Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
MANDATORY MANAGED CARE 
Early Lessons Learned by 
Medicaid Mental Health Programs 
JUNE GIBBS BROWN 
Inspector General 
JANUARY 2000 
OEI-04-97-00343  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended by Public Law 100-504, is to protect the integrity of the Department of Health and Human 
Services programs as well as the health and welfare of beneficiaries served by them. This statutory 
mission is carried out through a nationwide program of audits, investigations, inspections, sanctions, and 
fraud alerts. The Inspector General informs the Secretary of program and management problems and 
recommends legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of Inspector 
General. It conducts short-term management and program evaluations (called inspections) that focus 
on issues of concern to the Department, the Congress, and the public.  The inspection reports provide 
findings and recommendations on the efficiency, vulnerability, and effectiveness of departmental 
programs. 
OEI's Atlanta Regional Office prepared this report under the direction of Jesse J. Flowers, Regional 
Inspector General, and Christopher H. Koehler, Deputy Regional Inspector General.  Principal OEI 
staff included: 
REGION  HEADQUARTERS 
Dwayne Grant, Lead Analyst  Alan Levine, Program Specialist

Betty Apt  Barbara Tedesco

Josiah Townsel  Brian Ritchie

Janet Miller  Joan Richardson

To obtain copies of this report, please call the Atlanta Regional Office at 404-562-7723.  Reports are

also available on the World Wide Web at our home page address:

http://www.dhhs.gov/progorg/oei  T A B L E  O F  C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ......................................................1

INTRODUCTION .............................................................4

FINDINGS

Starting Managed Care Programs  ...........................................7

Transitioning From Fee For Service  .........................................9

Providing Access to Care .................................................10

CONCLUSIONS  ............................................................ 12

AGENCY COMMENTS  ...................................................... 13

APPENDICES

A: Summary of First Year Contracts ........................................14

B: Agency Comments  ...................................................15

HCFA ..........................................................16

SAMHSA .......................................................17

ENDNOTES ................................................................ 21
 E X E C U T I V E  S U M M A  R Y  
PURPOSE 
To describe early lessons learned by State Medicaid programs converting mental health services 
to persons with serious mental illnesses from a fee for service system of care to mandatory 
managed care. 
BACKGROUND 
States are increasingly converting their Medicaid programs from fee for service models to 
managed care models. Nearly every State has implemented, or is planning to implement, 
mandatory managed care for Medicaid beneficiaries who require mental health services. 
We surveyed seven State Medicaid programs that were among the first to mandate  managed 
care mental health services for persons with serious mental illnesses. In this report, we highlight 
early lessons learned by the first five States that converted to mandatory managed care.  We 
also included two States that recently converted to mandatory managed care. We included 
these two States because the Health Care Finance Administration identified them as having 
particularly innovative programs. 
Most of the practices we highlight were considered to be successful by State Medicaid staff in 
more than four of the seven States we studied. Those early States laid the ground work for 
other States that followed. Even within the group of seven, the first States who converted in 
1991-1992 were models for those that followed. 
EARLY LESSONS LEARNED 
The implementation successes and problems reported by the seven States we studied can be 
helpful for other States that are considering mandating managed care for mental health, or any 
other speciality services. We did not determine the effectiveness of the lessons learned reported 
by the States.  We believe, however, that such information can be helpful to States starting 
mandatory managed care programs, transitioning from fee for service, and providing access to 
out-patient services. 
Starting Managed Care Programs 
<  Separate mental health services from other health services

<  Phase In conversion

<  Exclude Drug formulary from managed care system

<  Use existing public health system

<  Keep contract language specific

Mandatory Managed Care - Lessons Learned  1  OEI-04-97-00343  Transitioning From Fee For Service 
<  Provide community education early and often 
<  Involve beneficiaries in conversion process 
<  Involve beneficiaries and family in treatment planning 
<  Ensure timely payment of providers 
Providing Access to Care 
<  Eliminate co-payments

