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An Introduction
Martin Kitchener, Micky Willmott, Alice Wong and Charlene Harrington.
UCSF National Center for Personal Assistance Services.
December 2006.
Introduction
In contrast to the rapid growth of Medicaid managed acute care programs, there has been much slower development of Medicaid managed long-term care (MLTC) defined as: any arrangement in which a Medicaid program contracts with an organization to provide a package of benefits which includes at least some long term care benefits on a risk basis (Saucier et al. 2005:4). Despite slow growth in Medicaid MLTC generally, the number of enrollees receiving home and community-based services (HCBS) such as home health is predicted to increase in the next couple of years through a combination of expansions to existing programs and the development of new initiatives. This part of the website provides an introduction to the development of Medicaid MLTC that delivers HCBS. The first section first reviews the (typically longer-standing) Medicaid MLTC programs that provide, at least some, HCBS. The second section discusses Medicaid MLTC programs that have been developed specifically to provide HCBS.
Medicaid MLTC Programs That Include Some HCBS
Initially, there were no provisions specifically addressing the use of managed care in the Medicaid program. Nevertheless, beginning with the Health Insurance Plan of Greater New York in 1967, mainstream Medicaid managed care programs emerged to provide mostly primary and acute coverage. Development was encouraged through the 1981 Omnibus Budget Reconciliation Act (OBRA) which altered federal law to allow states to require (mandate) Medicaid beneficiaries to enroll in Managed Care Organizations (MCOs) after obtaining a waiver of Medicaid beneficiaries right (under the Social Security Act [SSA]) to freely choose their provider. State programs that offer voluntary enrollment in MCOs do not require a waiver. Later, in 1997, Balanced Budget Act (BBA) modified Federal law to permit states to mandate enrollment of certain Medicaid beneficiaries into MCOs without a waiver (CMS 2004). The BBA also required a report to Congress on the protections needed to ensure that the health care needs of people with special health care needs are adequately met by Medicaid MCOs (Crowley & Elias 2003).
Following the changes in federal law to enable the growth of mainstream Medicaid managed care, the number of program participants receiving fully or capitated services rose sharply in the 1990s but slowed in the early 21st century, By 2004, 60.68 percent of Medicaid recipients (26,913,570 enrollees) were covered by managed care programs, a rise from 40.10 percent in 1996 (CMS 2004c). As of June 2004, 48 states (including D.C.) operated either mandatory and/or voluntary Medicaid managed care programs. The three states and one U.S. territory which do not operate managed care programs are Alaska, Mississippi, the Virgin Islands and Wyoming (CMS 2006)
Most states enroll people with disabilities on mainstream Medicaid managed care programs. In 1998, only four states and D.C. had managed care programs designed specifically for people with special health care needs (KFF March 2001). Six states enrolled more than 75 percent of the disabled Medicaid population on managed care programs (TN, NM, SD, AZ, OR, MD) (KFF March 2001). Studies of state managed care programs tend to focus on capitation rate setting, contracting issues, quality and utilization patterns amongst different beneficiary groups (Saunders and Heflinger, 2004).
In 1998, CMS produced non-mandatory guidance on the provision of managed care for people with special health care needs. However, studies have found that many managed care plans do not have the capacity to care adequately for people with disabilities and that advocacy activity has focused on other Medicaid issues, particularly deinstitutionalization (Vladeck 2003). It is also argued that states quality assurance mechanisms tend not to measure quality of managed care for disabled people (Regenstein and Anthony 1998).
Many managed care programs carve out mental health, substance use and behavioral health services and the effects on access have been widely studied (Hutchinson and Foster, 2002). A longitudinal study comparing children and adolescents access to behavioral health services in a managed care program (Tennessee) with access in a fee for service (FFS) model (Mississippi) found that managed care reduced access to behavioral health services (Saunders and Heflinger, 2004).
Most states provide Medicaid managed care under one of the following waivers of the Social Security Act; 1915(b), 1915(b) (c), 1115(a), 1932(a), and 1915(a). One state (Colorado) provides managed care under 1905(t) authority and several states operate more than one program under different authorities (e.g. California operates programs under 1915(b), 1115(a), 1932(a) and 1915(a) waivers) (CMS 2005).
