Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

JANUARY 2000 

OEI-04-97-00343 

MANDATORY MANAGED CARE 

Early Lessons Learned by 

Medicaid Mental Health Programs 
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 
TABLE OF CONTENTS 

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
EXECUTIVE SUMM ARY 

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 SAMHSA’s 

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 
INTRODUCTION 

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, obsessivecompulsive 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 - Children’s 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 

President’s Council on Integrity and Efficiency. 

Mandatory Managed Care - Lessons Learned 6 OEI-04-97-00343 
Early Lessons Learned 

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 organization’s accreditation requirements and 

accepted the managed care organization’s 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 organization’s provider base. 

Mandatory Managed Care - Lessons Learned 10 OEI-04-97-00343 
Encourage Liberal States believed that pre-authorizing a set number of initial outPrior 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 nonprofit 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 
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 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 
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 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 SAMHSA’s 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

State Date 

Start 

Type 

Waiver 

Managed Care Organization 

Type of 

Coverage Area 

Initial 

Covered 

Excluded 

Services 

from MCO 

Risk 

AZ Jan 

1992 

1115 Non-profit, public sector, 

CMHCs* 

Adults 

and 

Children 

Statewide 

CO Aug 

1995 

1915(b) Most areas non-profit, public 

sector CMHCs. 

Two rural areas - partnership 

between public sector 

CMHCs and private, forprofit companies 

Adults 

and 

Children 

6 test 

areas. 

Excluded 

largest 

metro area 

State hospital 

& drugs 

IA Mar 

1995 

1915(b) one private for-profit 

company for whole State 

Adults 

and 

Children 

Statewide State hospital 

& drugs 

MA Jan 

1992 

1915(b) one private for-profit 

company for whole State 

Adults 

and 

Children 

Statewide State hospital 

& drugs 

NC Jan 

1994 

1915(b) Non-profit, public sector 

CMHCs 

Children 

Only 

11 

counties, 

approx 

25% of 

state 

Outpatient 

care 

UT Jul 

1991 

1915(b) non-profit, public sector 

CMHCs 

Adults 

and 

Children 

8 of 11 

areas. 

80% of 

Medicaid 

population 

State 

Hospitals 

WA Jul 

1993 

1915(b) Non-profit public sector 

system 

Adults 

and 

Children 

6 of 14 

areas. 

66% of 

Medicaid 

population 

In-patient 

care 

* 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 

Carolina’s waiver only applies to children. 

9. Iowa implemented March 1995. Colorado implemented July 1995. 

Mandatory Managed Care - Lessons Learned 21 OEI-04-97-00343