Health Policy Commons^™

Public Health Insurance Design For Children: The Evolution From Medicaid To Schip, Sara J. Rosenbaum, Anne R. Markus, Colleen Sonosky

Health Policy and Management Faculty Publications

In 2005 Medicaid will turn 40, a momentous event in the life of the largest and most complex of all means-tested public entitlement programs. Since 1997, Medicaid has co-existed with the State Children’s Health Insurance Program (SCHIP), a small program which covers a fraction of the number of Medicaid enrolled children but whose legislative structure looms large against its much beleaguered companion. To the unpracticed eye, SCHIP and Medicaid appear to be quite similar in design; in reality however, their differences could not be more profound, and it is in these differences that clear directions for Medicaid’s possible future become …

Schip-Enrolled Children With Special Health Care Needs: An Assessment Of Coordination Efforts Between State Schip And Title V Programs, Anne R. Markus, Sara J. Rosenbaum, Soeurette Cyprien

Health Policy and Management Faculty Publications

This study explores how the State Children's Health Insurance Program serves children with special needs and assesses the role of the Title V Maternal and Child Health Services Block Grant program in filling in gaps in coverage. It also discusses the implications of state choices on publicly-funded health coverage for pediatric health care.

2003 State Of The State Addresses: Governors' Discussions Of Budget And Health Care Issues, Sara E. Wilensky, Betsy Schipani

Health Policy and Management Faculty Publications

A series of tables examines State of the State addresses nationwide to examine the frequency and content of Governors' discussions of budget and health care issues.

An Analysis Of The Medicaid Imd Exclusion, Sara J. Rosenbaum, Joel B. Teitelbaum, D. Richard Mauery

Health Policy and Management Faculty Publications

This report examines the Medicaid Institutions for Mental Disease (IMD) exclusion, one of the very few instances in which federal Medicaid law prohibits federal contribution to the cost of medically necessary care furnished by licensed medical care providers to enrolled program beneficiaries. The report begins with a brief overview of Medicaid's role in financing care for conditions and illnesses classified as "mental diseases" under professional medical guidelines and the allocation of state and federal funding responsibilities under Medicaid. The report then reviews the elements of the Medicaid IMD exclusion, as well as key judicial and administrative rulings related to the …

How Care Is Managed: A Descriptive Study Of Current And Future Trends In Care And Cost Management Practices Under Private Sector Employee Benefit Plans, Phyllis Borzi, Marsha Regenstein, Lee Repasch, Soeurette Cyprien, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

In the fall of 2001, the United States Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation (ASPE) asked the Center for Health Services Research and Policy in the School of Public Health and Health Services, The George Washington University Medical Center, to undertake a descriptive study of the current and future trends in cost and care management techniques used in the employment-based health insurance marketplace. The purpose of this study was to identify and report on (1) the cost and care management techniques currently in use in the private sector by health plans …

Behavioral Health And Managed Care Contracting Under Schip, Sara J. Rosenbaum, Colleen Sonosky, Karen Shaw, D. Richard Mauery

Health Policy and Management Issue Briefs

This Policy Brief examines behavioral health managed care contracting under separately administered State Children's Health Insurance Programs (SCHIP), i.e., programs that operate under the direct authority of Title XXI of the Social Security Act rather than as expansions of Medicaid. Most separate SCHIP programs buy managed care style health insurance for some or most of their enrolled children. Because Title XXI provides states with far greater administrative flexibility than Medicaid with respect to coverage and benefit design, provision of services, and administration of managed care arrangements, studying separate SCHIP managed care products sheds important light on how states might approach …

Model Managed Care Contract For Health Professionals And Clinical Providers Of Mental Illness And Addiction Disorder Treatment And Prevention Services, Sara J. Rosenbaum, Joel B. Teitelbaum, Brian Kamoie, D. Richard Mauery

Health Policy and Management Faculty Publications

The contracting process is one that health care professionals oftentimes find complex and confusing. Furthermore, studies of managed care service contracts between managed care organizations and health professionals who furnish mental illness and addiction disorder prevention and treatment services have found that these contracts often heavily favor the managed care organization by allowing the MCO broad latitude over a network professional's service responsibilities, the rate of payment for covered benefits and extensive discretion over treatment decision-making.

