ciation of America, 1995a). Designed to enable frail elderly persons to remain in their homes, ESP focuses on preventive and rehabilitative services that permit enrollees to maintain maximum independence. It provides a full range of services, including physician and nursing services, home care, meals, recreational therapy, and transportation to and from the ESP center.

Even in the absence of full financial integration of coverage for acute and long-term care, some plans permit case managers to authorize services outside the covered range of benefits, thereby increasing the plan's ability to be responsive to the unique needs of individuals and, at the same time, saving through more efficient use of plan resources (Fama and Fox, 1995). Those authors noted that case management is being used to shorten hospital utilization by reducing the length of stay for acute episodes of chronic conditions and assisting patients in returning home instead of entering skilled nursing or long-term-care facilities. They point to Family HealthCare Services (a subsidiary of Sierra Health Services, which provides all post-acute and long-term-care services to Sierra Health Services enrollees), whose case management approach is to "maintain enrollees in the least restrictive and most safe and cost-effective setting. . . . Case managers consider the whole range of alternative care settings and services-from skilled nursing facilities to group homes and from skilled nursing services to home maker services" (Fama and Fox, 1995).

The SeniorCare Options Program is sponsored by Allina Health Plans Group. Operating under the flexible benefits option of HCFA's Medicare Managed Risk Program, SeniorCare Options is a Medicare risk plan that offers Medicare beneficiaries "open access" to approximately 6,500 providers, including primary care and specialists. For a slightly higher premium, enrollees may self-refer directly to specialists. Upon enrollment, each new beneficiary is assigned a care advisor (either a geriatric nurse or a social worker) who assists the enrollee in navigating through the health plan. The care advisor performs a case management function and identifies low-, moderate-, and