed Care Policies Affecting Children with Chronic or Disabling Conditions

11/01/1996

Harriette B. Fox
Harriette Fox is the President of Fox Health Policy Consultants, a small Washington-based consulting firm specializing in the financing and delivery of maternal and child health services, and the co-director of the Maternal and Child Health Policy Research Center. She has had extensive experience managing projects examining Medicaid, private health insurance, and other financing arrangements to support services to children, with a particular focus on issues pertaining to managed care and health insurance reform. Her work has included analyses of Federal laws and policy options; evaluations of State Medicaid and maternal and child health programs; surveys of State and private industry insurance practices; and consultation to numerous State and private organizations. She has published extensively on the subject of health care financing and children. Before establishing Fox Health Policy Consultants in 1982, Ms. Fox was the Senior Program Analyst for the Select Panel for the Promotion of Child Health. She also had served as a consultant to the Institute of Medicine and the National Health Policy Forum.

Margaret McManus
Margaret McManus is President of McManus Health Policy, Inc., a small consulting firm which specializes in managed care and health insurance reform affecting children. She also co-directs a Maternal and Child Health Policy Research Center for Paul Newacheck and Harriette Fox, funded by the Federal Maternal and Child Health Bureau. For the past 15 years, Ms. McManus has consulted with the American Academy of Pediatrics' Committee on Child Health Financing and a variety of other national, State, and local organizations. She has recently assisted the Maternal and Child Health Bureau in convening a series of managed care work groups on definitions, capitation and risk adjustment, quality of care, and family participation. Ms. McManus has published extensively on the subject of health care financing and children. Most recently, with Harriette Fox, she has completed a report entitled, Medicaid Managed Care for Children with Chronic or Disabling Conditions: Improved Strategies for States and Plans.

