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MANAGED CARE GUIDING PRINCIPLES

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The National Council on Disability has developed a checklist of ten items they consider "Guiding Principles" that can be used to evaluate a state's managed care plan proposals.  Any plan put forth by the state should meet and exceed the expectations in these "Guiding Principles."   You can see the full explanation of these principles here.

  1. COMMUNITY LIVING
    The managed care plan must show how it will help individuals with disabilities live full, healthy, inclusive lives in the community.
      There must be a focus on both health care and long term supports that will enable individuals with disabilities to live as independently as possible.  It is essential that those covered by the managed care plan receive medical and non-medical supports that promote health and wellness, and improve their ability to live independetly in fully integrated community settings rather than institutions and congregate care facilities.

  2. PERSONAL CONTROL
    Managed care systems must be designed to support and implement person-centered practices, consumer choice, and consumer direction. 
    People with disabilities must be able to control their own lives and choose the services and supports that are consistent with their personal goals.  To do this, plans must offer a flexible array of high quality, personalized services and supports, and there must be providers available to deliver these services and supports.  Managed care plans must offer enrollees with disabilities the option of overseeing their own direct services and supports, and provide training they will need to effectively self-direct their services.

  3. EMPLOYMENT
    Iowans with disabilities must receive the supports needed to get and keep jobs.
    For working-age adults with disabilities, employment is an essential path to independence and community integration.  Employment at prevailing wages not only enhances an individual's sense of self worth and economic well-being, but often results in reductions (sometimes very big reductions) in service costs and support needs.  Managed care plans should increase opportunities for employment by providing the necessary supports both in and out of the workplace, and eliminating disincentives to maintaining a job.

  4. SUPPORT FOR FAMILY CAREGIVERS
    Families should get the help they need to effectively support their family members with disabilities.   Given funding shortages and direct careworker workforce shortages, family caregivers roles will continue to expand in the coming years.  Family members must recieve the information, counseling, training, and support they need to carry out these important responsibilities.  State policies should permit family caregivers to be paid for providing services.

  5. STAKEHOLDER INVOLVEMENT
    States must involve individuals with disabilties, family members, support agency representatives, and advocates in designing, implementing, and monitoring Medicaid managed care services to make sure they are effective and outcomes are achieved.  Active, open, and continuous dialogue with all stakeholders is the best way to make sure the system meets the needs of individuals with disabilities. The involvement of these stakeholders should not end when the Medicaid managed care plan is approved.  Instead, stakeholders should actively participate in the monitoring and implementation of the plan, and provide feedback on system performance and modifications needed at regular intervals.

  6. CROSS-DISABILITY, LIFE-SPAN FOCUS
    The system must be able to address the diverse needs of all plan enrollees, including children and adults with physical disabilities, intellectual and developmental disabilities, traumatic brain injuries, mental illnesses, and substance use disorders. The types of services and supports needed vary from person to person.  The needs of an 85 year old widow with Alzheimer's Disease are very different than the needs of a teenager with autism.  Both may require specialized medical services and prescription medications in combination with ongoing personal assistance, but the competencies of the team providing that care is very different.  A one-size-fits-all approach will not work.

  7. READINESS ASSESSMENT & PHASE-IN SCHEDULE
    States should make sure they are ready and not rush into managed care agreements that involve health services and long-term supports for individuals with disabilities.  Existing disability services systems are complex.  Creating a managed care service delivery system capable of addressing the diverse health and long-term care needs of individuals with disabilities is no easy task, and lack of planning can have disasterous consequences.  If the state's goal is to administer Medicaid-funded health services and long-term supports under a single managed care umbrella, state officials must work with stakeholders to assess how things are now, identify gaps in services, and plan accordingly. The goal of this assessment is to identify changes needed to existing facilities, programs, services, and administrative policies/practices before the managed care transition begins.

  8. PROVIDER NETWORKS
    The managed care organization's provider networks must include providers that offer health care, behavioral health, and long-term supports, and must include a balance of institutional, home, and community based providers.  Each network should have enough providers to allow choice.  Service providers must have the capacity and expertise to address the needs of each population included in the managed care plan, and must be available in both rural and urban areas.  Individuals with disabilities must have a voice in the selection of their provider.  The state should require managed care plans to allow individuals with disabilities access to services outside the network if it is necessary for that person to receive all the services they need.

  9. TRANSITIONING TO COMMUNITY-BASED SERVICES
    Managed care plans must include providers of home and community based services and supports, as well as institutional program, and this requirement should be built into the contracts.  Because of the US Supreme Court's Olmstead ruling, states must show how their Medicaid plans effectively transition eligible individuals with disabilities from long-term care institutions to home and community based settings.  Iowa's managed care plan waiver should strongly demonstrate compliance with the Olmstead ruling.