<  Assign health care coordinators

<  Allow any accredited provider to participate

<  Encourage liberal prior authorization policies

<  Initiate outreach programs

<  Develop rural services

<  Initially share financial risk to encourage development of services

CONCLUSION 
States have become more efficient in their managed care mental health programs.  Each State 
learns from the successes and mistakes of its predecessors. The continued sharing of lessons 
learned could greatly benefit other States that are considering converting to mandatory managed 
care, and those preparing for contract renewal. 
AGENCY COMMENTS 
Both HCFA and SAMHSA commented on our draft report. 
HCFA stated that the report provided good, first-hand information on changes to Medicaid mental 
health services resulting from mandatory managed care enrollment during the first few years. 
SAMHSA questioned whether the lessons learned should be referred to as findings.  They said  the 
word findings may cause the reported experiences of the seven States to be construed as scientific 
data. We agree that our results are not scientific in the sense commonly used by SAMHSA in its grant 
programs.  On the other hand, we did gather the early experience of States in a systematic way and 
presented a broad spectrum of assessments of the relevance and significance of these early efforts. For 
this reason, we believe the use of the work findings is appropriate. However, because of SAMHSAs 
concerns, we have renamed this section Early Lessons Learned in order to reduce any 
misunderstanding within the research community about the nature of our findings.  We also included in 
this report, a section on advantages and limitations of our methodology in order to emphasize that our 
results are based on a case study approach. 
SAMHSA also expressed concern that none of our selected States had integrated programs and that we 
Mandatory Managed Care - Lessons Learned  2  OEI-04-97-00343  therefore could not present a balanced comparison of integrated and carved out mental health systems of 
care. However, our purpose was to describe the lessons learned by States that were the first to 
implement  mandatory managed care.  None of these States utilized an integrated system of care. 
Therefore, we could not compare these different systems 
Additionally, SAMHSA expressed concern that we may not have adequately included the views of 
State mental health staff and stakeholders. As shown in our methodology, we considered input from 
such groups as highly important.  To illustrate, we interviewed at least 37 State mental health staff and 
stakeholders. 
We also made several technical changes suggested by SAMHSA. 
The full text of HCFA and SAMHSA comments are in Appendix B. 
Mandatory Managed Care - Lessons Learned  3  OEI-04-97-00343  I N T R O D U C T I O N  
PURPOSE 
To describe early lessons learned by State Medicaid programs converting delivery of mental 
health services to persons with serious mental illnesses from a fee for service system of care to 
mandatory managed care. 
BACKGROUND 
States are increasingly converting their Medicaid programs from traditional fee for service 
models to managed care models.  As of June 1998, over 16.5 million Medicaid beneficiaries 
were participating in some type of managed care program. This represents over 53 percent of 
the Medicaid population1. 
Nearly every State has implemented, or is planning to implement, mandatory managed care for 
Medicaid beneficiaries who require mental health services.  As of July 1998, 36 States have 
implemented mandatory mental health managed care programs.2  The first seven States all 
implemented mandatory managed care between 1991 and 1995. They laid the ground work for 
other States that followed.  Within the group of seven, the earlier ones that converted in 1991-
1992 were models for those that followed. 
Mental Illnesses 
Adults, age 18 and over, who currently or any time in the past year have had a diagnosable 

mental, behavioral, or emotional disorder that results in functional impairment which substantially

interferes with or limits one or more major live activity is defined as seriously mentally ill.3  The

annual prevalence of serious mental illness in the United States is estimated to be about 5

percent, or 10 million people.4  Some of the more commonly recognized disabling types of

serious mental illnesses include schizophrenia, bipolar disorder, major depression, obsessive-

compulsive disorder, and panic disorder.

Children, up to age 18, with the same diagnosis, are classified as seriously emotionally disturbed. 

An estimated 1 in 10 children are reported to have a serious emotional disturbance at any given

time.5  In fact, the estimated prevalence rate of serious emotional disturbances for children -

about 9 percent - is higher than the prevalence rate of serious mental illnesses for adults.6

In addition to the disorders that effect adults, children with a serious emotional disturbance may

also be commonly diagnosed with attention deficit disorder, autism, pervasive development

disorder, or Tourette's syndrome.

