Sidebar: Planned Changes in Child/Family/youth Services at One LME/MCO

Abstract

ncmedicaljournal.com 190 or more capitated, at-risk MCOs rather than with thousands of fee-for-service providers. Managed care offers states a single point of accountability by making it possible for there to be one designated manager for the entire continuum of services and supports for a specified geographic area. States can hold a single entity responsible for access, quality, and cost. A benefit of managed care for an entity receiving public funding, such as PBH, is that administrative funds are concentrated within the MCO. Currently, Medicaid administrative funds for Medicaid fee-for-services care and for the special Medicaid community waiver program of CAP-MR/ DD (Communities Alternative Program for Persons with Mental Retardation/Developmental Disabilities) are dispersed across several organizations, including ValueOptions, HP Enterprise Services, and a few LMEs. Diluting precious administrative resources compromises the capacity of any single entity to develop the infrastructure necessary for waiver operations. The infrastructure requirements include complex information technology, quality oversight systems, and highly qualified staff members to operate these systems and manage for outcomes. One of the advantages of the managed care Medicaid waiver program is that there is an option under 1915(b)(3) for states to use savings to reinvest in additional services that are not otherwise available to the state’s Medicaid population. The savings realized are converted to a special per-member, per-month payment that provides funding for the additional services in future years. Managed care systems create predictable business environments for providers by managing competition through a closed network. A closed network provides choice for consumers, but offers providers the opportunity to have sufficient market share to support investment in their local infrastructure. PBH’s use of evergreen contracts (contracts without an end date) provides additional assurances to providers. The managed care waiver program requires MCOs to ensure that consumers have both access to services and a choice of providers. Low-density populations can result in inadequate numbers of providers and poor access to care in rural areas. The MCOs are responsible for recruiting providers for underserved areas and can use financial incentives such as special rates to bring providers into a specific geographic area. The MCOs have full authority to ensure quality of serPlanned Changes in Child/Family/Youth Services at One LME/MCO