The main waivers are described below, with examples of managed care programs that include, at least some, HCBS.
1915(b) Waivers
Section 1915(b) of the Social Security Act (SSA) permits states to limit Medicaid recipients freedom of choice and mandate that they receive services from a single provider or plan. 1915(b) can also waive the necessities that programs are statewide and that there is comparability of services. 1915(b) waivers are valid for two years and can be renewed for successive two year periods. The waivers must be cost effective (cost no more than the Medicaid program would have cost without the waiver), cannot negatively impact beneficiary access or quality of services (CMS 2004a). States can opt to develop programs with carve outs (e.g. behavioral health services) (NASMD 2003).
25 states operate managed care programs under 1915(b) authority (CMS 2005) but few provide HCBS as part of the benefits in these programs and where they do, it is typically to very small numbers of people.
Three examples of programs which provide HCBS within 1915(b) programs are: California CalOptima (eligible population are 65+ in Orange County) which covers adult day care, personal care, respite, meals, transport, non-medical equipment, minor housing repair (CalOptima website 2005); New Jersey Managed Long Term Care Program which covers children with special health care needs (Family Voices of New Jersey 2005); and Utah has three MLTC initiatives (FlexCare, Weber MACS and Molina Independence Care) covering 11 counties and serve approximately 475 people (CMS 2004d).
The Utah MLTC program was initially developed as a three-county, 3 year demonstration program (FlexCare) to provide support (most commonly home health) in transitioning Medicaid-eligible adults (over 18) from hospital or nursing homes to the least restrictive long term care setting (Utah Olmstead plan 2005). Utah then expanded the MLTC program to include two more plans (CMS 2004d).
1915(b)/(c) Waivers
Due to limitations of both 1915(b) and 1915(c) waivers, some states have developed combination waiver programs. Combination waivers are required because 1915(b) waivers do not accommodate special eligibility populations (e.g., disabled adults) and standard 1915(c) waivers do not allow for states to limit freedom of choice. Therefore, combination waivers enable states to provide long-term care to specific populations, within specific geographic areas and to specify the providers used. States apply for each waiver separately and have to meet all CMS requirements for both waiver programs. States also have to report on the waivers separately due to the different reporting periods and mechanisms for each waiver (CMS 2004b).
Two states (TX and WI see below) operate 1915(b)/(c) M-LTC programs, a total of 4 states operate 1915(b)/(c) managed care programs (CMS 2005). Specialty Prepaid Inpatient Health Plans in Michigan and Floridas Comprehensive Adult Day Health Care provide some HCBS. Prepaid Specialty MH/SA Services and Supports for Persons with Developmental Disabilities in Michigan was approved in 1998 and provides specific carve out services (pre-paid mental health, substance abuse and developmental disability services) under a shared risk arrangement.
The Comprehensive Adult Day Health Care Program in Florida ran as a pilot between 2003 and 2005 in two counties, covering 100 Medicaid beneficiaries aged 75 and over living with their primary caregiver and provided enhanced day health care services (rehabilitation, therapies, personal care, caregiver support, transport and case management) in order to delay or prevent nursing home placement (CMS 2005a).
1115(a) Waivers
Section 1115(a) of the SSA allows states to develop research and demonstration programs. There are several different types of 1115 waivers. Three are likely to serve people with disabilities, these are; the Comprehensive State Health Reform, Specialty Service and Population, and Managed Care and Selective Contracting waivers.
There are also Independence Plus waiver templates which states use to apply for either 1115 or 1915(c) consumer-directed HCBS waiver programs. These are not managed care programs. At least 7 states have consumer-directed HCBS demonstration programs under 1115 authority (AL, AR, CA, CO, MN, NJ, OR). Several states have proposed consumer-directed HCBS under the 1115 Independence Plus template (others have used the more restrictive 1915(c) Independence Plus template). For example Kansas submitted a 1115 Independence Plus application in August 2004. If successful, this program will allow up to 10,000 HCBS recipients to direct their own personal care (CMS 2005d).
