Discussion Draft Specialized Services Committee

Discussion Draft Specialized Services Committee

PROPOSED POPULATIONS FOR MANAGED CARE IN PHASES I, II, AND III

DISCUSSION DRAFT – SPECIALIZED SERVICES COMMITTEE

September 13, 2010

MaineCare Eligibility Groups / Proposed
Phase / Mandatory
/Voluntary / PCCM[1] / Required Authority for Mandatory Inclusion / Potential Overlap with Specialized Services Populations
Parents and Children / 1 / Mandatory / Mandatory / SPA for most; 1915(b) required for children with special health care needs /
  • May include children with special health care needs (e.g, children with behavioral health needs; children with developmental disabilities; children who are medically fragile; children with physical disabilities).
  • May include adults with disabilities (e.g., adults with serious and persistent mental illness, adults with brain injury, adults with other disabilities)

Children in State Custody, Foster Care, Child Protective Custody and Adoptive Assistance / 1? / Voluntary? / Voluntary / 1915(b) /
  • May include children with special health care needs (e.g, children with behavioral health needs; children with developmental disabilities; children who are medically fragile; children with physical disabilities).

Non-categorical Waiver / 1 / Mandatory / Mandatory / Amendment to non-cat waiver /
  • May include adults with disabilities (e.g., adults with serious and persistent mental illness, adults with brain injury, adults with other disabilities)

Katie Beckett / 1? / Voluntary? / Excluded / 1915(b) /
  • Includes children requiring an institutional level of care

Breast and Cervical / 1 / Mandatory / Mandatory / SPA /
  • Includes persons with chronic medical conditions

HIV/AIDS Waiver / 1 / Mandatory / Excluded / Amendment to HIV waiver /
  • Includes persons with chronic medical conditions

MaineCare Eligibility Groups –
NON-DUALS
(MaineCare Only) / Proposed Phase / Mandatory/ Voluntary / PCCM* / Required Authority for Mandatory Inclusion / Potential Overlap with Specialized Services Populations
Blind/Disabled / 2 / Mandatory / Voluntary / SPA /
  • Includes adults with disabilities (e.g., adults with serious and persistent mental illness, adults with brain injury, adults with developmental disabilities, and adults with other disabilities)
  • Includes children with special health care needs (e.g, children with behavioral health needs; children with intellectual disabilities; children who are medically fragile; children with physical disabilities).

Aged Adults / 2 / Mandatory / Mandatory / SPA /
  • Includes older adults in good health and older adults with cognitive, behavioral and physical disabilities, and chronic conditions.

Adults Living in Facilities (NF and/or PNMIs) / 2 / Mandatory / Those in NF excluded;
In PNMI typically exempt / SPA /
  • Includes adults requiring an institutional level of care.
  • Includes adults with physical and medical conditions, developmental disabilities, brain injury, addiction disorders, and serious and persistent mental illness.

Home & Community Based Waiver / 2 / Mandatory / Excluded / SPA /
  • Includes adults requiring an institutional level of care, including adults with developmental disabilities, adults with physical disabilities, older adults and adults with other disabilities.

Spend Down/Medically Needy / 2 / Mandatory / Excluded / SPA /
  • May include adults with disabilities (e.g., adults with serious and persistent mental illness, adults with brain injury, and adults with other disabilities) and other conditions
  • May include children with special health care needs (e.g, children with behavioral health needs; children with medical conditions, children with physical disabilities).

MaineCare Eligibility Groups –
DUAL ELIGIBLES
(MaineCare and Medicare) / Proposed Phase / Mandatory/ Voluntary / PCCM / Required Authority for Mandatory Inclusion / Potential Overlap with Specialized Services Populations
Blind/Disabled / 3 / Mandatory / Excluded / 1915(b) / See above
Aged Adults / 3 / Mandatory / Excluded / 1915(b) / See above
Adults in Facilities (NF and/or PNMIs) / 3 / Mandatory / Excluded / 1915(b) / See above
Home and Community Based Waiver / 3 / Mandatory / Excluded / 1915(b) / See above
Spend Down/ Med Needy / 3 / Mandatory / Excluded / 1915(b) / See above
MAINECARE GROUPS NOT INCLUDED IN MANAGED CARE
Individuals residing in Public Institutions
Emergency Benefits
QMB Buy-in
SLIMB Buy-in
STATE ONLY GROUPS NOT INCLUDED IN MANAGED CARE
DEL Pharmacy Only
Maine Rx Plus Pharmacy
Eye care only

[1] Primary Care Case Management program. In the PCCM program, the member’s primary care physician provides or authorizes certain services. Mandatory PCCM populations may request an administrative or clinical exemption from mandatory participation in the PCCM program.

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