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The Exemption of Disabled Individuals from Required Enrollment with a Managed Care Entity Under the Medicaid Program S. 88 and H.R. 797

Congressional Sponsors: Senator Jim Bunning (R-KY) and Rep. Ken Lucas (D-KY).

Voice of the Retarded supports S. 88 and H.R. 797 for the following reasons:

* Many people with mental retardation have chronic, specialized health care needs. Most of these people rely on Medicaid for their health care. The ability of traditional managed care models to meet the unique and specialized health care requirements of many people with severe disabilities is uncertain.

* The General Accounting Office (GAO) has noted that to adequately safeguard the interests of disabled Medicaid beneficiaries, state programs must recognize that these beneficiaries are quite distinct from the general Medicaid population. Not only are their health care needs greater than those of the general population, but included among them are a small number of highly vulnerable individuals whose needs are extensive and critical to the prevention of death or further disability (July 1996, HEHS-96-136, p. 61).

* Congress recognized the challenges associated with providing health care for disabled Medicaid beneficiaries when it exempted SSI-eligible special needs children from mandatory managed care provisions of the Balanced Budget Act of 1997. This exemption reconciled the states' interest in maintaining cost control and flexibility in program management with the disability community's concern that managed care would negatively impact access to appropriate specialized health care. S. 88 and H.R. 797 correct an oversight in the Balanced Budget Act of 1997 by extending the safeguards afforded to children to all disabled individuals, regardless of age.

* A preliminary cost estimate by the Congressional Budget Office indicates that S. 88 and H.R. 797 will not result in any new federal Medicaid spending, based on estimates of identical legislation introduced in the 105th Congress (S. 1649 and H.R. 3281).

* S. 88 and H.R. 797 do not prohibit states from considering mandatory managed care. They do not create any new entitlements. They do not suggest any new programs. They will not result in any additional federal spending. They are corrective measures to ensure that states act responsibly prior to mandating managed care for eligible disabled people. States will have to develop a plan that is responsive to the specialized health care needs experienced by people with mental retardation. This is the process that existed prior to the enactment of the Balanced Budget Act of 1997.

* S. 88 and H.R. 797 merely reinstate the safeguards that were in place prior to the passage of the Balanced Budget Act of 1997. Prior to this Act, a state desiring to implement managed care for its Medicaid population sought approval from the Health Care Financing Administration to waive one or more of the provisions of the Medicaid law. Certain federal regulations, requirements and guidance influenced the development of state managed care programs and state monitoring of managed care plan performance. Current law, as enacted through the passage of the Balanced Budget Act, allows states to pursue Medicaid managed care by a state plan amendment, rather than the more stringent Waiver process.

* S. 88 and H.R. 797 will not radically change the system, they will not result in any additional federal spending, and they do not bar states from pursuing mandatory managed care for its Medicaid-eligible disabled population.

* Due to the exemption within in the Balanced Budget Act, states must still secure a Waiver if they wish to require SSI-eligible special needs children to participate in the Medicaid managed care plan. S. 88 and H.R. 797 would simply lift the age restriction. A state would have to secure an amendment to its current Waiver to implement mandatory managed care for its disabled population, regardless of age. The current age-based limitation is certainly arbitrary and may even be discriminatory since there is no reason other than age given for the sudden restriction of health care options. If you have visited developmental centers, you are certainly aware that people with severe and profound mental retardation who are Medicaid beneficiaries do not have fewer special health care needs as a result of reaching their nineteenth birthday. It makes sense that the safeguards afforded through the Waiver process for disabled children under 19 be afforded to those over age 19.

VOR supports S. 88 and H.R. 797 because they respond to the fact that people with disabilities, including people with mental retardation, are quite distinct from the general Medicaid population. This is common-sense legislation aimed at enhancing the quality of life of all persons with disabilities.

VOR * 836 S. Arlington Heights Rd., #351 * Elk Grove Village, Illinois * 60007

877-399-4VOR ph. * 847-253-0675 fax * tamie327@hotmail.com