Of the 48 states (including D.C.) which operated managed care programs in 2004, 16 states operated programs under 1115(a) authority (AZ, DE, HI, KY, MD, MA, MN, MO, NY, OK, OR, RI, TN, UT, VT, WI), (CMS 2005). In Arizona and Tennessee 100 percent of Medicaid recipients are enrolled in managed care under 1115 waivers, however the level of participation in these programs varies between states (CMS 2005c). Several 1115 managed care programs do cover some HCBS such as California Senior Care Action Network, Tenncare in Tennessee and Utahs Primary Care Network.
1932(a) Waivers
The BBA added a process through which States may implement mandatory managed care under the State Plan Amendment (SPA) process. Under section 1932(a), states submit a SPA for CMS approval but unlike section 1915(b) or 1115 waivers, section 1932(a) SPAs are not periodically renewed by CMS (Schneider et al 2002). Nor is there a requirement that such programs demonstrate cost effectiveness or budget neutrality (Cagey 2000).
There are restrictions on which populations may be included in mandatory managed care (e.g. children with special health care needs, dual eligible and Native Americans cannot be included). Also, 1932(a) authority only allows for certain service provision Primary Care Case Management and/or comprehensive managed care and it has been suggested that these restrictions explain why this authority has not been more popular (Cagey 2000). Sixteen states (AL, CA, GA, IA, KS, KY, ME, MS, NE, NV, NJ, NC, ND, SD, WA, WI) operate managed care plans under this authority (CMS, 2005) and two include LTC - California AIDS Healthcare Foundation program and HealthConnect Kansas.
1915(a) Waivers
This waiver allows managed care through voluntary health plans that may include HCBS (Walsh and Clark, 2002). Eleven states (CA, CO, DC, IL, MI, MN, NY, PA, SC, SD, WV) operate managed care programs under 1915(a) authority (CMS, 2005).
Medicaid Managed Long Term Care
This difference has been attributed to many factors, including resistance from consumers and the nursing home industry (Sparer 2003), long planning and start-up periods, federal-state policy difficulties, limited provider interest and inadequate state structure and budget (Saucier et al 2005).
Two key drivers for the development of MLTC programs are cost containment and quality improvement and it is argued that states have hoped that through their inherent incentives to achieve this, managed care organizations will also increase provision of HCBS and reduce Medicaid institutional bias (nursing home care) (Foxhall 2005, Sparer 2003). A recent review of literature regarding MLTC programs found that such programs do increase access to HCBS and experience high consumer satisfaction although there is no consensus on whether there are cost savings (Saucier et al 2005).
Although there is no formal list of managed care organizations which have Medicaid capitation agreements covering LTC (Meiners et al 2002) it is estimated that approximately 2.3 percent of Medicaid long-term care beneficiaries are in managed care programs (Saucier et al 2005). A recent review and survey of states found 73 managed care organizations which potentially offer LTC as part of Medicaid managed care programs but only 64 of these were active programs in 17 states (Meiners et al 2002). Although most MLTC organizations tend to be local non-profit plans or providers which have developed especially to meet the states requirements, Saucier and colleagues found that two national organizations account for a large proportion of the national enrollment (Evercare and AmeriGroup) (2005).
Drawing on a literature review and searches of organizations and initiatives for this briefing, a total of 8 states with 11 Medicaid MLTC programs were found. At least four states (CA San Diego county, WA, HI and MD) are considering initiatives in the near future (Saucier et al 2005) and several states have considered MLTC programs in the past with support from organizations such as CHCS and the Robert Wood Johnson Foundation and initiatives such as Independent Choices and the Social Health Maintenance Organization demonstration. For example, Delaware has explored the possibility of providing Medicaid MLTC programs for both the elderly and physically disabled (under 1915(b)/(c) authority) and for people with behavioral health needs (under 1915(b) authority). The plan built on the existing Medicaid managed care program (Diamond State Health Plan) and was approved by CMS in 2001 however, due to fiscal pressures and start-up costs they have not yet been implemented (Rusten 2002).