Mandatory Managed Care - Lessons Learned  4  OEI-04-97-00343  METHODOLOGY 
We reviewed the mental health managed care programs for seven States .  They were Arizona, 
Massachusetts, North Carolina7, Utah, Washington, Iowa, and Colorado. We highlight 
successful practices of the first five States with mandatory managed care programs for persons 
with serious mental illnesses for at least 3 years as of April 1997.8  Likewise, we included 
successful practices of two States, Iowa and Colorado that the Health Care Finance 
Administration identified as being particularly innovative programs.9  Most of the practices we 
highlighted were considered to be successful by State Medicaid staff in more than half of the 
seven States we studied. For comparison purposes, we provided a general description of each 
selected State program in appendix A. 
To identified successful practices, we interviewed Medicaid staff in each selected State. We 
also interviewed selected managed care organization officials, mental health care providers, and 
mental health stakeholders.  We asked them to describe the positive and negative experiences of 
managed care implementation. 
Advantages and General Limitations 
We used a case study approach in analyzing the early lessons learned by Medicaid mental health 
programs.  The advantage of this approach was that it allowed us to gain first-hand experiences 
from State officials, managed care organization representatives, mental health providers, and 
stakeholders. Our methods have general limitations in that the States or sites selected may not 
be typical, and we did not verify the testimonial information they provided to us. The information 
is also limited, because it reflects operations that occurred over a 2 to 3-year time period starting 
with each States first year contract. We are aware that State Medicaid managed care systems 
have continued to evolve with each new contract and waiver renewal, and that the structure of 
our surveyed States today may be quite different from their initial managed care contracts. 
Despite the general limitations of our inspection, we believe this report provides good, first-hand 
information on the early lessons learned by Medicaid mental health programs implementing 
mandatory managed care programs.  This type of information could be most useful when first 
implementing a new system of care. 
Definitions 
Seriously Mentally Ill - For purposes of this report, the serious mentally ill population refers to 
both adults and children, unless otherwise stipulated. 
Stakeholders - For the purpose of this report, stakeholders include persons with a serious 
mental illness, family members of persons with a serious mental illness, and State and national 
mental health organizations representing persons with serious mental illnesses. 
Mandatory Managed Care - Lessons Learned  5  OEI-04-97-00343  Companion Reports 
We issued a companion report titled Mandatory Managed Care - Changes in Medicaid Mental 
Health Services (OEI-04-97-00340). That report provides an early look at the changes that 
mandatory managed care had on State Medicaid mental health services for persons with serious 
mental illnesses. 
We also observed that children often face different challenges accessing mental health care than 
do adults.  These differences are presented in a companion report titled Mandatory Managed 
Care - Childrens Access to Medicaid Mental Health Care (OEI-04-97-00344). 
_____  ____  ____  _____ 
We did our field work between May 1997 and July 1997.  While conditions regarding mental 
health services in managed care settings may have changed since then, our report reflects 
conditions and patterns of care in the first few years of converting fee for service programs to 
managed care. Wherever possible we have updated our background information. We 
conducted the inspection in accordance with Quality Standards for Inspections issued by the 
Presidents Council on Integrity and Efficiency. 
Mandatory Managed Care - Lessons Learned  6  OEI-04-97-00343  E a r l y  L e s s o n s  L e a r n e d  
Within broad Federal guidelines, State Medicaid programs determine who is eligible for Medicaid 
benefits, as well as what services are provided. Given the ability of each State to tailor their programs to 
best fit their individual needs, it is understandable that no two State Medicaid programs are exactly alike. 
The overall uniqueness was evident in all seven State Medicaid mandatory mental health managed care 
programs we studied. However, we identified several common implementation characteristics that 
Medicaid staff in most of the seven States said were particularly successful.  According to Medicaid 
staff, the strategies highlighted below were used when starting a managed care program, transitioning 
from fee for service, and providing access to care for persons with serious mental illnesses. 
Starting Managed Care Programs 
Separate Mental Health  All seven States separated or carved out their mental health 
Services From Other  services from their general health services. By carving out mental 
Health Services	 health services, States helped ensure provision of care by 
specialized managed care organizations that are experienced with 
the challenges of treating serious mentally ill populations. The 
seven States said that general health care managed care 
organizations were not typically structured to handle the 
complex, long-term challenges presented by Medicaid serious 
mentally ill populations. 
Phase In Conversion	 Four of the seven States surveyed chose to first test mandatory 
managed care in a portion of the State.  These States reported 
fewer implementation problems than did States that immediately 
implemented State-wide programs without testing. States that 
