Chapter 7
Managed Care and HIV Disease  TOP

Introduction

Managed care combines health care financing and delivery in a system where the payer (usually an insurer) exercises some control over provider selection, treatment options, coverage, and payment methods. Managed care has the potential to enhance the development of coordinated care, restrain costs, and maximize use of limited health care dollars. It may have the effect of reducing access to specialty and tertiary care and pharmaceuticals.

The impact of managed care on financing and care of HIV-infected individuals has grown. State legislatures have made significant changes to Medicaid—the largest payer for HIV care— and other health insurance programs in an effort to reduce costs and expand access to care. This includes shifting large segments of their Medicaid enrollees from a retrospective fee-for-service payment system into a prospectively funded managed care system. The number of people with HIV disease enrolled in Medicaid managed care has increased significantly. However, some States have discontinued managed care in their Medicaid programs, reflecting the complexity of public approaches to financing of care.

Managed care enrollment has also increased among the beneficiaries of other insurers. In some health care markets, PLWH have enrolled in significant numbers in Medicare’s managed care program, Medicare+Choice. This often provides access to pharmaceutical coverage and reduced cost sharing for ambulatory care. In addition, HIV-infected individuals receiving private health insurance coverage through their employers are often enrolled in some form of managed care.

These changes affect both HIV-infected individuals and their care providers. CARE Act programs can help make transitions easier and ensure that the unique needs of PLWH are met by assisting managed care plans and payers, including Medicaid, with the design of HIV care systems. CARE Act programs can also help shape the financing of quality HIV services, ensure their agencies’ long-term solvency, and enhance access to care for HIV-infected populations by becoming participants in managed care plans.

The trend toward managed care has implications for the very survival of some CARE Act-funded providers and therefore for the maintenance of coordinated systems of care for PLWH. CARE Act-funded providers that lose Medicaid patients and revenue to managed care plans—but retain responsibility for caring for uninsured patients—may not have adequate funds to serve a growing uninsured population.

Legislative Background  TOP

While the CARE Act contains no specific references to managed care, multiple provisions require coordination of payers and programs in order to enhance services and keep the CARE Act as payer of last resort. The following legislative references therefore relate to CARE Act program involvement in managed care systems of financing.

Section 2613(c) requires consortia to submit applications to the State for funding, that, in part.

“(D) demonstrates that the consortium has created a mechanism to evaluate periodically—

(ii) the cost-effectiveness of the mechanisms employed by the consortium to deliver comprehensive care;”

Section 2616 allows States, under their AIDS Drug Assistance Programs (ADAP), to fund health insurance to pay for HIV treatments, as follows.

“(e) USE OF HEALTH INSURANCE AND PLANS.—

(1) IN GENERAL.—In carrying out subsection (a), a State may expend a grant under this part to provide the therapeutics described in such subsection by paying on behalf of individuals with HIV disease the costs of purchasing or maintaining health insurance or plans whose coverage includes a full range of such therapeutics and appropriate primary care services.
(2) LIMITATION.—The authority established in paragraph (1) applies only to the extent that, for the fiscal year involved, the costs of the health insurance or plans to be purchased or maintained under such paragraph do not exceed the costs of otherwise providing therapeutics described in subsection (a).”

Section 2617(b)(1)(c) requires States to prepare applications for Title II funding that include information concerning—

“(iii) the average cost of providing each category of HIV-related health services and the extent to which such cost is paid by third-party payors….”

Section 2617(b)(4) states that States are required to “establish priorities for the allocation of funds within the State based on,” in part the:

“(ii) availability of other governmental and non-governmental resources, including the State Medicaid plan under title XIX of the Social Security Act and the State Children’s Health Insurance Program under title XXI of such Act to cover health care costs of eligible individuals and families with HIV diseases….”