At present, only two states mandate enrollment on MLTC programs for Medicaid beneficiaries. These are Arizona and Texas. However, enrollment is only compulsory across the entire state in Arizona (it is compulsory only in certain counties in Texas) although the Texas program has the largest number of participants and is proposing a large expansion of the program (Saucier et al 2005).
Arizona
Arizona LTC System (ALTCS) began in 1988 and is part of the mandatory state managed care program, AZ Health Care Cost Containment System (AHCCCS). It covers the elderly, physically disabled, people with MR/DD and people at risk of institutionalization. ALTCS serves Medicaid and Medicare beneficiaries although providers are paid a capitated rate for Medicaid acute and LTC services, whereas Medicare services are paid on a fee for service basis (Rudolph & Lubitz 1999). ALTCS was the first statewide capitated Medicaid LTC program and as such as attracted much interest (Weissert et al 1997).
Florida
The voluntary Florida Diversion Program began in 1998 in 4 counties, following the successful implementation of the (also voluntary) Frail Elder Option MLTC program in Southeast Florida that began in 1987. The state legislature granted funding to expand the program to cover 25 counties in 2003. Then in 2004 it was mandated that the Frail Elder Option be folded into the expanding Diversion program (Saucier et al 2005).
Florida announced in July 2005 that will consolidate all the Medicaid programs currently providing LTC and healthcare to people aged 60+ and create a managed care program called Integrated Long-Term Care under 1915(b)/(c) authority. This pilot will be mandatory in 4 counties and voluntary in 4 counties (AHCA 2005a). Even more recently, it was announced that Floridas application for a 1115 comprehensive health care reform demonstration waiver was approved by CMS. This will move all Medicaid beneficiaries in the state to managed care programs (AHCA 2005b & c)
Massachusetts
Massachusetts has developed a program, Mass Health Senior Care Options, which provides MLTC to elderly (65+) dually eligible people without a waiver of Federal law (it is provided under State Plan authority). Implemented in 2004, this program is somewhat similar to the Program of All Inclusive Care for the Elderly (PACE) program (like the Wisconsin and Minnesota programs) but has more extensive eligibility than merely to people with a nursing home level of care. There are three contractors, two for-profit organizations (Senior Whole Health and Evercare MA) and a non-profit (Commonwealth Care Alliance) (CMS 2004f).
Minnesota
Minnesota Senior Health Options (MSHO) was the first State-initiated program to function under both Medicaid and Medicare waivers and was established using state funds, the Robert Wood Johnson Foundation and HCFA. It is a demonstration program integrating acute care and LTC for dually eligible elderly people (Rudolph and Lubitz 1999). Participation is voluntary and restricted to 10 counties and offers a range of Medicare and Medicaid services, including waiver services (it therefore also operates under 1915(c) waiver authority). Started in 1997, services are delivered through three fully capitated private managed care plans.
Minnesota Disability Health Options (MNDHO) began in 2001 and operates in 4 counties. Participants in 2 of the Minnesota waiver programs (Community Alternatives for Disabled Individuals and Traumatic Brain Injury) are eligible to enroll but participants in 3 other waiver programs (Community Alternative Care, Elderly Waiver, and Mental Retardation/Related Condition) are not eligible. People with a medical spend down are eligible to enroll, but are required to prepay their spend down to the state, participants may remain in the plan after the age of 65 or may move to MSHO. 4,762 people were enrolled on MSHO and 87 for MNDHO in 2002 (Parker 2002).
New York
During the early 1990s several PACE programs were established in New York on a demonstration basis and in 1994, the state received a planning grant from the Commonwealth Fund for a capitated managed care demonstration project for persons eligible for both Medicare and Medicaid and who were eligible for nursing home placement. In 1997 the state enacted legislation (The Long-term Care Integration and Finance Act) to implement a prepaid partially-capitated managed long-term care program for this population group. Participants access services through their primary care physician. In May 2003 there was a total of 9,078 participants covered by 11 MLTC plans and 4 PACE sites (Novello 2003). HCBS covered include; care coordination, day care, chore services and home health (CMS 2004e). Plans are monitored (including consumer satisfaction) by the state Department of Health.
