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Protection & Advocacy Inc. Advancing the Rights of Californians with Disabilities |
LEGISLATION & PUBLIC 1029 J Street, Suite 150 |
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Principles for Addressing the
Medi |
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California Department of Health Services (DHS) has
proposed moving its Medicaid program (Medi-Cal) for persons with disabilities
toward managed care as a way of saving money. Different managed care models
have been suggested including mandatory managed care and the Administrative
Services Organization ( The following principles, most of which are the work
product of a managed care working group – strongly opposed to mandatory
managed care and capitated based systems, should guide any dialogue about
providing managed health care services for persons with disabilities. 1. Enrollment in managed care must remain optional for Medi-Cal beneficiaries with disabilities. Fee-for-service must remain and option. 2. Recipients must have an opportunity to choose among managed care plans and/or the option to choose among providers within such plan. 3. Recipients must be objectively and fully informed about services and rights within managed care delivery systems. This information should be provided in a culturally competent and disability sensitive manner. 4. There must be access to all services under the Medi-Cal program. Financial disincentives associated with managed care could lead to reduced service for Medi-Cal recipients. Managed care should enhance, not diminish, the availability of medically necessary services for persons with disabilities. 5. All health plans that accept Medi-Cal must provide medically necessary care, including services, equipment, and pharmaceutical supplies. The contractual definition of medically necessary care must assure the provision of all items and services needed to maximize the patient’s functional ability and promote and preserve the patient’s ability to live independently in the community, consistent with the Medi-Cal medical necessity standard in Welfare & Institutions Code §§ 14059 & 14059.5. 6. Keeping people with disabilities healthy and able to function at home, school, work, and in the community must be the primary goal. To this end, managed care services must include access to specialists (including using the specialist as case manager/care coordinator when appropriate), assistive technology, and community-based services, and must be designed to move away from an institutional bias (e.g., nursing home and other institutional placement). 7. Continuity and coordination of all health care services including categorical programs for people with disabilities must be ensured. Where mental health services are delivered through a county mental health plans rather than through the Medi-Cal managed care plan, care by the plan and county mental health carve out must be coordinated so that both parts function as a single plan. The needs of chronic user and dually eligible populations, such as persons eligible for Medicare and Medi-Cal, should also be adequately addressed, including by the delivery of care through treatment teams as appropriate to this particular disability. Recipients with chronic conditions are entitled to transition from fee-for-service to managed care with no gaps in service. Therefore, recipients should be able to continue with existing providers until the managed care plan has services in place; alternately, the managed care plan must coordinate transfer prior to assuming responsibility for the case. Where a recipient is receiving both mental and other health services, there should not be any delays or interruption of services while it is determined who covers what services. The continued separation of mental health care
from other types of health care does a serious disservice to the people of
8. Any changes in eligibility and/or benefits must not have a disparate impact upon any one disability group. 9. Any reductions or other changes in the Medi-Cal program must be made as equitably as possible among disability categories. 10. Improved access to quality of care, not short-term cost savings, must be the driving force for moving a person with a disability into Medi-Cal managed care. Human rights matter more than maximizing outcome. Any cost savings that occur, whether short-term or long-term, should be captured and kept within the Medi-Cal system to improve the availability and quality of health care services for persons with disabilities. 11.
Any
efforts to move Medi-Cal beneficiaries from fee-for-service into managed care
should take advantage of systems and services that would improve the quality
of life for these beneficiaries. Such systems and services include but are not limited to:
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Employing health care providers whom the
oversight agency has deemed significantly experienced in the provision of
health care for people with disabilities.
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Adapting pre-existing programs, tailoring new
programs, and creating specific programs when needed to meet the unique needs
of people with disabilities. Health maintenance and wellness programs should
be accessible to people with disabilities and relevant to their needs.
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Assuring that an adequate number of providers
are available to serve this population.
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Assuring access to appropriate specialists.
