U.S. Department of Health and Human Services

The Exception Needs Care Coordinator in the Oregon Health Plan

Executive Summary

Edith G. Walsh, Ph.D., Gregory Todd French, M.P.P., and Fred Bentley, B.A.

Health Economics Research, Inc.

February 7, 2000

This report was prepared under contract #500-94-0056 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Health Economics Research, Inc. Additional funding was provided by the Health Care Financing Administration. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Hunter McKay, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Hunter.McKay@hhs.gov.

The research presented in this report was performed under Health Care Financing Administration (HCFA) Contract No. 500-94-0056, Paul Boben, Project Officer. The statements contained in this report are solely those of the authors and no endorsement by Department of Health and Human Services should be inferred or implied.

Oregon designed several consumer protections for the SSI population and other aged and disabled beneficiaries in Medicaid managed care under the State's 1115 waiver. The Exceptional Needs Care Coordinator (ENCC), a type of specialized case manager at the managed care plans, is a cornerstone of these consumer protections. The ENCC and other features of the Oregon Health Plan can effectively assist SSI and other aged and disabled beneficiaries in negotiating managed care and act as a counter balance to the inherent incentive to reduce services associated with managed care. States considering a similar program should look carefully at the lessons learned in Oregon about successes and limitations of Oregon's program design and implementation.

Other consumer protections for aged and disabled beneficiaries in the Oregon Health Plan include:

• Exemptions permitted from managed care for such reasons as continuity of care;
• Liberal plan switching policies;
• A State Ombudsman program;
• Grievance and hearing procedures at the state level;
• The Continuity of Care Referral (CCR) used by case workers to communicate important information about beneficiaries to ENCC or to request ENCC services; and
• Use of the term "medically appropriate" as a more inclusive term to guide coverage decisions than the traditional "medically necessary."

ENCCs are employees of the health plans charged with assisting aged and disabled beneficiaries navigate managed care. The State provides additional capitation payments (averaging about $6 per member per month) to the plans to implement this role. State regulations charge ENCC staff with:

• Early identification of those aged, blind or disabled OMAP members that have disabilities or complex medical needs;
• Assistance to ensure timely access to providers and capitated services;
• Coordination with providers to ensure consideration is give to unique needs in treatment planning;
• Assistance to providers with coordination of capitated services and discharge planning; and
• Aid with coordinating community support and social service systems linkage with medical care systems as necessary and appropriate.

The ENCC program has had a positive impact in Oregon, and has led to creative and flexible service plans for some beneficiaries. ENCC staff also serve as the point of contact in each plan for the Ombudsman's Office, which receives about 5000 calls a year regarding services to aged and disabled Medicaid beneficiaries. However, ENCC effectiveness is limited by several factors. As found in several consumer and provider surveys, beneficiary focus groups and key informant interviews, consumers and providers alike have very limited awareness of the ENCC program and other protections. As a result, the protections may be severely underutilized. In addition, the latitude the State afforded to plans as they implemented the ENCC program led to variation in the philosophy, staffing approaches, case finding, and ENCC practices at each plan. While some ENCC programs engage in creative case management, flexible service planning and active liaison with community agencies, others appear indistinguishable from traditional managed care member services and utilization review departments.

Oregon designed the ENCC role to provide an additional form of case management in addition to their existing home and community-based services and long-term care case management system. There are formal links between this case management system and the ENCCs to promote integrated care across the acute and long-term care systems. These agency case workers provide plan choice counseling and enrollment and have the authority to exempt individuals from managed care enrollment. They are also intended to serve as advocates on behalf of the aged and disabled in managed care, referring clients to ENCCs for assistance. However, most of the aged and disabled beneficiaries are not in the long-term care system, and do not have the same level of support or advocacy in dealing with managed care issues. For these beneficiaries, the ENCC may be the only potential advocate.

Recommendations

States implementing managed care for the SSI population would do well to incorporate a similar set of consumer protections as those designed by Oregon. Specialized health plan staff, such as Oregon's ENCCs, are a practical and effective way to assist the aged and disabled in managed care. However, to maximize effectiveness, states need to devise ways to increase utilization of these protections and to ensure that additional payments for specialized case management are used as intended. Contract language should include a clear set of expectations, including acceptable staffing models, expected ENCC activities, and standardized record keeping and reporting requirements.

To increase awareness of the ENCC and other consumer protections, states need to provide ongoing training for staff at collaborating agencies, advocacy groups, beneficiaries and providers. Training activities should be ongoing, in part due to staff turnover at these agencies. Involvement of advocacy groups to help design and publicize the program is also important since some persons with disabilities or chronic health problems are unable to advocate on their own behalf.