Action Steps:
Managed Care Organizations.
By Jenifer Simpson, Senior Policy Associate and Susan
Goodman, Esq.
(1999)
States generally do not have experience in designing capitated systems of
high quality for people with disabilities. Furthermore, commercial health plans
have little experience in providing health-related services to people with
disabilities and are unaccustomed to addressing needs beyond acute care. In
order to ensure that the assistive technology (A.T.) needs of individuals with
disabilities are met in managed care systems, a great deal of work needs to be
accomplished by individuals with disabilities and their families.
Below are some suggestions for activities that can be undertaken by advocates
to move emerging health systems towards meeting the A.T. needs of individuals
with disabilities.
1. Find out how many managed care plans are in effect in the state and these
plans are doing to address the needs of individuals with disabilities. For
example, in the District of Columbia the plan for children with disabilities is
called "Health Services for Children With Special Needs."
2. Get documents describing the details of the plan including a copy of the
plan, promotional and introductory literature, the initial "request for
proposal" issued by the state, and the contract entered into by the state
and the managed care plan. It will probably take some time to pull all these
together; however they are crucial in assessing what plans do or do not cover,
and what they say will cover.
3. Review the specific language that addresses the needs of people with
disabilities. Pay particular attention to how "assistive technology,"
"medical necessity," and "home health services" are defined
or limited, if at all.
4. Start an initiative to uncover instances of denial of any of these
services. Collaborate with staff from the various Protection and Advocacy
(P&A) programs (e.g., the vocational rehabilitation Client Assistance
Program, P&A for the Mentally Ill, P&A for persons with developmental
disabilities). Their reports will be of great help in developing an analysis of
the strengths and weaknesses of managed care entities in serving individuals
with disabilities.
Collect and document denials of A.T. for individuals with disabilities.
Include detailed information about what type of service or device was requested
and the reasons given for denial. Also include a brief profile of the consumer
(age, sex, disability, etc.).
Often a verbal denial is given by an employee with the managed care
organization. He or she will say that home environmental controls cannot be
covered or that a scooter, hearing aid or customized seating for a wheelchair is
not allowed. The parent or adult customer may be told the reason is that it is
not on the list of "approved items," it is not "medically
necessary," it is not on the fee schedule that it is not reasonable to
approve it at this time."
In the case of evaluations and recommendations for certain types of devices
or services, the response may be "we've never done this before." It is
important to encourage managed care customers to ask for these type of denials
in writing. It is also important to ascertain if a 'right to appeal'
notification was given to the consumer. Document the cost of medical care that
arises from the failure to provide the customized device, such as personal care
services.
5. If feasible, develop a survey for a group of managed care customers
discussing their experiences when requesting specific assistive technology
(e.g., augmentative communication devices, scooters, FM hearing devices, lifts
or elevators in homes).
6. Develop a report on the lack of consumer responsiveness in managed care
organization. Release it publicly through press conferences and related media
contact. Also, make sure that the Health Care Finance Administration (HCFA) in
Baltimore, Maryland receives a copy of your report.
7. Work with the A.T. advocacy programs (including the state Protection and
Advocacy program) to challenge the managed care organizations for lack of
service and provision of A.T.
8. If your state is still developing the requirements for contracts with
managed care organizations, it is important to "be at the table". This
means that the technology-related assistance program must 'be invited' to
planning and development meetings with persons in the Governor's office, state
Medicaid office and the state administration for mental
retardation/developmental disabilities. The following issues and questions
should be raised to facilitate customer service to people with disabilities by
managed care organizations:
- Can/does the HMO cut off Medicaid services to a person with a disability
currently receiving under the fee-for-service system (e.g., home-based
services and therapies)?
- Is there a full range of providers in the managed care network (e.g.
prosthetics dealers, pediatric specialists, personal assistance aides,
mental health providers)?
- Is the managed care organization knowledgeable about the requirements of
Early Periodic Screening Diagnosis and Treatment (EPSDT) for children?
- Is the state Medicaid office aware of requirements in the Individuals with
Disabilities Education Act that relate to interagency collaboration and
funding responsibilities? How will the plan coordinate with students'
Individualized Education Plan (IEP) teams or Individual Family Service Plan
(IFSP) teams and providers?
- Are case management needs spelled out, especially for persons with
developmental disabilities?
- How are people transferred from small service intensive providers into
managed care networks? What is the state doing to ensure a smooth
transition?
- How will clinics that provide services related to A.T. be affected?
- What are the differences between how managed care organizations as opposed
to the state Medicaid provider views medical necessity. How do these impact
services related to A.T.?
- Has the state reported on any pilot projects?
- What consumer protections exist? For example, is there a clearly defined
grievance procedure? Is there an ombudsman that is responsive about
disability needs?
7. Keep us informed of the progress you make in your state.
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