Health Policy Commons^™

Pegram V Herdrich: Implications For Consumer Protections In Managed Care, Sara J. Rosenbaum, Joel B. Teitelbaum

Health Policy and Management Faculty Publications

This Report, prepared for the Substance Abuse and Mental Health Services Administration, provides a brief overview of the United States Supreme Court's landmark decision in Pegram v Herdrich (hereinafter referred to as Herdrich). This report begins with a brief overview of the debate in the courts over how to distinguish between legal challenges to the conduct of managed care companies in which all state remedies are preempted by ERISA and those that may proceed under state law. It then summarizes the facts of the Herdrich case and the Court's holding. The report concludes with a discussion of the implications of …

Medicare, Managed Care, And Behavioral Health Care, Sara J. Rosenbaum, Barbara Markham Smith

Health Policy and Management Issue Briefs

This issue brief examines Medicare and managed care for Medicare beneficiaries with behavioral health needs. Although only a relatively small proportion of Medicare beneficiaries are enrolled in managed care arrangements at the present time, proposals to expand the use of Medicare managed care can be expected to receive a good deal of attention in the coming years as part of a larger debate over Medicare's long term future. Thus, this issue brief examines the Medicare+Choice (M+C) program from the perspective of Medicare beneficiaries with mental illness and addiction disorders.

Understanding Medicaid Home And Community Services: A Primer, Gary Smith, Janet O'Keeffe, Letty Carpenter, Pamela Doty, Brian Burnwell, Robert Mollica, Loretta Williams, George Washington University, Center For Health Policy Research

Center for Health Policy Research

No abstract provided.

Optional Purchasing Specifications For Child Development Services In Medicaid Managed Care, George Washington University Medical Center, Center For Health Services Research And Policy

Center for Health Policy Research

These sample purchasing specifications were prepared by the George Washington University Center for Health Services Research and Policy (CHSRP) with support from the Commonwealth Fund. Technical guidance on the content of child development services was provided by experts from the Fund and researchers at Northwestern University’s Institute for Health Services Research & Policy Studies (IHSRPS). This document is intended as a tool to assist interested state officials in purchasing child development services from managed care organizations (MCOs) on behalf of children under age three who are eligible for Medicaid.

These sample purchasing specifications are optional, and do not necessarily reflect …

Beyond Stigma: What Barriers Actually Affect The Decisions Of Low-Income Families To Enroll In Medicaid?, Jennifer P. Stuber, Kathleen A. Maloy, Sara Rosenbaum, Karen C. Jones

Health Policy and Management Issue Briefs

No abstract provided.

Mental Illness And Addiction Disorders And Medicaid Managed Care, Sara J. Rosenbaum, Joel B. Teitelbaum, D. Richard Mauery

Health Policy and Management Faculty Publications

This Special Report on mental illness and addiction disorders is part of Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, now in its third edition. Negotiating the New Health System is a nationwide point-in-time study of agreements between state Medicaid agencies and managed care organizations (MCOs) offering general or specialized managed behavioral health care products. Each individual edition of Negotiating the New Health System is a point-in-time study or "snapshot" of these agreements for a particular year. However, the current series of editions, taken together, are beginning to form a longitudinal basis for reviewing the …

Coverage Decisions Versus The Quality Of Care: An Analysis Of Recent Erisa Judicial Decisions And Their Implications For Employer-Insured Individuals, Sara J. Rosenbaum, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the evolution of this framework for analyzing health claims emanating from the conduct of ERISA-covered managed care arrangements and considers its implications for the provision of treatment for mental illness and addiction disorders. Both studies and anecdotal evidence suggest that managed care companies impose particularly rigorous controls over treatment for mental illness and addiction disorders. It is therefore perhaps not surprising that legal challenges to treatment decisions frequently involve individuals with these conditions. Consequently, to the extent that courts are in fact on the verge of …

An Evaluation Of Agreements Between Managed Care Organizations And Community-Based Mental Illness And Addiction Disorder Treatment And Prevention Providers, Sara J. Rosenbaum, Joel B. Teitelbaum, D. Richard Mauery, Marcie Zakheim, Michael Golde

Health Policy and Management Issue Briefs

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA), examines contracts between managed care organizations (MCOs) and community-based providers of mental illness and addiction disorder treatment and prevention services (MI/AD providers). Building upon initial research published in 1997, this brief explores in depth one of the most hidden aspects of managed care: the relationship between the managed care organizations and health care providers.

Designing A Complaint And Grievance System And Other Member Assistance Services Under Medicaid Managed Care, Sara J. Rosenbaum, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

Medicaid beneficiaries enrolled in managed care arrangements have two basic sets of procedural protections when benefits are denied. The first set consists of the right to timely and adequate notice of "any action affecting [a] claim" for medical assistance, as well as a fair hearing in the case of any individual "whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness." The second is the right to "internal grievance" procedures to "challenge the denial of coverage *** or payment [of medical] assistance." The Health Care Financing Administration (HCFA) is expected to delineate …

Health Centers' Role As Safety Net Providers For Medicaid Patients And The Uninsured, Sara J. Rosenbaum, Peter Shin, Anne R. Markus, Julie S. Darnell, Rachel Garfield, David Rousseau

Health Policy and Management Faculty Publications

In order to understand the role of health centers as safety net providers, as well as the potential impact of these trends, this issue paper provides an in-depth examination of federally-funded health centers. Using data from the Uniform Data System (UDS), a government-maintained system that collects extensive patient, revenue, and service data on a calendar-year basis from health centers that receive federal grants, this issue paper profiles federally-funded health centers. It presents information on health center patients and revenue sources and analyzes similarities and differences both between health centers and private practices and among health centers. Health centers perform a …

Effect Of The 1996 Welfare And Immigration Reform Laws On Immigrants' Ability And Willingness To Access Medicaid And Health Care Services, George Washington University, Center For Health Services Research And Policy

Center for Health Policy Research

No abstract provided.