Source: https://healthlaw.org/resource/q-a-managed-care-informing-and-disclosure-requirements-2/
Timestamp: 2019-04-25 01:55:01+00:00

Document:
 By 2010, about three quarters of Medicaid beneficiaries received services through some type of managed care arrangement. Subject to a few exceptions, States may require most Medicaid beneficiaries to enroll in managed care by amending their state Medicaid plans.æThis Q&A analyzes the responsibilities of states and managed care plans when they require persons with disabilities to enroll in managed care.
Q. My state?s Medicaid program will soon be requiring people with disabilities to enroll in managed care plans. What responsibility do state and managed care plans have to provide information about rights and services to new enrollees? Are there any cases addressing these requirements?
A. Federal law requires states and managed care plans to disclose information to enrollees and applicants. This includes services covered, enrollment and disenrollment rights, and notice and appeal rights. There are a few cases that address these requirements.
By 2010, about three quarters of Medicaid beneficiaries received services through some type of managed care arrangement.2 States may require most Medicaid beneficiaries to enroll in managed care by amending their state Medicaid plans.3 The exceptions are: (1) individuals eligible for both Medicare and Medicaid (dually eligible individuals), (2) children under age 19 with special needs, and (3) most Native Americans.4 If a state wants to require these populations to enroll, they may apply for a waiver through 42 U.S.C. § 1396n(b), which allows them to waive some Medicaid requirements. They may also require mandate enrollment through 42 U.S.C. § 1315 (also known as section 1115) which allows demonstration, experimental, and pilot programs to test alternative service delivery methods.
It is crucial that Medicaid applicants, enrollees, and other stakeholders have ready access to information about Medicaid managed care programs, including the services covered, the providers who participate in the plan, their rights to enroll and disenroll, to receive notices of adverse actions, to file grievances and to obtain an impartial hearing. Fortunately, there are legal requirements designed to ensure that this information is actually available and understandable.8 Obtaining this information is particularly crucial for people with disabilities, who have greater need for more expensive or ongoing services. When this population is enrolled in capitated managed care, there is an incentive to deny or restrict access to services in order to save money.
A number of courts have issued decisions dealing with Medicaid?s informational requirements.
The plaintiff children in this case claimed that D.C. was violating Medicaid?s Early and Periodic Screening, Diagnostic and Treatment requirements governing Medicaid services for children. The parties entered into a consent decree in 1994 and court- supervised monitoring has been conducted since then.
In another case filed on behalf of children, the federal district court ordered California state officials to take numerous steps to comply with EPSDT requirements to inform Medicaid enrollees about covered behavioral health services. Evidence showed that many of the county-operated mental health managed care plans (MHPs) were not familiar with the full scope of mental health services available for children and youth. Accordingly, the court ordered the state agency to distribute lists of supplemental mental health services to the MHPs. Supplemental mental health services is the phrase that California usese to indicate services that are not itemized in the state plan but covered for children and youth under age 21 pursuant to EPSDT?s requirements.
Three individuals requested information about Medicaid managed care plans through the state?s freedom of information act (FOIA) requiring disclosure of records by public agencies. They asked for information about reimbursement rates, fees, and preferred drug lists and formularies. Their requests were denied on the grounds that the MCOs were not performing a government function. The MCOs also claimed that the information sought included ?trade secrets? and forcing them to disclose the information would be an unconstitutional taking.
The petitioners in this case sought copies of contracts between a Medicaid managed care program and hospital providers under Pennsylvania?s Right-to-Know (RTK) law. An administrative law judge initially denied the petition, and the Pennsylvania Commonwealth Court reversed.
The court rejected the state agency and managed care plan?s argument that the contracts were not public because they were not in the agency?s possession, reasoning that the agency had the contractual right to obtain copies at any time. Moreover, the court held that the agreements were public because they were a product of the state agency?s relationship with the managed care plan. Because these contracts related to reimbursement of private providers with public Medicaid funds, the rationale for ordering disclosure was particularly compelling.
Medicaid services are increasingly provided by managed care plans. As non- governmental entities, many of which are for-profit enterprises, these plans are often not used to operating in a transparent manner. It is crucial for advocates to push for the maximum access to information about the services and administration of these entities.
Petition elected officials to bring pressure on MCEs to account for their actions.
1 Produced by the National Health Law Program with a grant from the Training Advocacy Support Center (TASC), which is sponsored by the Administration on Developmental Disabilities, the Center for Mental Health Services, the Rehabilitation Services Administration, the Social Security Administration, and the HealthResources Services Administration. TASC is a division of the National Disabilities Rights Network (NDRN).
2 CMS, Medicaid Managed Care Enrollment, July 1 2010, https://www.cms.gov/Research-Statistics-Data- and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/Downloads/2010July1.pdf.
3 42 U.S.C. § 1396u-2.
4 42 U.S.C. § 1396u-2(a)(2)(C).
5 42 U.S.C. § 1396b(m)(1)(A), 42 C.F.R. § 483.2.
6 42 C.F.R. § 483.2.
8 For further information, see Jane Perkins, Assuring Accountability and Stewardship in Medicaid Managed Care: Public Reporting Requirements for States and MCOs (June 2007) (available from TASC or NHeLP).
9 42 U.S.C. § 1396u-2(a)(5)(A); 42 C.F.R. § 438.10(b) (c), and (d).
10 42 U.S.C. § 1396u-2(a)(5)(C); 42 C.F.R. § 438.10(i).
11 42 U.S.C. § 1396u-2(a)(5)(D); 42 C.F.R. §§ 438.10(e)(2)(i)(E), (f)(6)(xii).
12 42 U.S.C. § 1396u-2(a(5)(B); 42 C.F.R. 438.10(f).
13 42 C.F.R. § 438.56(c).
14 42 C.F.R. § 438.438.56(d).
15 42 C.F.R. § 438.404.
17 750 F. Supp. 2d 65 (D.D.C. 2010).
18 Notably, in 2005, the state Attorney General?s office had written to urge the state Medicaid director to release the information related to reimbursement rates. The attorney general wrote: ?The critical public interest in openness and transparency in state contracting– especially involving more than $600 million of state funds — compels the release of these documents . . .? Op. Conn. Att?y Gen. (Oct. 2005), available at http://www.ct.gov/ag/cwp/view.asp?A=1770&Q=305398. For information about the advocacy in this case, contact Sheldon Toubman at New Haven Legal Services in Connecticut.
19 976 A.2d at 626.
20 Compare 65 Pa. Stat. § 66.1-66.2 (repealed 2009) and 65 Pa. Stat. 67.101-67.3103 (2012).
21 See, e.g., Honaman v. Twp of Lower Merion, 13 A.2d 1014 (Pa. Cmwlth. 2011) (citing Lukes with approval while noting repeal of earlier version of RTK law).

References: § 1396
 § 1315
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 § 483
 § 483
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 § 438
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 § 438
 § 1396
 § 1396
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 § 438
 § 438
 § 66
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