There have been several published studies of this program, including comparisons of the program with PACE (Nadash 2004) and an examination of how care management is achieved (Michaels Fisher and Raphael 2003). Nadash found that New Yorks managed care plan relied heavily on home health services and can be more effective (particularly during the first year of service provision) than the PACE model in keeping participants out of nursing homes (2004).
Pennsylvania
The Long Term Care Capitated Assistance Program (LTCCAP) is available in 3 counties in PA - Allegheny County, Beaver County and some parts of Philadelphia County. Designed as an alternative to nursing home care and based on the PACE model, the program offers a range of HCBS as well as primary health care, including; in-home supportive care, hospice care, personal care, medical and non-medical transportation, adult day health services, medical equipment and supplies, meals and home modifications (PA Dept of Public Welfare 2005).
Texas
Texas STAR Plus program was the first combination 1915(b)/(c) waiver program. Implemented in 1998, it uses 3 managed care organizations and a Primary Care Case Manager to deliver acute and long-term care services to elderly and disabled recipients. Many of the beneficiaries are dual eligible (receive Medicaid and Medicare) although Medicare freedom of choice is not limited (i.e., enrollment is required for Medicaid beneficiaries but not for Medicare recipients).
Wisconsin
Wisconsin Family Care program provides M-LTC under a 1915(b)/(c) waiver and was converted in 2000 from a 1115 waiver program for dual eligible adults called Partnership Program (CMS 2005, Saucier et al 2005). It had 8,713 enrollees as of June 30, 2004 and has a capitated reimbursement arrangement. A feature of the program is that counties serve as the managed care contractor, and accept financial risk for meeting the needs of participants requiring LTC in their community (Saucier et al 2005:6).
Vermont
Vermont recently received approval for a statewide demonstration MLTC program under 1115 authority. Choices for Care will provide LTC to categorically eligible and medically needy elderly or physically disabled adults (18+) and aims to provide equal access to either nursing facility care or home and community-based services, according to their choice and needs. Eligibility is determined through three categories; highest needs group, high needs group and moderate needs group. Services will be provided according to these assessments, with the moderate needs group having access to a much more limited range of services than the other two groups (case management, adult day services, homemaker services) (State of Vermont 2005). Over time, Vermont plans to replace this waiver program with a new comprehensive health care reform 1115 waiver Global Commitment to Health which will also encompass all other existing HCBS waivers (e.g. the TBI waiver) (Vermont Agency of Human Services 2005).
Summary table 1: States operating M-LTC programs under 1915(b)/1915(c) authority
StateProgram namePopulation coveredFurther informationTexasStar+PlusElderly and physically disabled adults HYPERLINK "http://www.nasmd.org/waivers/1915bcchart.htm" http://www.nasmd.org/waivers/1915bcchart.htm
HYPERLINK "http://www.cms.hhs.gov/medicaid/1915b/1915bc.asp"
http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/04_ManagedCare_FreedomofChoiceWaivers-Section1915(b).aspWisconsinFamily CareElderly (dual eligible for Medicaid/Medicare) HYPERLINK "http://www.cms.hhs.gov/medicaid/managedcare/er04net.pdf"
http://www.cms.hhs.gov/MedicaidManagCare/
HYPERLINK "http://www.nasmd.org/waivers/1915bcchart.htm" http://www.nasmd.org/waivers/1915bcchart.htm
Summary table 2: States operating M-LTC under 1915(a)/(c) authority