implemented State-wide experienced delays in converting and 
enrolling beneficiaries, lack of up-to-date eligibility information, 
cumbersome prior authorization procedures, and delays in 
paying providers.  Smaller test sites allowed States to resolve 
such service and logistical problems prior to State-wide 
implementation. 
Mandatory Managed Care - Lessons Learned  7  OEI-04-97-00343  Exclude Drug  States did not include the cost for prescription drugs in their 
Formulary from  managed care contract.  This was done primarily because States 
Managed Care System	 were unsure of how to accurately determine the cost for this 
benefit. Without reliable cost information, States said they could 
not correctly set the capitation rate for this benefit. States 
believed that if they did not set the capitation rate for prescription 
drugs at the correct level, managed care organizations would 
have an incentive to restrict access. Therefore, excluding 
prescription drugs from managed care contracts would protect 
beneficiaries. Beneficiaries continued to receive their 
prescription drugs through the traditional fee for service system. 
Use Existing Public  Most States contracted with their established public health 
Health System	 providers, typically Community Mental Health Centers 
(CMHCs), who formed non-profit managed care organizations 
to bid on contracts.  States believed that contracting with existing 
CMHCs would allow them to keep the existing public mental 
health system in place, allow for a more seamless conversion, 
and minimize the impact of change on beneficiaries. They also 
generally thought that existing CMHCs had more experience 
providing services to the Medicaid beneficiaries with serious 
mental illnesses. 
Keep Contract  In hindsight, most States acknowledged that their first managed 
Language Specific	 care contracts were weak and not as specific as they should 
have been. States learned from their experience and 
strengthened contract language in subsequent contract renewals. 
It is important that States not be naive about contracts. If 
something is not specified in the contract, it will not happen 
unless States are willing to pay more for it. 
Mandatory Managed Care - Lessons Learned  8  OEI-04-97-00343  Transitioning from Fee For Service 
Provide Community  States recommended educating and advising beneficiaries of 
Education Early and  pending system changes as early, and as often, as possible. 
Often	 These efforts should start during initial planning, and continue 
well after managed care implementation. States found such early 
outreach efforts well worth the effort and cost. 
Involve Beneficiaries in  Most States involved beneficiaries and family members in 
Conversion Process 	 planning and developing their mental health managed care 
programs.  Beneficiaries who were involved early in the 
contracting process felt the most in control and were the most 
receptive to the managed care conversion. 
Involve Beneficiaries  Family members and beneficiaries often felt that they were not 
and Family in  always respected or looked upon as a resource when providers 
Treatment Planning	 and managed care organizations developed treatment plans. 
These groups wanted more involvement in treatment plans. 
Managed care organizations that solicited and incorporated input 
from family members and beneficiaries on treatment plans 
received more favorable comments regarding their managed care 
programs. 
Ensure Timely  During the initial stages of conversion to managed care, 
Payment of Providers	 providers often waited long periods of time without receiving 
payment for mental health services rendered. This problem was 
more prevalent in those States that implemented mandatory 
managed care State-wide.  Payment delays caused a lot of 
animosity among providers.  It creating a financial hardship for 
some providers, particularly the traditional public providers who 
did not have capital reserves to withstand long payment delays. 
As an inducement to encourage timely payment of providers, one 
State included financial incentives and penalty clauses in the 
managed care organization contract. 
Mandatory Managed Care - Lessons Learned  9  OEI-04-97-00343  Providing Access to Care 
Eliminate  All States that had a fee for service co-payment requirement 
Co-payments	 eliminated it when they converted to managed care. States 
reported co-payments are typically used to discourage, or limit, 
use of services, and may have served as a barrier to out-patient 
treatment for Medicaid beneficiaries under the prior fee for 
service system. States believed discouraging use of services by 
charging a co-payment is inconsistent with the goals of public 
health programs, which is to provide services to those in need. 
While the eliminated co-payment was typically only a few dollars 
per visit, any fee can be a strong barrier to care for Medicaid 
beneficiaries. 
Assign Health Care  To improve access to services and coordination of care, some 
Coordinators	 States created health care coordinator positions. Each new 
Medicaid beneficiary would be assigned to a health care 
coordinator. Mental health stakeholders viewed health care 
coordinators as a proponent for services and care, rather than a 
gatekeeper, or someone who limits care. They not only assisted 
with obtaining mental health services, but they helped coordinate 
general health services, which is often a challenge for 
beneficiaries in a carved out health care system. 
Allow Any Accredited  Two States used any accredited provider language in their 
Provider to Participate	 managed care contracts.  This meant that any provider, that met 
the managed care organizations accreditation requirements and 
