Perspective: Information, Inspiration and Advocacy for People Living with HIV/AIDS

............
Ix:
ft4edic:aid Managed Care

consistent levels of HIV care, ensur
ordinated care, a focus on prevent
cluding early intervention, and redu
pendence on emergency room car
overarching challenge is ensuring th
health plans are well constructed
implemented, and appropriately re
for patient protection. Additionall
viduals need to be educated about, a
ported through, the more complex
delivery system. When it comes to
Medicaid patients into managed care
be critical that consumers and
advocates carefully evaluate the
process and the protections provided for patients. The patient
block represented by Medicaid
in many ways is undesirable
within the managed health care
industry, since it includes people
with the least resources and the
greatest overall medical needs.

ing coion inced de*e. The
at such. fairly
gulated
y, indind suphealth
shifting,it will

lish clear guidelines for plan amendments*
and review processes that include consumer. participation.
* The Balanced Budget Act also includes some. consumer protections for Medicaid manI aged care at the federal level although the I
protections are broad and it is unclear as
yet how they will be implemented. Patient. protections should be built into state Medi icaid managed care plans and monitored
* carefully.
Balanced Budget Act Protections

Changes
in Federal
Requirements
Before the Balanced Budget Act
of 1997 states were required to
apply to the federal government
for a waiver of certain Medicaid requirements in order to
move Medicaid recipients into
managed care. Waivers articulate states' plans for moving
people into the new system. The
process the state goes through
to produce the waiver typically
gives consumers and advocates
a chance to evaluate, critique
and provide input into the state
plan. The Balanced Budget act
eliminated one of the required
waivers. In some states this
could mean that advocates and
consumers have to look for

The consumer protections include:
0 There must be a choice of plans (at least two); in
areas, there must be an option of at least two prir
care doctors.
0 Individuals may change plans at any time with caL
0 Enrollment notices and information must be in a fc
which is easily understandable and include a broa
of information.
" Marketing materials must be approved by the stat
to door marketing and telephone marketing are pr
" Emergency care must be reimbursed under any c(
tions that a "prudent lay-person" (meaning you) w
reasonably expect to result in serious physical or
harm without immediate medical attention.
0 Health care plans must maintain a sufficient numb
and geographic distribution of providers with the
offer an appropriate range of services.
N The state must develop and implement a quality a
ment and improvement strategy.
N There must be an external independent review of
plan including quality outcomes and timeliness of
access to services.

At the personal level
Understand your state Medicaid situation.
In most states it is not mandatory for people
with HIV to enter into a managed care plan.
If you receive enrollment information for
Medicaid managed care do not assume you
have to sign up. The standard Medicaid
plan may be the better option for people
living with AIDS. However, if your state
does have mandatory managed care for
people with HIV/AIDS you must make a
decision regarding a plan, or you will be
automatically enrolled in one
of the participating plans.
Evaluate the plans carefully.
It can be very difficult to derural termine plan benefits, so get
uary help from local benefits counnary' selors, AIDS service organizations or other people living
ise. with HIV already enrolled in
one of the plans. You can also
rm call the Project Inform Treatd range ment Information Hotline
(800-822-7422) for a discuse; door sion of issues that may be
ohibited. helpful in evaluating health
maintenance organizations
ondi- (HMOs).
ould Learn about all your options.
mental Often there are ways to access
benefits that may not be imer, mix, mediately apparent (e.g.,
ability to sometimes a treatment may
only be available through a
prior approval process or anissess- other treatment access program). Work with benefits
each counselors, and local commuand nity based organizations to explore all of your options. Call
the Project Inform Hotline if
you are having a problem accessing a particular treatment.
Find, and get connected with, the best care
provider you can. Your care provider can
sometimes be your most effective advocate
in the managed care environment.
Get involved with your HMO. Some managed care organizations include patients on
the governing bodies or on boards of directors. This can be a very effective way to
become involved with your managed care
provider. Consumer boards and patient advocacy unions are effective if they go beyond merely advising and are given decision-making authority. Forming coalitions
with other Medicaid patients with similar
concerns will strengthen advocacy efforts.

other avenues to affect their state's move to
managed care.
One place to look may be state plan amendments. Under federal regulation, states planning to shift to mandatory managed care
are required to submit a plan amendment
to the Health Care Financing Administration (HCFA) for approval. The plan amendment is another area where the state outlines its plans and may provide another
chance for advocates to have substantive
input. Because plan amendments have not
been monitored very well in the past, advocates will have to make sure that states are
using the amendment process, that the
media is aware of this requirement, and that
regional and central HCFA offices estab
What You Can DO
Medicaid is a joint federal and state health
care program. It is overseen at the federal
level by the HCFA and must provide certain benefits. However, states decide what
options, such as prescription drug services,
will be provided. As states move Medicaid
further into managed care, much of the
focus of advocacy efforts will now be forced
to shift from the federal to the state level.
One of the most important advocacy targets will be the contracts states develop with
managed care entities serving the Medicaid
population. However, there are steps to be
taken at all levels.

22

PI PERSPECTIVE NUIVBER 23 NOVEIVBER 1 997