What is Managed Care?  TOP

Managed care is an approach to health care that integrates health care delivery and financing. Under managed care, insurers exercise some control over the selection of providers, treatment options, benefits, and payment to providers. The goal of managed care is to reduce medical costs while providing quality care by managing how care is delivered.

What is a Managed Care Organization (MCO)?

A managed care organization is a health care plan designed to provide medical services through groups of doctors, hospitals, and specialty providers. Generally, this involves contracting with health care providers to deliver health care services on a capitated (per member per month) basis.

Elements of Managed Care

Managed care plans vary according to the degree of control over the provider network, use of utilization controls, and payment methodologies. Their most common features include the following:

• Selection of Providers. Managed care organizations (MCOs) contract with physicians, hospitals, and other providers to serve members of the plan. Providers agree to the insurer's rules concerning payment, provision of services, and quality assurance.
• Utilization Controls. To reduce unnecessary physician visits and hospitalizations, MCOs establish rules for how patients access health services, such as requiring referrals from the primary care provider, prior approval of hospital and outpatient care, and notification of emergency admissions.
• Primary Care Provider as Gatekeeper. A primary care provider is usually selected by patients or assigned by the MCO as a “gatekeeper” who makes referrals and coordinates specialty and hospital care.
• Review Procedures. MCOs also conduct retroactive reviews of physician utilization and cost of services.
• Prepayment for a Defined Benefit Plan. MCOs typically offer prepayment or prospective benefit plans that are more generous than those of traditional fee-for-service indemnity plans, although benefits may be reduced or not covered at all if members receive medical care from a non-contract provider.
• Payment to Providers. Primary care providers and groups are typically paid on a capitation basis, which means that they receive a set payment for each member enrolled, whether the member obtains covered services or not. Specialists are typically paid on a fee-for-service basis according to a predetermined fee schedule.
• Provider Risk. MCOs place providers “at risk,” meaning that their fees or payments are adjusted if their members’ service utilization and costs are lower or greater than an estimated amount established as part of the provider’s contract. The degree of risk varies, and some plans have mechanisms to protect providers against catastrophic, high-cost cases.

Models of Managed Care

Managed care models vary in terms of how they implement the above features. Some are more restrictive (e.g., limited provider network, require use of network providers at all times, and require PCP referrals for all services). Others are more flexible and may contract more broadly, permit use of non-contract providers (generally with higher out-of-pocket costs to the patient), and permit specialist self-referrals in certain cases. Following are common health care financing and delivery models that involve some form of managed care:

• Health Maintenance Organizations (HMOs). HMOs are among the most common forms of managed care organizations in this country. HMOs are health care delivery systems that accept a pre-paid premium and provide a specific set of benefits and services, generally through a closed network of care providers. HMOs may hire their own physicians or contract with medical groups. Private practice physicians are free to accept patients from more than one managed care organization. HMO plans are called “full-risk” plans because they provide a set payment per member per month, regardless of services provided.
• HMO with Point-of-Service (POS) Plan. A POS HMO is a plan that allows patients to see providers both in network (e.g., from a selected primary care physician) and out of network (e.g., from the practitioner of their choice). Patients using out-of-network providers must pay an extra fee.
• Preferred Provider Organization (PPO). A PPO is a plan through which the insurer contracts with providers at discounted fees. Members may seek care from nonparticipating providers, but with higher co-payments or deductibles.
• Primary Care Case Management (PCCM). Under this model, a provider, usually the patient’s primary care physician, serves as a gatekeeper, responsible for approving and monitoring the provision of services. They are paid a monthly case management fee but to not assume financial risk for service provision. This model provides a greater choice of providers than “full-risk” managed care plans and has fewer restrictions on referrals. Affiliated providers receive a nominal monthly payment per member for care coordination and are reimbursed on a fee-for-service basis for medical care. In States using a PCCM model, managed care is often not significantly different from the fee-for service system. This model is primarily used by State Medicaid programs, but is beginning to be adopted by private insurers.
• Managed Indemnity Plan. This model allows members to receive services from their provider of choice but has certain restrictions on utilization and cost, such as a requirement for pre-authorization or a maximum fee schedule.