  10. COMPETENCY & EXPERTISE
    State Medicaid officials should draw upon the knowledge, expertise, and skills of their colleagues serving in other state agencies (including vocational rehabilitation, education, housing, transportation).  In other words, Medicaid directors should not design their plans without input from other states agencies involved in providing support to persons with disabilities.

  11. OPERATIONAL RESPONSIBILITY & OVERSIGHT
    State managed care plans should be supervised by a qualified state official that is looking out for the public interest.  Managed care should not be seen as a way for state agencies and lawmakers to shift responsibility to a private company (and away from them).  State policymakers need to make sure there are enough state workers to properly oversee the managed care system and hold contractors accountable for their performance.  It is very important for contracts to include clear performance standards, operating guidelines, data reporting requirements, and outcome expectations.  A state-of-the-art information management system is essential to effectively administering a managed care system.

  12. CONTINUOUS INNOVATION
    States should actively promote innovation in long-term services and supports for people with disabiliites.  Building a strong, resilient community-based infrastructure to support individuals with disabiltiies is essential to creating a sustainable health care delivery system.  This should include encouraging public-private partnerships; promoting better use of natural and community resources; broadening definitions of services and supports in order to achieve outcomes; and improving use of other government services that will help in reaching goals.

  13. MAINTENANCE OF EFFORT & REINVESTING SAVINGS
    States must not be allowed to cut back on services when moving to a managed care plan, and savings should be used to provide services to unserved or underserved individuals with disabilities.  States should require any savings from less reliance on high-cost institutional care, unnecessary hospital admissions, and improved service delivery be used in this way.  In Iowa, that could include addressing long waiting lists and expanding services to other types of disabilities (such as all types of developmental disabilities).

  14. COORDINATION OF SERVICES & SUPPORTS
    A well-balanced service system coordinates the service delivery of primary and specialty health services with long-term care services and supports.  The state should require managed care organizations to assign a health care coordinator with special knowledge and experience in assisting individuals with disabilities.  If the state chooses to administer health services separately from long-term care servcies, managed care agreements should spell out the collaborative steps each system will take to ensure that the health care and long-term services and support needs of the individual are in sync.

  15. ASSISTIVE TECHNOLOGY & DURABLE MEDICAL EQUIPMENT
    Managed care plans must give individuals with disabilities access to the durable medical equipment and assistive technology they need to function independently and live in the least restrictive setting.  Covered services must include professional assesssments of the need for the equipment, as well as set-up, maintenance, and user training.

  16. QUALITY MANAGEMENT
    The state's quality managment system must protect vulnerable individuals, while measuring how effective services are in helping an individual achieve their goals.  The state's quality management system must monitor strategies that make sure services are person-centered and appropriate, and make sure that quality measures are being reviewed continuously.

  17. CIVIL RIGHTS COMPLIANCE
    All health services and supports must be provided in settings that meet ADA requirements.  Individuals with disabilties must have ready access to all services and sites where Medicaid services are provided. These sites must be in full compliance with the Americans with Disabilities Act, including physical, cognitive, and sensory accessibility standards.

  18. CONTINUITY OF MEDICAL CARE
    People should be allowed to keep ther doctors and other health care providers, as long as those providers are willing to accept the Medicaid managed care plan's rules and payment schedules.  This is sometimes called "any willing provider."  People should be allowed to choose a new primary care doctor at any time.  Continuity of care is important, but so is the patient-doctor relationship.  People enrolled in a managed care plan should be allowed to keep current providers, switch providers when they are unhappy, and change managed care plans periodically.

  19. DUE PROCESS
    People with disabilities shoud be fully informed of their rights and obligations under managed care plans, including steps necessary to access services.  States should develop and implement an aggressive education and outreach strategy to make sure people know what is expected of them, and how services and supports are accessed.  The state should work with community-based organizations to spread the word. 

  20. APPEALS
    Medicaid managed care plans should have a transparent appeals process, clearly communicating how a person can resolve complaints and disputes.  Appeals should comply with all existing Medicaid requirements, except in the case of plans serving dual eligibles when Medicare protections are stronger.
We know this is a lot to take in, but we hope that you use these 20 guiding principles when you look at the plans developed by the state.  Please use these principles when talking to the Governor and your legislators.  If you see something important to you in these 20 principles, ask your legislators and the Governor to make sure the state's managed care plan addresses it.  Good luck, and keep coming back to www.infonetiowa.org for more information!