home and community-based services. In any case, it is not clear what EPSDT services are effectively available to Medicaid-covered children in each state.

Adding to the complexity of summarizing state Medicaid coverage, most states have been rapidly enrolling beneficiaries in managed care programs, whose specific coverage and other policies also vary. Under Section 1915(b) waivers of “freedom-of-choice” provisions of Title XIX, states can require Medicaid enrollees to enroll in comprehensive or specialized (e.g., behavioral health) managed care plans (HCFA/CMS, 2001a). The Balanced Budget Act of 1997 allows states to institute mandatory enrollment through an amendment to their state plan and thereby bypass this waiver process. One exception is that states must still get a waiver to require managed care enrollment for children with special health care needs, a group that will include some children with fatal or potentially fatal medical conditions (Gruttadaro et al., 2001). This restriction recognizes the particular care requirements and vulnerabilities of special needs children.

In 2000, 56 percent of Medicaid beneficiaries were enrolled in some form of managed care, up from 40 percent in 1996 (HCFA/CMS, 2000b).13 These percentages include some who were enrolled in more than one kind of plan. In 1998, the percentage of Medicaid beneficiaries enrolled in managed care plans ranged from zero in Alaska and Wyoming to more than 75 percent in a dozen states (HCFA/CMS, 2000b). More than 55 percent of all Medicaid managed care enrollees were children.

In addition to the freedom-of-choice waivers, states can also obtain waivers that allow them to include additional populations or services not otherwise covered under Medicaid. As discussed further below, under Section 1915(c) waivers, states can provide additional home and community-

13  

As defined by the Health Care Financing Administration (HCFA), now CMS, several Medicaid managed care options exist. PCCM (primary care case management) provider is usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians who contracts to locate, coordinate, and monitor covered primary care (and sometimes additional services). This category includes PCCMs and those prepaid health plans that act as PCCMs. PHP (prepaid health plan) provides less than comprehensive services on an at-risk basis or provides any benefit package on a nonrisk basis. For example, medical-only PHP, dental PHP, transportation PHP, mental health PHP, substance abuse PHP, etc. Commercial MCO (managed care organization) is an HMO, an eligible organization with a contract under Section 1876 or a Medicare+Choice organization, a provider-sponsored organization, or any other private or public organization that meets the requirements of Section 1902(w). These MCOs provide comprehensive services to commercial and/ or Medicare enrollees, as well as Medicaid enrollees. Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not to commercial or Medicare enrollees. HIO (health insuring organization) provides or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services. “Other” managed care entity is used if the plan is not considered a PCCM, PHP, MCO or HIO.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement