Health Policy Commons^™

The Medicaid Buy-In Program: Lessons Learned From Nine "Early Implementer" States, Donna Folkemer, Allen Jensen, Robert Silverstein, Tara Straw

Center for Health Policy Research

For many individual Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) recipients, the risk of losing Medicaid coverage linked to their cash benefits is a powerful work disincentive. Eliminating barriers to health care and creating incentives to work can greatly improve financial independence and well being. To support this goal, Congress included a Medicaid Buy-In option in the Balanced Budget Act of 1997 and enacted the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in 1999. These laws authorized states to create Medicaid Buy-In programs to extend Medicaid coverage to persons with disabilities who go to work. …

Policy Frameworks For Designing Medicaid Buy-In Programs And Related State Work Incentive Initiatives, Allen Jensen, Robert Silverstein, Donna Folkemer, Tara Straw

Center for Health Policy Research

This report provides policy frameworks to assist stakeholders (such as Medicaid directors, state legislators, and cross-disability coalitions) design and implement Medicaid Buy-In programs and related work incentive initiatives to enhance the level of economic self-sufficiency of persons with significant disabilities. Of particular focus of the paper are the design decisions affecting enrollment, costs, and a state's fiscal exposure.

The policy frameworks describe the interrelationships between federal and state cash assistance programs (particularly SSDI, SSI, and state SSI supplementation programs) and health entitlements (particularly the Medicaid program). The policy frameworks are derived from the experiences of the nine early implementation states …

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 …

Welfare Reform Reauthorization In 2002:What Are The Issues For Tribal Communities And Indian Families?, Kathleen A. Maloy

Health Policy and Management Issue Briefs

American Indian tribes have new options under the 1996 Welfare Reform legislation that created Temporary Assistance for Needy Families (TANF), a block grant enacted to replace the Aid to Families with Dependent Children (AFDC). TANF, which expires in September of this year, provides cash assistance to poor families with children, including poor American Indian Families, and gives tribes the option to design and administer their own family assistance programs following approval of the plan by the Department of Health and Human Services. As Congress considers TANF reauthorization, three new publications prepared for the Kaiser Family Foundation provide insight into the …

An Analysis Of Contracts For The Delivery Of Managed Behavioral Health Care Services In State Correctional Facilities, D. Richard Mauery, Joel B. Teitelbaum, Jeffrey Lerman, Sara J. Rosenbaum

Health Policy and Management Issue Briefs

This issue brief, prepared by the George Washington University Center for Health Services Research and Policy (CHSRP), presents an analysis of a sample of contractual agreements entered into by State Departments of Corrections with managed care organizations (MCOs) for the provision of managed behavioral health care services in State prisons. It is part of a series of contract studies undertaken by CHSRP that examine the implications of managed care contracting by public and private sector purchasers for the financing and delivery of behavioral health care services.

Child Development Programs In Community Health Centers, Sara J. Rosenbaum, Michelle Proser, Peter Shin, Sara E. Wilensky, Colleen Sonosky

Health Policy and Management Faculty Publications

This report, the third in a series that reviews federal health policy related to child development, examines the role of community health centers in providing child development programs for children age 3 and younger. It also presents an analysis of health centers using the Uniform Data System, a database maintained by the federal Bureau of Primary Health Care (BPHC) that contains user, utilization, and financial information on each reporting center. In addition, the report presents findings from a 2000 survey of four categories of child development programs at 79 health centers; examines the new prospective payment system for health centers …

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.

Access To Pediatric Services Under Medicaid Managed Care In The District Of Columbia, Karen Shaw, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

No abstract provided.

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 …

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, Marcie Zakheim, Michael Golde

Health Policy and Management Faculty Publications

This study, undertaken by the Center for Health Services Research and Policy at the George Washington University (GWU) School of Public Health and Health Services for the United States Department of Health and Human Services' Substance Abuse and Mental Health Services Administration, analyzes the devolution of the legal duties assumed by managed care organizations (MCOs) in their contracts with group purchasers. Specifically, this study 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 …

A Crosswalk Between The Final Hipaa Privacy Rule And Existing Federal Substance Abuse Confidentiality Requirements, Brian Kamoie, Phyllis Borzi

Health Policy and Management Issue Briefs

This Issue Brief provides an overview of and crosswalk between the Privacy Rule and the federal Confidentiality of Alcohol and Drug Abuse Patient Records statute, 42 U.S.C. § 290dd-2, and its implementing regulations at 42 C.F.R. Part 2 ("42 C.F.R. Part 2"). The crosswalk is intended to highlight the differences between the requirements of the Privacy Rule and 42 C.F.R. Part 2. In addition, this Issue Brief addresses the Privacy Rule's applicability to special populations and psychotherapy services provided by substance abuse paraprofessionals.

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.

State Benefit Design Choices Under Schip - Implications For Pediatric Health Care, Sara J. Rosenbaum, Anne Rossier Markus, Colleen Sonosky, Lee Repasch

Health Policy and Management Issue Briefs

This policy brief1 is the second in a series of reports focusing on the design of state SCHIP programs as they near full implementation. It examines the extent to which state agencies adopt conventional insurance norms or adhere to special principles of Medicaid coverage design for children in designing separately administered (or freestanding) SCHIP programs. The issue of coverage design is particularly relevant for children with low prevalence conditions and special health care needs. Increasingly, conventional insurance uses standardized coverage norms to limit coverage and treatment. These standardized norms take the form of across-the-board treatments and exclusions, limited definitions of …

Care Coordination And Physical And Behavioral Service Integration In Managed Care Contracts: Analysis And Sample Purchasing Specifications, Sara J. Rosenbaum, D. Richard Mauery, Brian Kamoie

Health Policy and Management Issue Briefs

This double Issue Brief on the issue of managed care contracts and care coordination has been prepared for the Substance Abuse and Mental Health Services Administration as part of a series that examines legal issues in managed care for persons with mental illness and addiction disorders. This Issue Brief is presented in two parts. Part 1 presents an analysis, based on managed care contract data bases developed by CHSRP, of the extent to which public and private group purchasers maintain agreements that specify care coordination as part of the standard of care for persons with co-occurring physical and/or behavioral illnesses …

Behavioral Health Benefits For Public Employees: Effect Of Mental Health Parity Legislation, Phyllis Borzi, Sara J. Rosenbaum

Health Policy and Management Issue Briefs

Recently, the Center for Health Services Research and Policy through a grant from the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, examined contracts providing for mental health benefits for state employees in eight states to assess whether legislative attempts to require parity between physical and mental illnesses resulted in noticeable differences in behavioral health benefits for state employees.

We concluded that, except in states that have mandated full parity for some or all types of mental illnesses, behavioral health benefits for state employees have not changed significantly as a result of …

State Schip Design And The Right To Coverage, Sara J. Rosenbaum, Barbara Smith

Health Policy and Management Issue Briefs

No abstract provided.

How Can Health Serve As A Bridge For Peace? Certi Crisis And Transition Tool Kit, Rosalia Rodriguez-Garcia, James Macinko, F. Xavier Solorzano, Marita Schlesser, George Washington University School Of Public Health And Health Services

Global Health Faculty Publications

No abstract provided.

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.

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.

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 …

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.

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 …

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 …

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.

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.