Trends In Managed Care Enrollment

Enrollment in managed care increased rapidly during the 1990’s as insurers sought to restrain costs, improve predictability of those costs, and retain or enhance their beneficiaries’ access to care. In 2000, 104 million Americans were enrolled in some form of managed care. According to Managed Care magazine, enrollment in HMOs reached a high of 81.3 million as of January 1999, then dropped slightly to 80.9 million by January 2000. There was continued enrollment growth in other types of managed care plans, such as point-of-service plans and PPOs. The pool of people insured under indemnity plans continues to drop. HMO consolidation has begun; the number of HMOs in the United States dropped from 643 on January 1, 1999 to 568 one year later.

The managed care trend has been particularly dramatic for Medicaid, which provides health care services to eligible low-income individuals. In 1983 only 750,000 Medicaid recipients (3 percent) were enrolled in managed care. By 2000, this number had grown to 18.8 million of the nearly 44 million enrolled in Medicaid (43 percent). As of June 2000, according to the Henry J. Kaiser Family Foundation, 43 States and the District of Columbia had more than 25 percent of their Medicaid populations enrolled in managed care, and 14 States had more than 75 percent enrolled.

Alternate Payment Arrangements

Some States are exploring or implementing alternative payment arrangements. One approach is the use of risk adjustment payments that provide the MCO a rate based on the composition and relative healthiness of its beneficiaries. This approach compensates providers of high-cost services (e.g., HIV care services) with a higher per-patient (capitated) payment than providers of other (often less costly) health care services. For example, New York State contracts with HIV Special Needs Plans and pays the MCOs based on their enrollment of Medicaid recipients with HIV and AIDS. There are multiple payment categories based on age and stage of illness. Other States are exploring other risk adjustment practices such as risk corridors, risk sharing arrangements, and chronic disability payments.

Medicaid and Managed Care  TOP

Medicaid Waivers for Managed Care

The Medicaid program is administered by States, which can design their own programs as long as they comply with Federal law (the Social Security Act). Medicaid was created as a fee-for-service program with a defined set of mandatory and optional services. However, States can request waivers to design programs that deviate from legislative requirements. Sections 1915(b) and (c) and Section 1115 of the Social Security Act provide two mechanisms by which Federal requirements can be waived. These waivers require approval by the Center for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA). Program waivers [1915(b) and (c)] and research and demonstration waivers [1115] have been used by States to develop program innovations, including Medicaid managed care initiatives. These waivers allow States to waive such provisions as:

• Patient freedom to choose providers
• Comparability of services across populations and all areas of the State
• Federal and State Medicaid HMO standards regarding access to and quality of services, provider solvency, and enrollment and marketing practices, and
• Eligibility, where States can expand or reduce eligibility

Medicaid Managed Care Models

Most Medicaid managed care is delivered by one of two models:

• The PCCM model, under which the primary care physician is paid a monthly fee to "manage" patient care by approving referrals.
• The full-risk plan, or HMO, in which the insurer assumes financial risk and is paid a fixed amount per member per month for a comprehensive set of services.

The Balanced Budget Act

The Balanced Budget Act (BBA) of 1997 contains significant changes for the Medicaid program. For the first time, States are allowed to make enrollment of Medicaid beneficiaries into managed care mandatory without a waiver. States are only required to submit to CMS a State Plan Amendment (SPA) to their Medicaid plan describing the State’s basic eligibility, coverage, reimbursement, and administrative policies.

Unlike the waiver process, the SPA process does not require public notice or public participation in the development of a mandatory managed care program. However, it does require CMS to review the draft/model contracts between States and MCOs to assure that they meet all statuary and regulatory requirements. HRSA has developed “model” contract specifications to assist in the review of State contracts.