TABLE 1. State Medicaid Policies Regarding Children Served by Fully Capitated Plans
DRAFT-Not for Publication
State Categorical Groups Enrolled Voluntary or Mandatory Enrollment1 Specific Exemptions for Non-institutionalized Special-Needs Children Pediatric Services Carved Out of Managed Care Contracts2
Arizona AFDC, AFDC-related, SSI Mandatory Children receiving developmental disability services Mental health and substance abuse (capitated), hospice, personal care, specialty services for CSHN-eligible children
California4 AFDC, AFDC-related, SSI, Foster Care Mandatory in 3 counties; voluntary in 17 counties; mandatory for AFDC only in one county None Mental health services for SED-eligible children, intensive substance abuse, early intervention, health-related special education, dental5(capitated), certain comprehensive case management, specialty services for CSHN-eligible children
Colorado AFDC, AFDC-related, SSI, Foster Care Voluntary None Intensive mental health, certain substance abuse, intensive ancillary therapies, dental, hospice, personal care
Delaware AFDC, AFDC-related, SSI, Foster Care Voluntary None Mental health, substance abuse, health-related special education, dental, prescription drugs
District of Columbia AFDC, AFDC-related Voluntary None Mental health, substance abuse, early intervention, health-related special education, dental, vision
Florida AFDC, AFDC-related, SSI, Foster Care Voluntary Children receiving CSHN services Intensive mental health, intensive substance abuse, hospice, dental5, vision5, personal care, multi-handicap assessments, specialized services for foster care children
Hawaii AFDC, AFDC-related, Foster Care, Demonstration Eligibles Mandatory None Mental health services for SED-eligible children (capitated), dental (capitated), personal care
Illinois AFDC Voluntary None Dental (capitated), vision, comprehensive case management
Indiana AFDC, AFDC-related Voluntary None Mental health, substance abuse, vision
Iowa AFDC, AFDC-related6 Voluntary None Substance abuse, health-related special education, dental, prescription drugs5, durable medical equipment5
Maryland AFDC, AFDC-related, SSI Voluntary None Certain early intervention, certain health-related special education, hospice, personal care, certain EPSDT expanded benefits7
Massachusetts AFDC, AFDC-related, SSI Voluntary None Dental, prescription drugs, vision, personal care, intensive durable mental equipment5
Michigan AFDC, AFDC-related, SSI, Foster Care Voluntary Children receiving CSHN services Intensive mental health, health-related special education, certain dental, personal care
Minnesota AFDC, AFDC-related Mandatory in eight counties; voluntary in one county Children who are determined to be seriously emotionally disturbed prior to enrollment, determined blind or disabled but not eligible for SSI, likely to be terminally ill, or receiving an adoption subsidy8 Case management for SED-eligible children
Missouri AFDC Mandatory None Mental health services for SED-eligible children, intensive substance abuse, health-related special education, dental, prescription drugs, hospice, certain case management, EPSDT expanded benefits
New Hampshire AFDC, AFDC-related, Foster Care Voluntary None Intensive mental health, intensive substance abuse, intensive ancillary therapies, early intervention, health-related special education, dental, prescription drugs, intensive personal care, comprehensive case management, durable medical equipment
New Jersey AFDC, AFDC-related, SSI, Foster Care Voluntary Children who have chronic debilitating conditions, language difficulties, or who have a provider relationship that would be substantially disrupted Mental health, substance abuse, intensive ancillary therapies, health-related special education, personal care
New York AFDC, AFDC-related, Foster Care (not in NYC) Mandatory in one borough; voluntary elsewhere Children receiving CSHN services, certain children who have specific medical needs that cannot be met through an HMO Intensive mental health, intensive substance abuse, early intervention, health-related special education, dental5, vision5, hospice, personal care, comprehensive case management, durable medical equipment5
North Carolina AFDC Voluntary None Mental health and substance abuse (both capitated), dental, vision, personal care
Ohio AFDC, AFDC-related Mandatory in two counties; voluntary elsewhere None Hospice
Oregon AFDC, AFDC-related, SSI, Demonstration Eligibles Mandatory in 28 out of 36 counties Children who have an existing provider relationship that would be disrupted or who have specific medical needs that cannot be met through the HMO9 Mental health in all but 3 counties, intensive substance abuse, health-related special education, dental5 (some capitated), personal care
Pennsylvania AFDC, AFDC-related, SSI, Foster Care Mandatory in one county; voluntary elsewhere None Certain intensive mental health, early intervention, personal care, specialized services for foster care children5, certain services for mentally retarded and developmentally disabled children
Rhode Island AFDC, AFDC-related, Demonstration Eligibles Mandatory None Intensive mental health, mental health services for SED-eligible children, intensive substance abuse, certain early intervention, certain health-related special education, dental, personal care, comprehensive case management, EPSDT expanded benefits
Tennessee AFDC, AFDC-related, SSI, Foster Care, Demonstration Eligibles Mandatory None Intensive mental health, personal care
Texas AFDC, AFDC-related Mandatory None Intensive mental health, early intervention, health-related special education, dental, vision, prescription drugs, comprehensive case management, durable medical equipment, EPSDT expanded benefits
Utah AFDC, AFDC-related, SSI, Foster Care Voluntary None Mental health (capitated), substance abuse, early intervention, health related special education, dental5, prescription drugs5, certain services for mentally retarded and developmentally disabled children
Virginia AFDC, AFDC-related Voluntary None Intensive mental health, health-related special education
Washington AFDC, AFDC-related Mandatory Children whose distance from delivery sites makes enrollment impractical, who have language difficulties, who have an existing provider relationship that would be substantially disrupted, or who have a significant medical need that cannot be met through the HMO10 Most mental health (capitated in some areas), substance abuse, early intervention, health-related special education, dental, eyeglasses, personal care, comprehensive case management
Wisconsin AFDC, AFDC-related Mandatory None Dental5
AFDC-related = children who qualify for Medicaid because of their poverty-level status as regular or optional Medicaid eligibles as well as children whose families meet the AFDC income criteria but do not receive AFDC benefits.
CSHN = state Title V program for children with special health care needs
SED = state comprehensive community mental health services program for children and adolescents with serious emotional disturbances
  1. In some states, Medicaid-eligible children were required to choose between enrollment in a fully capitated plan or in another form of managed care, such as a primary care case management program. These states are shown as having voluntary enrollment.
  2. Use of the qualifying term "inclusive" in this column means services beyond plan limits or services required by special high-need populations. The use of the qualifying term "certain" means only particular services within a category or services provided by a specific type of provider (usually a publicly-funded provider). Where the word "capitated" appears in parentheses after a service, this means that the state had developed a separate capitated arrangement for this service.
  3. Arizona enrolls children in foster care in a separate fully capitated plan.
  4. California is operating a number of different Medicaid managed care arrangements and policies differ across arrangements. Information in the table is correct for the geographic managed care model.
  5. Plans have the option of including this service in their contracts.
  6. Iowa allows AFDC and AFDC-related children who enter into foster care to continue to receive care through an HMO, if they elect to do so. In such instances, specialized services for foster care children are paid for separately.
  7. A carve-out of "EPSDT expanded benefits" means that a state had carved out of its contract federally-allowable Medicaid services that would not otherwise be covered under its regular Medicaid plan or expanded coverage of services that otherwise would have limitations.
  8. Minnesota also exempts children who are refugees or who have a primary care provider outside of Itasca County from HMO enrollment.
  9. Oregon also exempts children who are Native Americans from HMO enrollment.
  10. Washington also exempts children who are Native Americans or homeless from HMO enrollment.
SOURCE: Information was obtained by Fox Health Policy Consultants through telephone interviews with state Medicaid agency staff during the spring and summer of 1994 and was verified by the states as being accurate as of March 31, 1995.

