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| Publications | ||
| Managed Care |
Reports: State SCHIP Requirements and Innovations for Children with
Special Health Care Needs The Strengths and Weaknesses of Private Health Insurance Coverage for Children with Special Health Care Needs by Harriette B. Fox, Margaret A. McManus, and Mary B. Reichman. Report, 62 pages, January 2002, $55.00. This report presents findings from a detailed analysis of private health insurance benefits for services important to children with special health care needs. The report examines the extent of plan coverage available for services required by six hypothetical children with different chronic conditions: asthma, attention deficit hyperactivity disorder, cerebral palsy, major depressive disorder with attempted suicide, spina bifida, and substance abuse with bipolar disorder. The analysis considers the availability of the benefit, access restrictions or protections relevant to the child´s particular condition, and limits in amount and duration of coverage. The report also provides a review of plan coverage policies for 22 medical, behavioral health, and specialized health services. Detailed tables on benefit limits and coverage requirements as well as cost-sharing provisions are included. Information for the study was obtained from contract documents for the most commonly sold HMO and PPO products in each state. Download a free pdf of this report. An Analysis of Safeguards for Children with Special Needs in States´ Medicaid Managed Care Contracts, 1999 by Harriette B. Fox, Margaret A. McManus, and Jonathan S. Austrian. Issue Brief No. 4, 24 pages, December 2000, $30.00. This issue brief provides an analysis of the extent to which the 34 states that mandatorily enrolled BBA special-needs child groups into managed care organizations at the end of 1999 used contract requirements consistent with HCFA´s interim review criteria. The brief includes background on the 34 states´ mandatory enrollment policies for each of the five BBA groups as well as an examination of their definitions for and methods of identifying these children; contract requirements concerning treatment plans, case management, and coordination; contract requirements concerning provider network capacity and access; and state policies governing quality assurance and payment protections. This analysis was based on telephone interviews with state Medicaid officials and an examination of state managed care contract documents. Pediatric Provider Networks for Children with Special Needs in the Current Health Insurance Market: Report from an Expert Work Group by Margaret A. McManus, Harriette B. Fox and Paul W. Newacheck. Report, 25 pages, November 2000, $35.00. This report summarizes the major barriers experienced by pediatricians serving children with special health care needs in managed care arrangements. The report includes a comprehensive literature review on pediatrician satisfaction with managed care. A set of recommendations to address these problems is also included. Download a free pdf of this report. An Analysis of States´ Medicaid Managed Care Enrollment Policies Affecting Children, 1996-1999 by Harriette B. Fox, Jonathan S. Austrian, Wesley Hsu, and Stephanie J. Limb. Issue Brief No. 3, 19 pages, October 2000, $25.00. This issue brief provides an analysis of states´ policies concerning the mandatory and voluntary enrollment of children into managed care entities at the end of 1999 and how these enrollment policies have changed over the four-year period between 1996 and 1999. It addresses both primary care case management (PCCM) programs and managed care organizations (MCOs) and also describes the approach taken by states that have elected to use the option to mandatorily enroll most Medicaid-eligible children into managed care without a federally approved waiver. Included in the report are detailed tables on the populations of children enrolled into PCCMs and MCOs, the type of enrollment requirement, and the geographic scope of enrollment for each state. Information for this issue brief was obtained through and analysis of state managed care contracts and telephone interviews with state Medicaid officials. An Analysis of States´ Medicaid Managed Care Plan Arrangements and Service Requirements Affecting Children, 1995-1999 by Harriette B. Fox, Stephanie J. Limb, Christine Y. Chen, and Margaret S. Hayden. Issue Brief No. 2, 24 pages, April 2000, $35.00. This issue brief provides an analysis of plan arrangements and coverage requirements in effect at the end of 1999 and the extent to which these requirements changed in the five-year period from 1995 to 1999. It looks at both general and specialized plan arrangements and also at the scope of capitated services and contractual requirements governing the EPSDT benefit. The report includes detailed state tables on the ownership and membership of participating plans, carve-out policies, and EPSDT contract language based on telephone interviews with state Medicaid officials and an analysis of state managed care contracts. An Analysis of Medical Necessity Standards in States´ Medicaid Managed Care Contracts, 