There are exceptions to SPA mandatory enrollment in managed care. Individuals with dual eligibility for Medicare and Medicaid, children with special needs, and members of Federally recognized tribes cannot be mandated into managed care under the SPA.

The BBA provides some protections for Medicaid recipients selecting or enrolled in MCOs. Recipients must have a choice of at least two managed care entities—either a managed care organization (MCO) and/or a PCCM. In rural areas, individuals who are not offered a choice between two entities are permitted to seek services outside the plan. Beneficiaries are permitted to disenroll with cause at any time, and without cause within the first 90 days of enrollment and every 12 months thereafter.

Significance of Managed Care for CARE Act Programs  TOP

The rapid growth of managed care in Medicaid has significance for CARE Act entities since Medicaid is the largest payer of care for PLWH nationally. While early efforts to move Medicaid beneficiaries to managed care often focused on women and children, States have extended managed care enrollment to people with serious disabilities or chronic illness. As States move Medicaid populations into managed care, PLWH increasingly will be enrolled in managed care programs. Implications for CARE Act programs include:

• Access to care
• Financing of PLWH care costs, and
• Demands on CARE Act programs

Access to Care

Medicaid managed care offers PLWH a promise of improved quality of care and early access to preventive services, more coordinated care to better serve vulnerable populations with multiple health and social service needs, and potential restraint of rising health care costs. However, built-in financial and organizational incentives also create the potential for reduced access to more costly services such as pharmaceuticals and specialty care.

Financing of PLWH Care Costs

As the demand for primary health care and HIV treatments skyrockets due to the high cost of combination therapies, all appropriate funding streams need to be used effectively to meet the needs of PLWH. However, the CARE Act of 2000 legislation mandates that the CARE Act be the payer of last resort. Thus, other funding streams such as Medicaid must be tapped first. For example, CARE Act providers that are members of managed care plans serve Medicaid managed care enrollees through their Medicaid contracts. If managed care provider reimbursement does not cover the cost of care, CARE Act providers lose money on each patient served.

In addition, CARE Act-funded providers that do not participate in managed care plans may lose Medicaid revenues and patients to Medicaid’s managed care plans. For example, in States that mandate enrollment of Medicaid beneficiaries in managed care plans, providers will need to be part of a managed care plan to get reimbursed by Medicaid for the services provided. CARE Act-funded providers who are not part of a Medicaid managed care plan may be left with the responsibility for caring for Medicaid-eligible individuals for whom they cannot get any Medicaid reimbursements without receiving sufficient funds to serve them.

Impact of Managed Care on ADAP and HICP

CARE Act grantees and planning bodies are involved in the planning and implementation of several programs that are affected by managed care, including ADAP and health insurance continuation programs (HICP). CARE Act clients often receive their medical care through Medicaid and their medications through ADAP.

While the Federal mandatory Medicaid benefit package does not include prescription drugs—and States decide on such benefits—most State Medicaid agencies provide prescription drug coverage. However, States often place limits on this benefit. For example, the covered cost of medications may be capped at a certain dollar amount annually or there may be limits on the amount of medication dispensed per script or the number of scripts per month. Medicaid managed care may place additional limitations on such coverage. Therefore, PLWH may rely more on ADAP to meet their medication needs not covered by Medicaid. Similarly, as managed care plans dominate the health insurance marketplace, PLWH enrolled in HICP may face some of the same issues as Medicaid managed care beneficiaries. Such limitations may lead States to prioritize and fund ADAP.

Roles of CARE Act Entities in Implementing Managed Care  TOP

CARE Act entities can help ensure that PLWH needs are addressed as local and State areas implement managed care. As discussed below, they can educate others about managed care, enhance provider capacity to participate in managed care, and assist with feedback and evaluation of managed care.

