Medicaid Managed Care Key Concerns

1. Medicaid Managed CareKey Concerns • Input of Stakeholders • Enrollment and Marketing • Services and Benefits • Access to Experienced Providers • Reimbursement • Quality Management and Monitoring

2. Ryan White Programs public health mission population driven enabling services medically and culturally appropriate providers provide care to uninsured accessible sites experience with vulnerable populations social model MCOs for profit mission market driven mandated benefits only cost efficient contracted providers care only to members “commercial” sites experience with middle class medical insurance model Ryan White Programsand MCOs

3. Input of Stakeholders • Inclusion of stakeholders • e.g. waiver development, implementation & monitoring of waiver • Defining key terms e.g. case management, gatekeeper • Participation in quality assurance activities

4. Enrollment andMarketing • Awareness of HIV/AIDS among eligible beneficiaries • Protections against discriminatory practices • Assuring patient confidentiality • Provision of enrollment materials sensitive to HIV: • exemption options, lock-in periods, changing providers, disenrollment, grievance procedures • on site enrollment by RW funded providers, other SNP • Variables in default assignment algorithm • assignment to traditional provider of care

5. Services and Benefits • Comprehensive benefit package • Rx, substance abuse treatment, mental health, wide range of specialty medical care, home health, infusion therapy, dental services, hospice, nutritional counseling , • Case management to coordinate w/wrap around services • housing, food services, transportation, vocational counseling, non-covered services • Definition of medical necessity • Access to new treatments and therapies • Viral load, protease inhibitors, clinical trials

6. HIV Providers • Expert & experienced providers in HIV disease • survival has been linked directly with patient’s access to experienced HIV care providers • Designation & role of gatekeeper • Specialists as gatekeeper • Referrals to specialists • delays/denials can have catastrophic impact • Provisions for out of network providers • Adequate number & distribution of primary & specialty care • Inclusion of traditional providers of care, especially Ryan White Funded programs

7. Quality Assurance • Indicators to assess quality & utilization of services for PLWH • Standards to assure access to primary care and specialty care providers • Consumer Satisfaction Surveys • importance of over-sampling • Expedited grievance procedures

8. Reimbursement • Adequate reimbursement to MCOs & providers to cover cost of providing care • assurances of adequate reimbursement to providers in contracts • Use of risk adjustment • Variables used to develop rates • Inclusion of Rx therapies in capitation • Rates adjustments to account for costly new therapies & lab tests

9. Challenges to CBOs • Loss of clients • Decreased patient revenues • 33% of Title III clients have Medicaid coverage; 11% with Medicare or private insurance • Increased costs • caring for more uninsured patients • patients with managed care coverage • Loss of traditional referral sources • Cultural Change - • Learning to be competitive, marketing Services to MCOs • Believing managed care is “here”