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Recognizing and protecting the enrollees'
ability to obtain out-of-plan services if specialty care is not appropriate
or accessible/ available or adequate within the plan.
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Protecting the enrollees’ ability to choose
from the providers and case managers within the plan.
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Emphasizing the power of coordinated care,
when it focuses on the range of social and medical services a person needs to
maximize his/her functional ability, to maximize resources and reduce costs.
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Assuring linkages with non-Medi-Cal services
needed to serve this population.
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Assuring that new pharmaceuticals, related
tests, and new treatment modalities will be accessible and available in the
care delivery system. § Emphasizing creativity and flexibility to assure responsiveness to individual needs in a timely manner. 12. Managed Care Organizations and participating providers should comply with all relevant requirements of the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, and the Unruh Civil Rights Act as a basis for participation in the Medi-Cal program, with active monitoring of this requirement. The state should describe how it will monitor
compliance and respond to reports and evidence of disability discrimination. Managed
care organizations must similarly monitor their contractors’ compliance. The state should provide resources and technical
support to enable small, safety-net Medi-Cal providers to comply with these
laws. Compliance includes, but is not limited to, providing:
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Consent forms, care instructions, medication
labels and instructions, plan policies and changes in policy, payment
information, grievance and appeals forms and any mailings in accessible
formats for people with vision or other disabilities.
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Sign language interpreters and assistive
listening technology for people from the deaf and hard-of-hearing
communities.
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Accessibility of all facilities, medical
equipment, services, and programs.
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Basic training of providers, medical groups,
and staff in cross-disability awareness, accommodating and interacting with
people with disabilities, and providing effective and appropriate treatment. 13.
Due
process must be ensured. Procedures should assure that recipients obtain a
“prompt resolution” of their complaints and assure the participation of
individuals who have the power to require corrective actions. Denials,
including denials for physician requested referrals and treatment shall set
out the legal and factual grounds for denial, and the Medi-Cal appeal rights
and internal grievance rights. Procedures should also provide for an
independent second opinion. 14.
Quality care
must be ensured through an independent, external review of
acknowledged standards of care and performance outcomes DHS should ensure that managed care delivery
systems develop and implement incentives that support quality, preventive
care as a primary goal. DHS should institute adequate mechanisms to evaluate
recipient satisfaction. Managed care delivery systems should have governing
boards with equal representation of recipients and providers. 15. Quality standards and monitoring of these standards must be developed specifically with respect to health care for persons with disabilities. Standards and monitoring should:
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Take advantage of lessons learned from other
states’ experience regarding transitioning people with disabilities into
managed care.
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Be predicated on a study of the baseline of
satisfaction and health status for people with disabilities prior to
enrollment in managed care
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Take advantage of care coordination as a
mechanism for assuring identification of service needs, timely receipt of
services, sharing of information within the care system, and efficient use of
resources.
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Be developed and informed by ongoing meetings
between all stakeholders, including Medi-Cal beneficiaries with disabilities
or their representatives, and advocates from diverse disability communities.
16.
Reimbursement or capitation rates must cover
the real costs of providing medical care to people with disabilities and
chronic health conditions. Such rates also must recognize that serving some
individuals with disabilities takes more time and resources than serving
other populations, and that it may require high initial investment to produce
long-term savings. The managed care organization must not have financial
arrangements that create an incentive to withhold medically necessary care. 17.
Development
of models and contracts for Medi-Cal managed care, and development and
implementation of state oversight of these models, should involve
representatives of enrollees with disabilities in substantive,
decision-making roles. 18. Disability representatives in this oversight group should include beneficiaries with disabilities, representatives of children with developmental and other disabilities, and qualified advocates with disabilities. Disability representatives should help develop standards for appropriate services for these populations and advise state agencies on innovative, cost-effective approaches to improving care for these communities. Diverse disabilities should be represented in the oversight group. |
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Policy #1003.01 |
Adopted |
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