StateProgram namePopulation coveredFurther informationFloridaFrail Elder Option (ElderCare)Elderly (65+) HYPERLINK "http://ahca.myflorida.com/Medicaid/long_term_care/index.shtml" http://ahca.myflorida.com/Medicaid/long_term_care/index.shtml FloridaFL DiversionElderly (65+) HYPERLINK "http://www.hhp.umd.edu/AGING/MMIP/grantees/Florida.html"
http://www.aarp.org/research/assistance/medicaid/ib79_mmltc.html MinnesotaMN Disability Health Options (MDHO)Physically disabled adults (18-64) HYPERLINK "http://www.dhs.state.mn.us/main/groups/healthcare/documents/pub/dhs_id_008666.hcsp"
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_006272 MinnesotaMN Senior Health Options ProgramElderly (65+) HYPERLINK "http://www.dhs.state.mn.us/main/groups/healthcare/documents/pub/dhs_id_008666.hcsp"
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_006271New YorkManaged Long Term Care ProgramElderly (65+) HYPERLINK "http://www.health.state.ny.us/health_care/managed_care/mltc/index.html"
http://www.health.state.ny.us/health_care/managed_care/mltc/index.htmPennsylvaniaLong Term Care Capitated Assistance ProgramElderly (60+) HYPERLINK "http://www.dpw.state.pa.us/Health/AccessHealthCare/SuppServWaivers/003671635.htm" http://www.dpw.state.pa.us/Health/AccessHealthCare/SuppServWaivers/003671635.htm
Summary table 3: States operating M-LTC under 1115 authority
StateProgram namePopulation coveredFurther informationArizonaArizona LTC System (ALTCS)Elderly, disabled, MR/DD HYPERLINK "http://www.ahcccs.state.az.us/Services/Programs/ALTCS.asp" http://www.ahcccs.state.az.us/Services/Programs/ALTCS.aspVermontChoices for CareElderly HYPERLINK "http://www.dad.state.vt.us/" http://www.dad.state.vt.us/
HYPERLINK "http://www.dad.state.vt.us/1115waiver/finalMedWaiverRegs.pdf" http://www.dad.state.vt.us/1115waiver/finalMedWaiverRegs.pdf
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h t t p : / / w w w . c m s . h h s . g o v / P r o m i s i n g P r a c t i c e s / D o w n l o a d s / n y m l t c . p d f y K . . / . . / . . / . . / L o c a l S e t t i n g s / T e m p o r a r y I n t e r n e t F i l e s / O L K 1 / % 0 d h t t p : / - - w w w . c m s . h h s . g o v - P r o m i s i n g P r a c t i c e s - D o w n l o a d s - n y m l t c . p d f D y K D h t t p : / / w w w . c m s . h h s . g o v / r e s e a r c h e r s / d e m o s / M a s s H e a l t h S C O F a c t S h e e t . p d f y K h t t p : / / w w w . c m s . h h s . g o v / r e s e a r c h e r s / d e m o s / M a s s H e a l t h S C O F a c t S h e e t . p d f e D y K < h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / n s s t a t e o a 0 4 . p d f y K x h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / n s s t a t e o a 0 4 . p d f = D y K 2 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / f l a l z f s . p d f y K d h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / f l a l z f s . p d f Y D y K 9 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / 1 1 1 5 1 2 0 4 . p d f y K r h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / 1 1 1 5 1 2 0 4 . p d f 5 D y K 0 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 1 1 5 / k s w o r k . a s p y K ` h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 1 1 5 / k s w o r k . a s p D y K Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 2 8 3 5 9 y K h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 2 8 3 5 9 ] D y K : h t t p : / / w w w . s p a n n j . o r g / f a m i l y w r a p / m e d i c a i d _ f a c t _ s h e e t s . h t m y K t h t t p : / / w w w . s p a n n j . o r g / f a m i l y w r a p / m e d i c a i d _ f a c t _ s h e e t s . h t m D y K ) h t t p : / / w w w . n a s m d . o r g / w a i v e r s / w a i v e r s . h t m y K R h t t p : / / w w w . n a s m d . o r g / w a i v e r s / w a i v e r s . h t m A D y K 3 h t t p : / / w w w . n p a o n l i n e . o r g / w e b s i t e / s