As an aid to its members, the American Medical Association (AMA) has drafted a "model" provider agreement that gives physicians in both individual and …

The Devolution Of Managed Care Contractor Duties: Analysis And Implications For Public Policy In Managed Behavioral Health Care, Sara J. Rosenbaum, Anne R. Markus, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

This Issue Brief analyzes the devolution of the legal duties assumed by managed care organizations (MCOs) in their contracts with group purchasers. Specifically, this brief examines the delegation of MCO contractual duties related to member care and services to individual network providers by comparing the language used in master contracts between purchasers and MCOs with the language contained in agreements with network health care providers who serve members covered under the master contract.

The Ticket To Work And Work Incentives Improvement Act Of 1999: Implications For The Design And Support Of Comprehensive Integrated Health Systems For Persons With Mental Illness And Addiction Disorder Disabilities, Sara J. Rosenbaum, Joel B. Teitelbaum, Brian Kamoie

Health Policy and Management Faculty Publications

This report is designed to provide an overview of the Medicaid provisions of the Ticket to Work and Work Incentives Improvement Act of 1999, Public Law 106-170. This report considers the implications of the Act for the design and support of comprehensive, Medicaid-financed systems of health care for workers with severe disabilities and impairments, with a specific focus on persons with mental illness and addiction disorder disabilities. The Act, described by advocates for persons with disabilities as the most important piece of disability-related legislation since the enactment of the Americans with Disabilities Act of 1990, expands the availability of health …

Olmstead V L.C.: Federal Implementation Guidelines, And Analysis Of Recent Cases Regarding Medicaid Coverage Of Long Term Care Services For Persons With Disabilities, Sara J. Rosenbaum

Health Policy and Management Issue Briefs

This analysis reviews the key elements of the United States Supreme Court's 1999 decision in Olmstead v L.C. as well as Federal implementation guidelines issued by the United States Department and Human Services. The Olmstead decision interprets the Americans with Disabilities Act ("ADA," PL 101-336), whose requirements apply to the use of all public funds. However, Medicaid represents the single largest source of public funding for both institutional and non-institutional services for persons with disabilities. As a result, when states expend Medicaid funds on care for persons with disabilities, two independent sets of legal requirements are triggered: those contained in …

An Overview Of Legal Developments In Managed Care Caselaw And Selected Case Studies Of Legal Developments In State Contracting For Managed Behavioral Health Services, Sara J. Rosenbaum, D. Richard Mauery, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

This analysis provides an overview of recent legal developments in managed care case law. Three types of cases are reviewed: claims brought by managed care enrollees against managed care companies and health plans; cases related either directly or indirectly to managed care and brought by both beneficiaries and managed care organizations against state Medicaid agencies and other public agencies engaged in the purchase of managed care; and cases brought by individual health professionals against managed care organizations.

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 …

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 …

The Americans With Disabilities Act: Implications For Managed Care For Persons With Mental Illness And Addiction Disorders, Sara J. Rosenbaum, Joel B. Teitelbaum, Robert Silverstein

Health Policy and Management Issue Briefs

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the Americans with Disabilities Act ("the ADA") and its application to managed care. The ADA provides important protections for persons with disabilities who are members of managed care arrangements, regardless of whether their membership is sponsored by an employer, Medicare, or Medicaid or is purchased privately. The interaction between the ADA and managed care is complex, and different issues can arise under publicly and privately sponsored plans.

Coverage Decision-Making In Medicaid Managed Care: Key Issues In Developing Managed Care Contracts, Sara J. Rosenbaum, Joel B. Teitelbaum

Health Policy and Management Issue Briefs

Coverage provisions are the most complex part of any managed care contract. This is particularly true for Medicaid agencies, because of important differences between Medicaid and insurance. This Issue Brief identifies general issues that should be addressed as managed care contracts are developed and drafted, and it specifically explores the challenges faced by public purchasers when drafting managed care coverage provisions.