Policy Role

CARE Act entities should keep informed of managed care developments in their communities, such as what providers will provide HIV care and the types, quality, and cost of services. CARE Act entities have the opportunity to provide input or formally comment upon their State's draft managed care legislation, waiver, or State Plan Amendment as they are developed. They can also ask to review the State's draft or model contracts with MCOs and inform Medicaid officials of provisions that are needed to ensure quality care for PLWH, such as:

• Adequacy of and Access to Provider Network. Access to experienced, culturally competent HIV/AIDS providers is necessary to address complex HIV-related health care needs. PLWH should be able to designate a specialist (e.g., infectious disease specialist, immunologist) as their primary care physician or be allowed open referrals to physicians with experience in treating HIV/AIDS.
• Designation of Experienced HIV Providers. MCOs should require HIV/AIDS services to be delivered by experienced providers. Studies demonstrate that mortality rates of PLWH treated by such providers are lower than for those treated by less experienced providers. While there is no consensus definition of "experienced" providers, many experts recommend that HIV providers should have treated 20-50 PLWH. MCOs must design training and develop experience criteria for HIV providers.
• Standards of Care. State Medicaid contracts with MCOs should require these entities to adhere to HIV treatment guidelines.
• Continuity of Care Treatment. Individuals newly enrolled into managed care may not be able to obtain an appointment with an experienced HIV provider within their first few weeks in a plan. MCOs should permit continuation of existing treatment plans and pharmaceuticals for a designated period of time to allow for transition into managed care.
• Adequate Reimbursement to MCOs and Participating providers. MCOs must receive adequate reimbursement to cover the high cost of care for PLWH. CARE Act entities should seek special rates for clinicians caring for PLWH and other individuals with chronic illnesses. States should be encouraged to consider whether some high-cost services for special-needs populations should be carved out and paid for on a fee-for-service basis.
• Marketing and Enrollment Procedures. Individuals should have sufficient information to make informed decisions about selecting a health plan and provider. MCOs and third party enrollment brokers should be required to provide details about benefits and provider networks (including specialists) before patients have to choose a plan. In cases where people do not make a selection and are automatically enrolled by the State with a provider, the State should consider the individual's previous provider when making an assignment.
• Broad Range of Covered Services. Managed care contracts should cover the services that PLWH require, such as prescription drug benefits. Patient cost sharing and out-of-pocket payments should be specified and limited.
• Quality Assurance Activities. A good contract requires that a strong quality management system be in place, with ongoing data collection and evaluation processes. Quality improvement goals and patient outcome measures should be identified, and outcome measures that relate to HIV treatment should be specified.
• Mechanisms to Protect Patient Rights. A defined grievance and appeals process provides PLWH with a way to appeal when:
  • Primary care physicians knowledgeable about HIV disease are not available
  • Investigational or experimental therapies are refused
  • Confidentiality is breached, and
  • Other serious problems with access or service delivery are encountered.

Monitoring and Evaluation Role

CARE Act entities should monitor MCO implementation to make sure that PLWH are receiving adequate health care services. Grantees and planning bodies can assist with monitoring by:

• Maintaining links with community-based organizations
• Communicating with State HIV and Medicaid representatives about trends and needs of PLWH
• Undertaking special studies of PLWH in managed care
• Developing mechanisms to monitor grievance patterns for various plans and providers, and
• Urging States to monitor and evaluate managed care plans on an ongoing basis.

Capacity-Development Role

Community-based organizations and other providers with a significant number of Medicaid-eligible patients typically need to focus on the following areas in order to take part in managed care networks:

• Planning. Provider organizations should undertake strategic planning to determine whether and how managed care fits with their organizational mission and culture. Providers may consider partnerships with other providers to create a larger, more competitive and fiscally viable network. Strategic decisions include selection of MCOs with whom to partner and contract.
• Rethinking Client Services. Some providers may need to change their overall operations and/or repackage their services to remain competitive. For example, case management organizations can reposition themselves to contract with MCOs by providing treatment adherence services.
• Marketing Services. Providers should develop marketing strategies, including communicating to MCOs their expertise in providing essential HIV-related services to PLWH in a cost-effective manner.
• Strengthening Management Information Systems (MIS). Organizations should develop computerized record keeping systems to track and analyze the demographic composition of beneficiaries and the cost and utilization of services being provided. Such data are necessary to calculate costs of services and project adequate capitation rates. Providers that do not know the exact cost of their services run the risk of contracting for an inadequate reimbursement rate.
• Preparing for Contract Negotiations. Community-based providers need to learn to negotiate viable contracts with MCOs that recognize adequate reimbursement for cost of services and spread risk.

Providers also need to continue to serve current patients and maintain existing service infrastructures. If these basic networks cease to exist, many HIV patients could find themselves without access to high quality services.

CARE Act programs can help build the capacity of its funded providers to compete in a managed care environment. For example, they can help CARE Act-funded providers adapt administrative and financial systems to meet managed care requirements. The need for such assistance might be assessed as part of the determination of capacity development needs of providers serving traditionally underserved populations, which are then prioritized.

Education Role

Many people are unfamiliar with how managed care works. Educating PLWH consumers is crucial to assuring access to quality care for PLWH. States, planning bodies, and funded providers can help to educate PLWH on how best to interact with the managed care system to get their needs met. Consumer education is especially critical when a managed care system or initiative is being introduced in a State. It might cover:

• How to select a health plan
• How to obtain access to health care providers, and
• How to file a grievance when care is unavailable or inadequate.

Education efforts should target CARE Act case managers as well, because clients often turn to their HIV case manager with questions about notices they receive from the State Medicaid program about managed care (and other matters).

HAB has developed resources and funded training programs to educate consumers about managed care. For example, Your Passport to Managed Care is a pocket-sized guide to assist consumers with tracking information needed to negotiate the system. To obtain this document, see References below.

Funding Issues  TOP

Methods of Funding Providers

CARE Act entities need to reassess how they fund providers in a managed care environment. The standard grant or contract approach of programs submitting applications and receiving funding annually may not be consistent with the Medicaid managed care infrastructure. Most MCOs prefer a single contract versus multiple ones, especially for a full continuum of services. Also, some of the CARE Act providers currently being funded for case management, outreach, and other activities may not be large enough to come to the managed care table and secure contracts to provide services. Planning bodies and grantees need to rethink how they approach programming and funding to assure the viability of their funded providers in the managed care market place.

The Role of HIV Case Management in Managed Care

Traditionally, in the managed care marketplace, case management has meant utilization review—authorizing the services in the most cost-effective setting for the patient’s health status. By contrast, HIV case management makes sure that all services needed by PLWH to stay engaged in the health system are available. This is not well recognized or understood in the managed care marketplace. Planning bodies—including PLWH members and their funded providers—will need to convey firmly to State Medicaid officials and to MCOs the importance of including HIV case management as a covered service. Overall, clear communications are necessary among MCOs, planning bodies, and providers on expectations about case management.

Case management can play an important role in the transition period from traditional fee-for-service Medicaid to managed care plans. Case managers, especially those with experience serving PLWH, can provide vital information regarding the overall quality of service and success rates for individual patient treatment. The case manager is a key contact person and should receive information about all services accessed by a given patient in order to identify gaps in the health care delivery system. Case management records can provide valuable information regarding service quality, costs, and success rates and integrate different types of information. To take advantage of case management services in this manner, a managed care plan should establish a communication network and incorporate case managers, primary care and specialist providers, consortium members, and community-based CARE Act-funded providers.

Managed Care Resources  TOP

Managed Care Technical Assistance. HRSA Center for Managed Care.

Risk adjustment practices and their impact on HIV services. See a summary report of a HRSA-sponsored risk adjustment meeting held in May 1997, “HIV Capitation Risk Adjustment Conference Report.” Available from The Kaiser Family Foundation at 1-800-656-4533.

