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Medicaid managed care plans with case management programs may benefit children with disabilities more than fee-for-service plans

Relatively few State Medicaid plans require children with special health care needs (CSHCN) to enroll in managed care (MC) plans. This is due to concerns that MC financial incentives to control costs may result in undertreatment, less access to procedures and providers, and adverse effects on care quality. However, Medicaid MC plans with case management programs may benefit children with disabilities eligible for Supplemental Security Income (SSI), suggests a study supported in part by the Agency for Healthcare Research and Quality (HS10912). The study was based on telephone interviews with a random sample of over 1,000 caregivers of predominantly black children with disabilities eligible for SSI enrolled in the District of Columbia's Medicaid program.

The interviews revealed fewer unmet health care needs among CSHCN enrolled in the District's partially capitated Medicaid MC plan than those enrolled in its Medicaid fee-for-service (FFS) plan. Almost 46 percent of FFS children had one or more unmet needs reported compared with 37 percent of MC children. Fifteen percent of FFS compared with 11 percent of MC children had an unmet need reported for medical equipment or supplies.

Jean M. Mitchell, Ph.D., of the Georgetown Public Policy Institute, and Darrell J. Gaskin, Ph.D., of Johns Hopkins University, speculate that several factors may account for some of these differences in unmet need. These factors include the case management services offered under the MC option, which assist the family in navigating the health care system in order to obtain medical care for the CSHCN; low Medicaid FFS provider reimbursements compared with MC reimbursement rates, and less FFS provider availability. The partially capitated MC plan used 20 percent of total capitation payments to cover administrative expenses, including case management services and outreach, and the other 80 percent to reimburse providers for services and to cover transportation costs for enrollees.

More details are in "Factors affecting plan choice and unmet need among supplemental security income eligible children with disabilities," by Drs. Mitchell and Gaskin, in the October 2005 HSR: Health Services Research 40(5), pp. 1379-1399.

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