 

TABLE 2. Medicaid Services to Children Excluded from Contracts
DRAFT-Not for Publication
Services Carved Out of Contracts Number of States (n=29) Percent of States
Dental services 20 69%
Health-related special education services 16 55
Personal care 15 52
Some mental health services 13 45
Early intervention services 10 34
Case management 9 31
All mental health services 9 31
Vision services 9 31
Prescription drugs 7 24
Hospice 7 28
Durable medical equipment 5 17
EPSDT expanded benefits 4 14
Some ancillary therapies 3 10
CSHN specialty services 2 7
Specialized services for foster care children 2 7
SOURCE: Information was obtained by Fox Health Policy Consultants through telephone interviews with state Medicaid agency staff in March 1995, and was verified by the states as being accurate as of March 31, 1995.

 

TABLE 3. EPSDT Language in State Medicaid Managed Care Contracts Regarding Diagnosis and Treatment
State Specifies and Explains the EPSDT Benefit1 Includes Core Elements of OBRA '89 EPSDT Language Incorporates Federal EPSDT Law or Rules by Reference Incorporates State EPSDT Law or Rules by Reference
Requires services to correct or ameliorate identified defects, illnesses, or conditions Requires services for both physical and mental health problems Requires all federally allowable diagnostic, treatment, and other health care services
Arizona X X X X   X
California X         X
Colorado X       X  
Delaware X X X X X  
District of Columbia            
Florida X     X X X
Hawaii X X X X X  
Illinois X X X   X  
Indiana X       X  
Iowa X       X  
Maryland X X   X    
Massachusetts X X   X X X
Michigan X       X  
Minnesota X       X  
Missouri2 X     n/a X  
New Hampshire X X X X X  
New Jersey X X X   X  
New York X X X X    
North Carolina X X X      
Ohio X         X
Oregon3 n/a n/a n/a n/a n/a n/a
Pennsylvania X X X X X  
Rhode Island2 X X   n/a    
Tennessee X       X  
Texas2 X     n/a X  
Utah X X X X    
Virginia X X X X    
Washington X   X   X X
Wisconsin X X X X X X
TOTAL 27 of 28 15 of 28 13 of 28 12 of 25 18 of 28 7 of 28
  1. Certain states substitute their own program names for the Early Periodic Screening, Diagnosis and Treatment benefit. For the Purposes of this analysis, these states were considered to have specified and explained the EPSDT benefit if their contracts explicitly addressed each component (screening, diagnosis and treatment) in their definition of the benefit.
  2. This state's contract excludes all expanded EPSDT benefits (services beyond those included in the state plan). However, the contractor is responsible for all other diagnostic and treatment services.
  3. Oregon has waived EPSDT requirements under a Section 1115 waiver.
SOURCE: Information is based on an analysis of contracts in effect in December 1995, performed by Fox Health Policy Consultants. Provider manuals, administrative rules, and other documents referenced in the state contracts were included in the analysis.

 

TABLE 4. Medical Necessity Language in State Medicaid Managed Care Contracts
State Medical Necessity Defined in Contract If included in contract, Criteria Used to Define Medical Necessity
General Child-Specific Includes Services for Preventive Purposes as well as Diagnostic and Treatment Purposes Includes Treatments for a "Condition," "Disability," or "Handicap" in Addition to an "Illness or Injury" Qualifies Terms Such as "Disability," "Handicap" or "pain" with "severe" of "significant" Requires Conformance with Standards of Good Medical Practice or Prevailing Community Standards Requires the most appropriate level of services that can be provided safely Requires the Least Costly Alternative Treatment of Equal or Reasonably Equal Effectiveness Requires Evidence of Effectiveness or Proven Medical Value
Arizona X   X X          
California                  
Colorado X   X X   X X    
Delaware                  
District of Columbia                  
Florida X   X X X X X X  
Hawaii X         X      
Illinois X     X   X      
Indiana                  
Iowa X     X   X   X  
Maryland X   X            
Massachusetts X   X X   X      
Michigan                  
Minnesota X   X X X X      
Missouri                  
New Hampshire   X X X          
New Jersey                  
New York X   X X X        
North Carolina                  
Ohio X       X X   X  
Oregon X   X     X X   X
Pennsylvania                  
Rhode Island X     X          
Tennessee X         X X    
Texas                  
Utah                  
Virginia                  
Washington X   X X   X   X  
Wisconsin X   X X   X X X X
TOTAL 16 of 29 1 of 29 11 of 17 with definitions 12 of 17 with definitions 4 of 17 with definitions 12 of 17 with definitions 5 of 17 with definitions 5 of 17 with definitions 2 of 17 with definitions
SOURCE: Information is based on an analysis of contracts in effect in December 1995, preformed by Fox Health Policy Consultants. Provider manuals, administrative rules, and other documents referenced in the state contracts were included in the analysis.

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