1995-1999 by Harriette B. Fox, Margaret A. McManus, and Margaret S. Hayden. Issue Brief No. 1, 10 pages, January 2000, $25.00. This issue brief provides an analysis of current state medical necessity standards affecting children and the extent to which these standards have changed in the five-year period from 1995 to 1999. The analysis addresses medical necessity criteria pertaining to the scope of health problems covered, evidence-of-effectiveness requirements, and cost requirements. The report includes detailed state tables on each of these criteria. Information was obtained through an analysis of managed care contracts. Private Health Insurance Coverage for Children: A Survey of 450 Employers by Margaret A. McManus, Harriette B. Fox, Michael Perry, Evan Stark, and Susan Kennel. Report, 22 pages, February 1999, $25.00. This report presents the findings from a nationally representative survey of 450 small, medium, and large employers conducted in September 1998. It addresses three topics on children´s health insurance coverage: employer perspectives and employee decisions regarding health insurance coverage for children, employer premium contributions and scope of coverage for children´s coverage, and future directions in employer-based coverage for children. Download a free pdf of this report. A Summary of Interviews with State Medicaid Managed Care Directors Regarding Developmental Support Services for Families with Young Children by Harriette B. Fox, Dominique G. Kim, and Margaret A. McManus. Report, 19 pages, January 1999, $20.00. This report describes state Medicaid financing outside of capitated arrangements for developmental support services to young children enrolled in Medicaid managed care organizations. The analysis addresses the nature and extent of carve-out policies for six types of developmental support services: comprehensive risk assessments, telephone advice lines, parent education, parent counseling, home visiting, and case management. It includes information on service providers, billing categories, and the extent of coordination with managed care organizations. The analysis was based on telephone interviews conducted in the fall of 1998 with Medicaid managed care staff. State Medicaid Managed Care Contract Provisions Regarding Developmental Support Services for Families with Young Children by Harriette B. Fox, Margaret A. McManus, and Dominique G. Kim. Report, 20 pages, December 1998, $20.00. This report presents a summary of Medicaid managed care contract provisions related to developmental support services for young children and their families based on an analysis of state managed care contracts in effect in April 1998. The analysis focuses on six types of developmental support services: comprehensive risk assessments, telephone advice lines, parent education, parent counseling, home visiting, and case management. It includes a description of the five states with the most expansive set of contractual requirements. A Compendium of Federally Funded Projects on Managed Care and Children with Special Health Care Needs by the MCH Policy Research Center. 40 pages, February 1998, $20.00. This compendium of federally funded projects on managed care and children with special health care needs provides a summary of over 50 projects funded in nine areas: definition and identification of children with special health care needs, pediatric-risk adjusted capitation methods, quality of care, family participation, provider network capacity, special managed care program demonstrations and evaluations, coordination of general managed care and behavioral health plans, and integration of public program services with managed care. For each topic there is also a discussion of background findings and gaps in knowledge. Evaluating Managed Care Plans for Children with Special Health Care Needs: A Purchaser´s Tool by Margaret A. McManus. Institute for Child Health Policy, University of Florida at Gainesville, 7 pages, 1998 This evaluation tool, presented as a brochure, is intended to assist purchasers of health insurance for children in assessing the capacity of plans to cover necessary pediatric services, make appropriate providers available, and assure quality. It provides information relevant to coverage of children with and without chronic conditions. Download a free pdf. Current Policies and Future Directions in State Medicaid Managed Care Arrangements for Children by Harriette B. Fox, Margaret A. McManus, and Ruth A. Almeida. Report, 93 pages, March 1997, $40.00. This report presents information on states´ 1996 Medicaid managed care policies affecting children and on the ways in which these policies are expected to change in the future. The report describes states´ use of primary care case management and fully capitated arrangements to serve children. With respect to fully capitated plans, the report also examines the types of plans states use, the scope of capitated services, guidance given to plans about coverage, methods used for setting pediatric capitation rates, and monthly premium amounts paid for children. Information for the report was obtained through telephone interviews with state Medicaid