THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Wednesday, October 5, 1994 TAG: 9410050476
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: Long : 136 lines
Beginning next month, most beneficiaries of the state's insurance program for the poor will have more doctors to choose from, richer benefits and fewer out-of-pocket costs - if they take the plunge and join a private health maintenance organization.
The state recently awarded its first Medicaid HMO contract to a private company, Optimum Choice Inc., based in Rockville, Md.
In doing so, it joins a national trend of states moving Medicaid clients into privately run HMOs. Last year, 39 states were offering Medicaid managed care, covering 12 percent of the total Medicaid population.
In Virginia, the move to Optimum Choice means eligible Medicaid beneficiaries - 70 percent are children and 30 percent are single mothers - will have access to the same level of health care that privately insured individuals have been receiving for years.
Many private physicians now reject Medicaid patients, forcing beneficiaries to use public health clinics or emergency rooms for primary care.
Under Optimum Choice, members can choose from more than 170 private primary-care physicians in Hampton Roads, including 50 pediatricians. They will provide immunizations, well-baby care and annual physicals, as well as see kids when they're sick. And it won't cost the patients a cent.
And, instead of heading to the emergency room for an ear infection or a cold, Optimum Choice members will be able to call their primary-care physician 24 hours a day, seven days a week for medical advice.
That should reduce emergency room use and overall health care costs, said Lawrence Bates, vice president for managed care at Children's Hospital of The King's Daughters.
Even doctors, who often shy away from Medicaid patients because of the program's notoriously low reimbursement rate, are expected to benefit. They'll receive the same reimbursement for Medicaid patients as they do for any other HMO patient.
Optimum Choice will compete with the state's own, 2-year-old managed care Medicaid plan, MEDALLION, and, the state hopes, eventually put it out of business in areas where at least two Medicaid HMOs are offered.
That's because Virginia, which spends $1.65 billion on Medicaid each year, saves 5 percent in medical costs for each beneficiary who signs on with Optimum Choice.
The state pays the HMO a set amount each month for every person enrolled in Optimum Choice. For an infant under 1, for instance, the plan receives $490.84 a month. For a 15- to 20-year-old male, the rate is $46.65.
Optimum Choice then pays a set amount each month - a capitation rate - to primary-care physicians for each member who signs up with them.
Regardless of the amount of medical care the physician provides, the capitation fee remains the same.
Under MEDALLION, physicians receive the same reimbursement, plus a $3 administrative fee.
The state welcomes the competition, and will even help market the Optimum Choice plan to the 235,000 eligible beneficiaries.
``For the first time, these people who don't have choices over much of their lives have a choice over which medical care they want,'' said Susan Bareford, the state's HMO coordinator.
And the choice involves greater dignity, she noted. ``When someone switches to an HMO they no longer get a Medicaid card, and the perceived stigma of Medicaid is over.''
The challenge for Optimum Choice will be persuading MEDALLION members to switch to the HMO.
``Our benefits are richer, we have no copays and our provider network is competitive,'' said Richard K. Slater, executive vice president for Optimum Choice's corporate parent, MidAtlantic Medical Services Inc. ``This is a market we can have an impact in, both from attracting membership and providing quality health care.''
The program emphasizes preventive health care, Slater said. Members are urged to see their primary-care physician for a health evaluation within 90 days of enrolling. They also attend seminars on how to use the program, and receive informational mailings, as well as a personal phone call or home visit, when they join the program.
Optimum Choice won't be the only HMO in town for long. The state has three other Medicaid HMOs under consideration, including one from Norfolk-based Sentara Health System, which owns the similarly named Optima HMO. ILLUSTRATION: Graphics
ABOUT THE HMO PLAN
Who is eligible: Anyone now eligible for Aid to Families with
Dependent Children, single mothers, and needy people.
Who is not eligible: The aged, blind, disabled and those in
long-term care and those in special programs, such as Medicaid's
program for AIDS patients.
What does it cost the beneficiary: Nothing.
How does it work? Each member selects a primary care physician
who acts as a gatekeeper to the rest of the health care system. If
the member wants to see a dermatologist, for instance, the primary
care provider would have to agree and write a referral. All
hospitalizations, elective surgeries, therapies and durable medical
equipment require pre-authorization from the plan.
Is there any paperwork, or bills to pay? No. The member should
not receive any bills and does not have to file any claims.
COMPARING THE PLANS
A comparison of some of the benefits provided by Optimum Choice
and the state's Medicaid managed care plan, MEDALLION *:
Early and periodic screening, diagnosis and treatment for people
under 21, including unclothed physical examinations, health history,
developmental and nutritional checkups, immunizations, eye and
hearing tests, laboratory tests and semiannual dental checkups:
MEDALLION: Covered. No copayment.
Optimum Choice: Covered. No copayment.
Inpatient acute hospital care for people under 21:
MEDALLION: Covered. No limit on the length of time in hospital.
$100 copayment.
Optimum Choice: Covered. No limit on length of time in hospital.
No copayment.
Inpatient acute hospital care for people 21 and older:
MEDALLION: Coverage provided for up to 21 days of hospital care
for the same or similar diagnosis within 60 days. $100 copayment.
Optimum Choice: Coverage provided for up to 90 days annually of
care. No copayment.
Outpatient hospital care:
MEDALLION: Covered. $3 copayment.
Optimum Choice: Covered. No copayment.
Prescription drugs:
MEDALLION: Covered. $1 copayment.
Optimum Choice: Covered. No copayment.
MEDALLION clients under age 21, or those receiving
pregnancy-related services, drugs or supplies, or family-planning
services, drugs or supplies, or any service delivered in an
emergency room or deemed an emergency, are not subject to
copayments.
Both plans also cover family planning, eye exams, home health
visits, durable medical equipment, maternal and infant care
coordination, expanded prenatal services and renal dialysis.
Transplants, hospice, long-term care and respite care are among
the services not covered by either plan.
by CNB