accepted the managed care organizations reimbursement rates, 
was eligible to participate in the managed care system. By 
requiring that managed care organizations not restrict provider 
participation, States were able to expand beneficiary choice of 
providers, as well as increase system capacity by expanding the 
managed care organizations provider base. 
Mandatory Managed Care - Lessons Learned  10  OEI-04-97-00343  Encourage Liberal  States believed that pre-authorizing a set number of initial out-
Prior Authorization  patient services reduced administrative bureaucracy and costs, 
Policy  and improved timeliness of services. Providers were also more 
satisfied with managed care when they were given this flexibility. 
Requiring each individual service to be approved in advance 
proved to be cumbersome and labor intensive for both providers 
and managed care organizations. 
Initiate Outreach  One State said they increased the number of beneficiaries 
Programs	 accessing mental health services by requiring beneficiary out 
reach programs. The State required managed care organizations 
to contact new Medicaid enrollees and to periodically send a 
newsletter or program information to all enrollees.  This initiative 
was highly touted by the State as a reason they were able to 
increase the percentage of Medicaid enrollees accessing mental 
health services 
Develop Rural  Several States encouraged the development of rural programs by 
Services	 providing a higher capitated rate for these areas. Rural areas 
present special problems because an adequate number of 
providers and services are often not close by. Populations are 
often not large enough to spread the risk to make capitation 
feasible. 
Initially Share Financial  To ensure that new managed care organizations were ready to 
Risk to Encourage  provide needed out-patient services, several States initially 
Development of  shared the financial risk for services with managed care 
Services  organizations. This allowed managed care organizations to 
develop adequate services and programs.  It also allowed 
States to test their newly set capitation rates for accuracy without 
risking the financial stability of the managed care organization. 
This sharing of risk was particularly helpful to newly created non-
profit organizations which did not have financial reserves to 
sustain extended operational losses. States also felt that initially 
sharing financial risks would reduce the incentive for providers to 
restrict services. 
Mandatory Managed Care - Lessons Learned  11  OEI-04-97-00343  C O N C L U S I O N  
States have become more efficient in their managed care mental health programs. Each State learns 
from the successes and mistakes of its predecessors.  The continued sharing of lessons learned will 
greatly benefit other States that are considering converting to mandatory managed care, and those 
preparing for contract renewal. 
Mandatory Managed Care - Lessons Learned  12  OEI-04-97-00343  A G E N C Y  C O M M E N T S  
Both HCFA and SAMHSA commented on our draft report. 
HCFA stated that the report provided good, first-hand information on changes to Medicaid mental 
health services resulting from mandatory managed care enrollment during the first few years. 
SAMHSA questioned whether the lessons learned should be referred to as findings.  They said  the 
word findings may cause the reported experiences of the seven States to be construed as scientific 
data. We certainly agree that our results are not scientific in the sense commonly used by SAMHSA in 
its grant programs. On the other hand, we did gather the early experience of States in a systematic way 
and presented a broad spectrum of assessments of the relevance and significance of these early efforts. 
Keeping in mind the source and nature of the information, it seems prudent to try to learn as much as 
possible from what these seven States have done so far.  It was our hope, as SAMHSA has put it, that 
the lessons learned by the seven States are valuable for ongoing implementation by other States. 
Nevertheless, because of SAMHSAs concerns, we have renamed this section Early Lessons Learned 
in order to reduce any misunderstanding within the research community about the nature of our findings. 
We also included in this report a section on advantages and limitations of our methodology in order to 
emphasize that our results are based on a case study approach. We believe our discussion on our study 
advantages and limitations will help readers understand what can and cannot be inferred from our field 
work. 
SAMHSA also expressed concern that none of our selected States had integrated programs and that we 
therefore could not present a balanced comparison of integrated and carved out mental health systems of 
care. However, our purpose was to describe the lessons learned by States that were the first to 
implement mandatory managed care early. None of these States utilized an integrated system of care. 
Therefore, we could not compare the different systems 
Additionally, SAMHSA expressed concern that we may not have adequately included the views of 
State mental health staff and stakeholders. As shown in our methodology, we considered input from 
such groups as highly important.  To illustrate, we interviewed at least 37 State mental health staff and 
stakeholders. 
We also made several technical changes suggested by SAMHSA.  For example, we clarified  Appendix 
A to show services that were excluded from risk by managed care organizations during their first year 
contracts. 
We present the full text of HCFA and SAMHSA comments in Appendix B. 
Mandatory Managed Care - Lessons Learned  13  OEI-04-97-00343  APPENDIX A 
Summary: First Year Medicaid Managed Care Mental Health Contracts

