This document outlines the tasks for week 6 of a health services course, including readings related to Medicaid managed care, assignment details for analyzing Medicaid profiles of three states, and discussion topics on the complexities of Medicaid managed care compared to private sector programs. It provides historical context on Medicaid expansion since 1965, enrollment growth, and barriers to care, as well as information about the TRICARE system for military healthcare. The document also touches on private health insurance roles globally and provides grading criteria for essay questions.

1. Week#6-To Do List-SMHS
1. Week 6: Readings
Please use the assigned course book to read the following
sections:
Part V: Special Markets
Chapter 25: Medicaid Managed Health Care
Chapter 26: The Military Managed Care Health System
Chapter 27: Managed Care in a Global Content
Click on the links below to access additional recommended
readings:
https://www.youtube.com/watch?v=wtB9VQ3eRRk&list=PL5AJ
oKAXemI5ufCHHM8ga3YcU18zBWyAa
https://www.youtube.com/watch?v=OCgwxXV049s
https://www.youtube.com/watch?v=LD3L5CSaYLY
2. Week 6: Assignment
The use of Medicaid use services among consumers varies state
by state. This assignment calls for you to report on the
Medicaid profiles of 3 states, which can be found at the
following website: http://medicaid.gov/Medicaid-CHIP-
Program-Information/By-State/By-State.html Include within
your report, all statistical data and charts that identify:
Eligibility levels
Enrollment data
Targeted enrollment strategies used
Participation rates

2. 3. Week 6: Discussion
What are some of the reasons Medicaid managed care is more
complex than developing private sector managed care programs
and has led to more specialized firms dominating this market?
Medicaid Managed Health Care, The Military Managed Care
Health System and Managed Care in a Global Context
WEEK 6 LECTURE
History of Medicaid
Health coverage for the uninsured for over 45 years.
Entitlement program established in 1965 as part of President
Johnson’s “Great Society”
Initially intended as a health coverage supplement for those
receiving cash assistance (predominantly women of child
bearing age and children).
Overtime, Congress has expanded eligibility substantially to fill
coverage gaps left by private insurance. Therefore, States have
expanded their programs by
(1) raising the income eligibility levels for aid categories; and
(2) adding and/or expanding new populations.
Medicaid pays for nearly 40% of all newborn deliveries and
covers 1 in 4 children.
Medicaid now provides benefits to more people than any other
public or private insurance program, including Medicare.
History of Medicaid
When the Balanced Budget Act (BBA) was passed in 1997, it
created Title XXI or the State’s Children Health Insurance
Program (SCHIP)—a grant in aid statute, expanding eligibility

3. for States to cover uninsured children who did not qualify for
Medicaid
Incentives (FFP) given to States increased the opportunity for
more children to receive “medical assistance”
From Dec 1999-Dec 2010, the SCHIP enrollment has grown
from 2.7M to approximately 8M consumers
Medicaid enrollment increased from 31.7M consumers in June
2000 to 58M in 2010
Access to Care Barriers
In 2009, consumers covered by Medicaid and private insurance
appear to have an equally low percentage of no usual source of
care when compared to the uninsured.
The evaluation of benefits reveals that only 60% of the covered
services are federally mandated
Managed Medicaid
First generation programs targeted the “Syndrome”:
Guarantee medical home
Impose structure, coordination, management on care seeking
and delivery
Promote primary and preventive care to extent possible given
episodic eligibility of beneficiaries
Enroll low income women and children rather than disabled and
chronically ill
Principal Current Managed Care Models
HMO/prepaid health plan
Initially voluntary, later mandatory
Primarily in urban areas, some statewide

4. Mix of commercial and Medicaid-only plan initially, but
Current trend toward Medicaid-only plans
Primary Care Case Management (PCCM)
Similar to primary care gatekeeper, but PCP authorization not
always required
Typically, state agency managed
Usually fee-for-service w/ care management fee
Recent efforts to add additional features
Private Health Plan (PHP) or Health Insuring Organization
(HIO)
Terms use is variable and inconsistent
Refers to a private vendor managing the program
Uses a few managed care elements such as precertification
Pharmacy benefits usually managed separately by state using
“favored nation” pricing
TRICARE
TRICARE is a federal program that provides health care
coverage to active duty military and their families as well as
retired military and their families.
Available worldwide
Managed in three US regions (North, South, West) and one
overseas region
Includes multiple plan options
TRICARE Standard
TRICARE Extra
TRICARE Prime
Active duty service members and activated Guard or Reserve
members must enroll in TRICARE Prime, the managed care
option.
Active duty family member, retirees and their family members
can enroll in any option.
TRICARE Prime includes regional carriers plus a handful of US
Family Health Care plans.

