Position Paper
Managed Care

Aging Life Care Professionals™ … coordinating services to optimize health and quality of life.

The Aging Life Care Association® (ALCA), formerly National Association of Professional Geriatric Care Managers, is an organization of practitioners who use a holistic, client-centered approach to caring for older adults or people with disabilities facing health challenges. ALCA is committed to maximizing health care recipients’ independence and autonomy and strives to ensure the highest quality and most cost effective health and social care services. Members help older persons, people with disabilities, and their families cope with aging and health challenges through education, advocacy, counseling, referrals, and direct services.

Managed Care is a health care delivery system organized to manage cost, utilization, and quality of care. It is used for both acute and chronic care services and Managed Care systems exist in a variety of forms throughout many federal, state and private insurance programs, including Medicare and Medicaid.

Well-designed programs offer best practices in delivery of coordinated care and preventative care, with lowered costs to all parties. But poorly designed programs often put overly stringent restrictions on the care services and choice of providers that a member is covered for.

ALCA supports:

  1. Choice by all consumers to opt in or opt out of Managed Care programs, with the existence in all localities of viable alternatives.
  2. Choice for consumers of Managed Care plans to opt for providers outside of the plan’s network for a cost that is shared by both the plan and the consumer without an unreasonable burden falling to the consumer.
  3. The right of the consumer to a consumer-friendly appeals process for denied or uncovered services and for such appeals to be decided by an independent authority following an internal appeal.
  4. The rights of consumers to fair legal recourse against the Managed Care plans.
  5. A “Patient Bill of Rights” in all areas of service.
  6. Thorough transparency by Managed Care plans regarding all restrictions limiting care, medications, durable medical equipment, and provider services.
  7. Coverage by Managed Care Plans for emergency services without prior authorization and inclusion of out-of-network providers if an in-network provider is not available at the time of need.
  8. Coverage of comprehensive preventative care programs, including regular check-ups for general health and screening for a wide variety of diseases.
  9. Choice by consumers among a variety of licensed home care agencies as well as through Consumer Directed programs that offer the ability of the consumers to hire aides of their choice.
  10. Decisions for pre-authorization of services should be under the supervision of qualified physicians.
  11. Mechanisms in place throughout the program to ensure the privacy rights of individual medical information.
  12. Inclusion of consumers’ participation in care plans, with necessary and helpful information to be provided by the Managed Care Plans to consumers on issues relevant to the consumers’ care needs.
  13. Ease of access to necessary medical and chronic care services in a prompt and timely manner and freedom from burdensome procedural hurdles in obtaining from the Managed Care plans approval for coverage of needed services.
  14. Enrollment and access to all services regardless of race, gender, age, sexual orientation, or other protected group category.
  15. Open enrollment regardless of pre-existing condition rules, in line with the Affordable Care Act of 2010.
  16. Mandatory provision for the Care Plans to provide to all members and prospective members clear written communications on all aspects of information relating to the Care Plan. Such written communications should meet a 5th grade reading standard. Where programs serve a population where over 5% communicate in a language other than English, interpreters and written material in translation should be available. Such written material should include: eligibility requirements, specific terms of individual policies, dates of coverage and renewal, premium payments, billing, procedures for filing claims, procedures and rights for filing appeals, and general educational material regarding health and wellness.

ALCA advocates that:

  1. All services offered by Managed Care programs should meet the “best standards and practices” available within the specialty of service.
  2. All Managed Care programs provide for mental health services to the equivalent of physical health services in scope and number of visits, with integration of the two services to assure continuity of care.
  3. Government and private payers provide sufficient compensation to providers to attract a high level of qualified professionals and services.
  4. Care be delivered under a patient-centered approach where appropriate.
  5. Managed care plans, at the least, meet the standards set by original Medicare plans, in all areas, including rehabilitative services.

Position Paper was reviewed, updated, and approved by the Public Policy Committee on January 9, 2017.
Approved by the Board of Directors on January 27, 2017.