Start  Waiver  Type of  Initial  Services 
State  Date  Type  Managed Care Organization  Coverage  Area  Excluded 
Covered  from MCO 
Risk 
AZ  Jan  1115  Non-profit, public sector,  Adults  Statewide 
1992  CMHCs*  and 
Children 
CO  Aug  1915(b)  Most areas non-profit, public  Adults  6 test  State hospital 
1995  sector CMHCs.  and  areas.  & drugs 
Two rural areas - partnership  Children  Excluded 
between public sector  largest 
CMHCs and private, for- metro area 
profit companies 
IA  Mar  1915(b)  one private for-profit  Adults  Statewide  State hospital 
1995  company for whole State  and  & drugs 
Children 
MA  Jan  1915(b)  one private for-profit  Adults  Statewide  State hospital 
1992  company for whole State  and  & drugs 
Children 
NC  Jan  1915(b)  Non-profit, public sector  Children  11  Outpatient 
1994  CMHCs  Only  counties,  care 
approx 
25% of 
state 
UT  Jul  1915(b)  non-profit, public sector  Adults  8 of 11  State 
1991  CMHCs  and  areas.  Hospitals 
Children  80% of 
Medicaid 
population 
WA  Jul  1915(b)  Non-profit public sector  Adults  6 of 14  In-patient 
1993  system  and  areas.  care 
Children  66% of 
Medicaid 
population 
* Community Mental Health Centers 
Mandatory Managed Care - Lessons Learned  14  OEI-04-97-00343  APPENDIX B 
Agency Comments 
Health Care Financing Administration (HCFA)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Mandatory Managed Care - Lessons Learned  15  OEI-04-97-00343  Mandatory Managed Care - Lessons Learned  16  OEI-04-97-00343  Mandatory Managed Care - Lessons Learned  17  OEI-04-97-00343  Mandatory Managed Care - Lessons Learned  18  OEI-04-97-00343  Mandatory Managed Care - Lessons Learned  19  OEI-04-97-00343  Mandatory Managed Care - Lessons Learned  20  OEI-04-97-00343  ENDNOTES 
1. National Summary of Medicaid Managed Care Programs and Enrollment, Medicaid Managed care 
Enrollment Report, The Health Care Financing Administration, June 30, 1998 
2. State Profiles on Public Sector Managed Behavioral Health Care and Other Reforms.  Managed 
Care Tracking System, Substance Abuse and Mental Health Services Administration, July 31, 1998 
3. Federal Register, Volume 58, Number 96, May 20, 1993 page 29425 
4. The 12-Month Prevalence and Correlates of Serious Mental Illness (SMI)  Mental Health, United 
States, 1996. Center for Mental Health Services, Substance Abuse and Mental Health Services 
Administration, 1996 
5. Prevalence of Serious Emotional Disturbance in Children and Adolescents.  Mental Health, United 
States, 1996. Center for Mental Health Services, Substance Abuse and Mental Health Services 
Administration, 1996 
6. ibid 
7.  In February 1999, North Carolina requested to withdraw its 1915(b) waiver extension of the 
Carolina Alternatives Program. The State proposes to move all recipients back to a fee for service 
system on or before June 30, 1999. 
8.  Oregon and Tennessee have been under managed care for a minimum of 3 years, but did not phase 
in their seriously mentally ill populations until January 1995 and July 1996 respectively. North 
Carolinas waiver only applies to children. 
9. Iowa implemented March 1995. Colorado implemented July 1995. 
Mandatory Managed Care - Lessons Learned  21  OEI-04-97-00343