Medicaid Managed Care Key Concerns J Input of Stakeholders J Enrollment and Marketing J Services and Benefits J Access to Experienced Providers J Reimbursement J Quality Management and Monitoring

Ryan White Programs and MCOs Ryan White Programs J public health mission J population driven J enabling services J medically and culturally appropriate providers J provide care to uninsured J accessible sites J experience with vulnerable populations J social model MCOs J for profit mission J market driven J mandated benefits only J cost efficient contracted providers J care only to members J “commercial” sites J experience with middle class J medical insurance model

Input of Stakeholders J Inclusion of stakeholders P e.g. waiver development, implementation & monitoring of waiver J Defining key terms e.g. case management, gatekeeper J Participation in quality assurance activities

Enrollment and Marketing J Awareness of HIV/AIDS among eligible beneficiaries J Protections against discriminatory practices J Assuring patient confidentiality J Provision of enrollment materials sensitive to HIV: P exemption options, lock-in periods, changing providers, disenrollment, grievance procedures P on site enrollment by RW funded providers, other SNP J Variables in default assignment algorithm P assignment to traditional provider of care

Services and Benefits J Comprehensive benefit package P Rx, substance abuse treatment, mental health, wide range of specialty medical care, home health, infusion therapy, dental services, hospice, nutritional counseling, J Case management to coordinate w/wrap around services P housing, food services, transportation, vocational counseling, non-covered services J Definition of medical necessity J Access to new treatments and therapies P Viral load, protease inhibitors, clinical trials

HIV Providers J Expert & experienced providers in HIV disease P survival has been linked directly with patient’s access to experienced HIV care providers J Designation & role of gatekeeper P Specialists as gatekeeper P Referrals to specialists I delays/denials can have catastrophic impact P Provisions for out of network providers J Adequate number & distribution of primary & specialty care P Inclusion of traditional providers of care, especially Ryan White Funded programs

Quality Assurance J Indicators to assess quality & utilization of services for PLWH J Standards to assure access to primary care and specialty care providers J Consumer Satisfaction Surveys P importance of over-sampling J Expedited grievance procedures

Reimbursement J Adequate reimbursement to MCOs & providers to cover cost of providing care P assurances of adequate reimbursement to providers in contracts J Use of risk adjustment P Variables used to develop rates J Inclusion of Rx therapies in capitation P Rates adjustments to account for costly new therapies & lab tests

Challenges to CBOs J Loss of clients P Decreased patient revenues P 33% of Title III clients have Medicaid coverage; 11% with Medicare or private insurance J Increased costs P caring for more uninsured patients P patients with managed care coverage J Loss of traditional referral sources J Cultural Change - P Learning to be competitive, marketing Services to MCOs J Believing managed care is “here”