agency staff and through an analysis of state managed care contracts. The Effect of Managed Care on Medicaid Financing for Public Programs Serving Children with Special Needs by Harriette B. Fox, Margaret A. McManus, Ruth A. Almeida, and Cara Lesser. Report, 21 pages, October 1996, $20.00. This briefing report, prepared for the National Health Policy Forum, assesses the effects that Medicaid managed care has had on five major public programs serving children with special health needs: the Title V program for children with special health care needs, the special education program, the early intervention program, the children’s mental health services program, and the Title IV-E child welfare program for children in foster care. Information for the report was obtained through a literature review, a telephone survey of state Medicaid agency staff, and a review of state managed care contracts. Medicaid Managed Care for Children with Chronic or Disabling Conditions: Improved Strategies for States and Plans by Harriette B. Fox and Margaret A. McManus. Report, 67 pages, July 1996, $40.00. This report presents findings and recommendations from an extensive study of Medicaid managed care arrangements for children with developmental, emotional, behavioral, or complex physical conditions. The report describes the range of chronic conditions and disabilities among children, provides a snapshot of current Medicaid managed care policies and plan practices affecting children, and presents a discussion of alternative structural arrangements that states might use in serving these children through managed care. It also identifies essential components of state managed care contracting policies and plan practices. Information for the report was obtained through an extensive literature review and interviews with plans, state Medicaid agency staff, pediatric providers, and families. Expert advice was also obtained through an advisory group and key informant interviews. Impacts of State Medicaid Demonstration Waiver Programs on Children: Results From Hawaii, Oregon, Rhode Island, and Tennessee by Harriette B. Fox and Margaret A. McManus, Report, 100 pages, March 1996, $40.00. This report presents findings from an examination of four state Section 1115 Medicaid demonstration waiver programs to assess their impacts on children. The report addresses each program´s impact on uninsurance among children, the extent to which the enrollment process facilitated appropriate plan placement, the adequacy of plans´ pediatric provider networks and coordination mechanisms, the appropriateness of service coverage and authorization policies, the sensitivity of quality assurance measures for children, and the impact on publicly funded programs that traditionally serve children with special health needs. Information for the report was obtained primarily through on-site interviews with key officials, providers, families, and plan medical directors in the four states. Children with Special Health Care Needs in Managed Care Organizations: Definitions and Identification, Family Participation, Capitation and Risk Adjustment, and Quality of Care by the Division of Services for Children with Special Needs of the Maternal and Child Health Bureau. 39 pages, 1996, $20.00. This report is a summary of expert work group meetings on four topics related to managed care: identification of children with special needs, family participation, capitation and risk adjustment, and quality of care. For each topic, the discussion includes a problem statement, examples of current research and innovative approaches, and recommended activities. Strategies to Enhance Preventive And Primary Care Services For High-Risk Children In Health Maintenance Organizations by Margaret A. McManus and Harriette B. Fox. Report, 52 pages, 1995, $25.00. This report provides background information on children who are at high risk for biological, behavioral, or environmental problems and describes 15 recommended design elements to improve preventive and primary care. It addresses needs assessment, access initiatives, and enhanced preventive and primary care. For each of the design features, implementation issues and illustrative examples are presented. Information was obtained through telephone and on-site interviews of staff from innovative programs and through a literature review.
A National Study of Commercial Health Insurance and Medicaid
Definitions of Medical Necessity: What Do They Mean for Children? How Far Have State Medicaid Agencies Advanced in Performance
Measures for Children? An Examination of State Medicaid Financing Arrangements
for Early Childhood Development Services Managed Care´s Impact on Medicaid Financing for Early
Intervention Services Improving State Medicaid Contracts and Plan Practices for
Children with Special Needs Medicaid Managed Care Policies Affecting Children with
Disabilities: 1995 and 1996 Enhancing Preventive and Primary Care for Children with
Chronic or Disabling Conditions Served in Health Maintenance Organizations State Implementation of OBRA ´89 EPSDT Amendments
within Medicaid Managed Care Arrangements |
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