5. TRICARE does not just fund care, it also provides healthcare
services through military treatment facilities (MTFs).
TRICARE Benefits Levels
TRICARE Standard
Formerly referred to as CHAMPUS
Allows access to most doctors and hospitals
Higher deductibles and coinsurance than other TRICARE
options
Patients can be balanced billed for charges not paid by the
program
TRICARE Extra
Limits access to Preferred Providers
Deductibles and coinsurance apply but usually lower than
TRICARE Standard
Patients cannot be balanced billed
TRICARE Benefits Levels
TRICARE Prime
The managed care option
Active duty service members and activated Guard or Reserve
members must enroll in TRICARE Prime but can choose one of
three options:
Military Treatment Facility (MTF) option requiring enrollees to
obtain care only from a specified military treatment center
Regional Contractor option for health care provided by one of
three regional contractors serving various parts of the US:
North, South, and West
US Family Health Plan option limiting care to a specific US
Family Health Plan

6. TRICARE
Benefits for TRICARE Prime in each of the three regions for
care that is not provided by military providers or treatment
facilities, are administered by private managed care contractors.
Contractors must compete with other qualified MCOs every
three years to be the manager for one or more regions.
Only one private company manages a region at any one time.
Private Insurance Internationally
Only a few countries in the world have a national health system
based primarily or heavily on multiple private insurers.
Among high-income countries, a national system based
primarily on multiple private insurers exists only in the United
States.
Even in the United States, public sources account for 45 percent
of health expenditures nationwide.
Roles for Private Health Insurance Globally
As a “primary” plan or substitute for public programs (i.e.
enrollees opt out of the public system)
As a complement to public programs (i.e. out-of-pocket costs
incurred under the public system are reimbursed)
As a supplement to public programs (i.e. services not covered
under the public system are reimbursed; care from private
providers is reimbursed)
Exporting Managed Care
In middle-income countries with a growing middle class, MCOs
can play a complementary role:

7. Upper and middle class citizens can purchase private plans,
while the public system focuses on low-income groups.
Concerns:
Potential to undermine the solidarity of public programs, and
the creation of two-tier systems.
Lack of private sector regulation.
Introduce competing MCO-like plans: Private insurance
organizations can compete with social insurance.
Complementary or supplementary insurance for high/middle
income groups who want greater coverage or fast access to
elective services (e.g. Australia, France).
Incorporate managed care techniques such as utilization and
care management tools into existing government systems (e.g.
United Kingdom).
Looking Forward
Role of private plans as the primary source of insurance is
likely limited to low/middle income countries.
In high income countries, private health insurance can serve
complementary or supplementary roles.
Even if no role for private health insurance exists, managed care
tools can be adopted within local provider and administrative
organizations.
Framework for Assessing Managed Care Readiness
Health financing and organization infrastructure in a country
determines which U.S. managed care tools can be applied:
Degree of central/regional government control
Autonomy of private health plans
Choice of health plan
Choice of provider
Degree of provider integration and organization

8. Degree of provider-directed financial controls and incentives
Essay Questions Grading Rubric
Level of Achievement
Criteria Needs Improvement Developing Accomplished
Exemplary
General
Presentation
(0 - 27 Points)
Does not address the question.
States no relevant arguments.
Is not clearly or logically
organized.
(28 - 31 Points)
Does not address the question
explicitly, although does so
tangentially. States a
somewhat relevant argument.
Presents some arguments in a
logical order.
(32 - 35 Points)
Combination of

9. exemplary traits, but
less consistently
represented.
(36 - 40 Points)
Provides a clear and
thorough introduction and
background. Addresses the
question. Presents
arguments in a logical order.
Reasoning,
Argumentation
(0 - 27 Points)
Does not demonstrate an
understanding of the question,
inaccurate. Does not provide
evidence to support response
to the question.
(28 – 31 Points)
Demonstrates minimal
understanding of question, still
accurate. Uses a small subset
of possible ideas for support of
the argument.
(32 - 35 Points)
Uses only one
argument and
example that
supports conclusion.
(36 - 40 Points)
Demonstrates an accurate

10. and complete understanding
of the question. Uses
several arguments and backs
arguments with examples,
data that support the
conclusion.
Spelling/Grammar
& APA Style
(0 - 13 Points)
Grammar, punctuation, and
spelling errors are prominent.
Often fails to conform to APA
rules for formatting and
citation of sources.
(14 - 15 Points)
Some grammar, punctuation,
and spelling errors throughout.
Conforms to APA rules for
formatting and citation of
sources with several major
exceptions.
(16 - 17 Points)
Grammar,
punctuation, and
spelling errors exist,
but at a minimum.
Conforms to APA
rules for formatting
and citation of
sources with minor
exceptions.

11. (18 - 20 Points)
No Grammar, punctuation,
and spelling errors.
Conforms to APA rules for
formatting and citation of
sources with little to no
exceptions.
MHCM 6310 Strategic Management of
Health Services Organizations
Key Terms
–Based Services Waivers (HCBS)
-eligible
Uniformed
Services (CHAMPUS)