Managed Care

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Geriatric Care Managers … coordinating services to optimize health and quality of life.

The National Association of Professional Geriatric Care Managers (NAPGCM) is an organization of practitioners whose goal is the advancement of expert assistance to older adults and their families.  NAPGCM is committed to maximizing the independence and autonomy of elders and strives to ensure the highest quality and most cost-effective health and human services. Members help older persons and their families cope with the challenges of aging, through education, advocacy, counseling, and service delivery.

Managed Care

The term “Managed Care” represents a broad range of health insurance options ranging from Health Maintenance Organizations (HMOs) to Preferred Provider Organizations (PPOs).  For the elderly and the users of Medicare, Medicare Advantage Plans provide the primary framework through which managed care is provided.  In light of the diverse managed care options available, public policy advocacy by NAPGCM should focus on those managed care systems and federal, state and local policies most relevant to the elderly.  Given that HMO’s are the model typically offered by Medicare Advantage plans, and historically have provided the elderly with less choice and flexibility than standard Medicare, NAPGCM and its membership should prioritize public policy efforts, where necessary, on managed care/HMO public policy advocacy.  NAPGCM and its membership should take a leadership role, through federal, state, and local public policy advocacy, to ensure managed care legislation and carriers respect clients’ self-determination and consumer rights, as well as insure that care meets the highest standards.

I. Information

A. NAPGCM supports:

1. The prohibition of discrimination on the basis of race, age, gender or health status in the marketing of plans, enrollment of participants, and provision of care.
2. Providing enrollees, upon enrollment, with information on benefits, providers, prior authorization requirements, grievance procedures, disenrollment procedures, and appeal rights.
3. Managed care plans disclosure of restrictions or limitations such as enrollees’ access to prescription or non-formulary drugs.

B. NAPGCM advocates that:

All written information provided by managed care organizations to consumers, including billing, insurance processing claims, medical or educational information, and service descriptions should be clear, easily read in a large size, and understood by individuals with a 5th grade reading level.  Where programs serve a significant population of participants who speak a language other than English, interpreters and/or bilingual materials should be available to them.

II. Rights

A. NAPGCM supports:

1. The “Patient Bill of Rights” in all areas of service and supports managed care services that enforce these rights in their delivery of care.
2. The active involvement of patients and family members in all decisions about their medical care and for them to be informed in a timely manner of care options not covered by their health plans.

B. NAPGCM advocates:

1. For consumers to have the right to seek added (uncovered services) and denied specialty services (after an appeal process) at the same rates offered through the plan within the prescribed deductible.
2. That consumer grievance and appeal processes be timely and responsive to consumer needs, particularly within emergency/urgent healthcare situations.
3. For the prohibition against managed care plans denial of coverage for healthcare services rendered through approved clinical trials.
4. Consumers have a review and appeal process, via an outside panel for denials.
5. For consumers to have legal recourse against their managed care plans for infringements on their contracts, including care decisions made by providers considered to be malpractice.

III. Choice

A. NAPGCM advocates:

1. For the right of choice for consumers within the plan.
2. That managed care programs have at least three options whenever possible within each specialty from which consumers may choose.
3. For legislation that will insure consumer choice within universal health care coverage, so that HMO/managed care enrollment is not required of all beneficiaries.

IV. Quality

A. NAPGCM advocates:

1. For managed care providers to have credentialed, highly qualified professionals with adequately staffed offices, which provide timely, accessible health care services.
2. For consumers to have access to the highest quality health services absent of financial incentives for providers to limit care.
3. That all services offered through managed care be consistent with established clinical best practices and monitored for clinical effectiveness.
4. That managed care organizations subscribe to the best practices in their industry.

V. Accessibility

A. NAPGCM advocates for consumers to have:

1. Easy access to quality specialty care.
2. Access to emergency services 24 hours a day and coverage for such services when the consumer has acute symptoms of sufficient severity such that a prudent layperson could reasonably judge the need for immediate care.  This should be available without prior authorization and without additional charge, if services are provided by an out-of-network provider.

VI. Other

A. NAPGCM advocates for managed care:

1. To have defined, preventive, specialized geriatric programs that provide diagnostic, treatment, and care coordination for older adults.
2. Plans to provide parity in the reimbursement of mental health and physical health services as well as integration of the two services to assure continuity of care.
3. To clearly differentiate the role of gate-keeper from the role of care manager, where the former manages services for the providers and the latter is an independent, nationally certified professional unaffiliated with the health insurance provider.

Resolutions Approved by the NAPGCM Board of Directors June 27, 1998 and Revised October 22, 1998.
Reviewed, changed and updated by Public Policy Committee, September 8, 2008.
Reviewed and approved by NAPGCM Board of Directors October 23, 2008