CARE Act and Medicaid coordination. See “Improving Coordination between Medicaid and Title II of the Ryan White CARE Act,” April 28, 1995, prepared by the Office of Legislative and Intergovernmental Affairs, Health Care Financing Administration (HCFA), U.S. Department of Health and Human Services.

Managed Care Terms and Definitions. See one of the following: Making Medicaid Managed Care Work: An Action Plan for People Living with HIV, published by the National Association of People with AIDS (NAPWA), February 1997. Medicaid Reform and Managed Care: Implications for People with HIV and the Organizations that Serve Them, an AIDS Action Foundation Report, 1996.

References  TOP

Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). “HIV Services and Managed Care.” CARE Act National Technical Assistance Call Report. Rockville, MD: U.S. Department of Health and Human Services, July 1997.

HRSA/HAB. Access to and Quality of HIV/AIDS Care in Medicaid Managed Care Programs: A Summary of HAB’s Research Program, 1996-2000. Rockville, MD: U.S. Department of Health and Human Services, 2001.

HRSA, HAB. “By Definition: The Language of Managed Care.” INNOVATIONS: Issues in HIV Service Delivery. Winter 1995.

HRSA, HAB. “HMOs and HIV: The Managed Care Revolution,” INNOVATIONS: Issues in HIV Service Delivery. Rockville, MD: U.S. Department of Health and Human Services, Winter 1995.

HRSA, HAB. “Identifying the Unknown: Developing Capitation Rates for HIV Services,” INNOVATIONS: Issues in HIV Service Delivery. Rockville, MD: U.S. Department of Health and Human Services, Winter 1995.

National Association of People With AIDS. Making Medicaid Managed Care Work: Action Plan for People Living with HIV. Washington, DC: National Association of People with AIDS, 1997.

HRSA, HAB. “Managed Care and HIV/AIDS,” HRSA Care ACTION. Rockville, MD: U.S. Department of Health and Human Services, June 1998.

“For first time ever, HMO enrollment drops in 1999.” Managed Care Outlook. Managed Care, November 2000.

HRSA, HAB. “Managed Care Survival: Options for Safety Net Providers,” INNOVATIONS: Issues in HIV Service Delivery. Rockville, MD: U.S. Department of Health and Human Services, Winter 1995.

Kaiser Commission on the Future of Medicaid. “Medicaid and Managed Care,” Medicaid Facts. Washington, DC: Kaiser Commission on the Future of Medicaid, 1997.

“Developing a Managed Care Delivery System in New York State for Medicaid Recipients with HIV.” AJMC. November 1999.

“Developing a Managed Care Delivery Section for People with HIV/AIDS.” AJMC. November. 1999.

Kaiser Commission on Medicaid and the Uninsured. “Medicaid and Managed Care.” Kaiser Family Foundation, December 2001.

Westmoreland, Tim. “Medicaid and HIV/AIDS Policy: A Basic Primer.” Federal Legislation Clinic of Georgetown University Law Center, 1999.

Mathematica Policy Research. New Rules, New Roles: How Title V/MCH and Ryan White Programs and Providers are Adapting to Medicaid Managed Care. October 1999.

AIDS Action Foundation. Medicaid Reform and Managed Care: Implications for People with HIV and the Organizations that Serve Them. Washington, DC: AIDS Action Foundation, 1996.

Center for Health Policy Research “HIV/AIDS Related Provisions of Medicaid Managed Care Contracts,” May 1998.

Center for Health Policy Research, George Washington University School of Public Health. “Experiences of HIV-Infected Beneficiaries in the Move to Mandatory Medicaid Managed Care in Three States.” Washington, DC: George Washington University School of Public Health, March 1999.

Center for Health Policy Research. A Nationwide Study of Medicaid Managed Care Contracts. Washington, DC: George Washington University School of Public Health, 1998.