r t i c l e . a s p ? i d = 7 1 y K f h t t p : / / w w w . n p a o n l i n e . o r g / w e b s i t e / s r t i c l e . a s p ? i d = 7 1 D y K S h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / p d f / m l t c _ i n t e r _ r e p . p d f y K h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / p d f / m l t c _ i n t e r _ r e p . p d f D y K R h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / D H S _ i d _ 0 1 7 4 9 3 . p d f y K h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / D H S _ i d _ 0 1 7 4 9 3 . p d f D y K Q h t t p : / / w w w . d p w . s t a t e . p a . u s / H e a l t h / A c c e s s H e a l t h C a r e / S u p p S e r v W a i v e r s / 0 0 3 6 7 1 6 3 5 . h t m y K h t t p : / / w w w . d p w . s t a t e . p a . u s / H e a l t h / A c c e s s H e a l t h C a r e / S u p p S e r v W a i v e r s / 0 0 3 6 7 1 6 3 5 . h t m % D y K , h t t p : / / w w w . u r b a n . o r g / U p l o a d e d P D F / o c c a 1 1 . p d f y K X h t t p : / / w w w . u r b a n . o r g / U p l o a d e d P D F / o c c a 1 1 . p d f D y K Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 5 3 y K h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 5 3 D y K Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 4 1 y K h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 4 1 ! D y K + h t t p : / / w w w . k f f . o r g / m e d i c a i d / 2 2 3 6 - i n d e x . c f m y K V h t t p : / / w w w . k f f . o r g / m e d i c a i d / 2 2 3 6 - i n d e x . c f m E D y K 4 h t t p : / / w w w . d h s . s t a t e . u t . u s / p d f / T h e O l m s t e a d - P l a n . p d f y K h h t t p : / / w w w . d h s . s t a t e . u t . u s / p d f / T h e O l m s t e a d - P l a n . p d f i D y K = h t t p : / / w w w . d a d . s t a t e . v t . u s / 1 1 1 5 w a i v e r / f i n a l M e d W a i v e r R e g s . p d f y K z h t t p : / / w w w . d a d . s t a t e . v t . u s / 1 1 1 5 w a i v e r / f i n a l M e d W a i v e r R e g s . p d f @ @ @ N o r m a l CJ _HaJ mH sH tH : @ : H e a d i n g 2 7$ 8$ @&H$ D A@ D D e f a u l t P a r a g r a p h F o n t V i@ V T a b l e N o r m a l :V 4 4
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! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > @ ? A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n p o q r s t u v w x y z { | } ~ 8 3 *urn:schemas-microsoft-com:office:smarttagsCity B *urn:schemas-microsoft-com:office:smarttagscountry-region 9 *urn:schemas-microsoft-com:office:smarttagsState = *urn:schemas-microsoft-com:office:smarttags PlaceType = *urn:schemas-microsoft-com:office:smarttags PlaceName 9 *urn:schemas-microsoft-com:office:smarttagsplace hW 3 3 3 3 3 3 3 3 3 3 +( ( Je Ne e e Tk Uk 2 w y >% ?% *- ,- ? ? F F Q Q W W X X Z Z [ [ \ \ ^ ^ Oc c c c d d e Ie Bf if g g g 9g Kg Kg g g ] R h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / D H S _ i d _ 0 1 7 4 9 3 . p d f I Z S h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / p d f / m l t c _ i n t e r _ r e p . p d f 5 " W 3 h t t p : / / w w w . n p a o n l i n e . o r g / w e b s i t e / s r t i c l e . a s p ? i d = 7 1 Z _ T ) h t t p : / / w w w . n a s m d . o r g / w a i v e r s / w a i v e r s . h t m 7 & Q : h t t p : / / w w w . s p a n n j . o r g / f a m i l y w r a p / m e d i c a i d _ f a c t _ s h e e t s . h t m K N Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 2 8 3 5 9 % * K 0 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 1 1 5 / k s w o r k . a s p S R H 9 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / 1 1 1 5 1 2 0 4 . p d f E 2 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / f l a l z f s . p d f $ B < h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / n s s t a t e o a 0 4 . p d f p s ? D h t t p : / / w w w . c m s . h h s . g o v / r e s e a r c h e r s / d e m o s / M a s s H e a l t h S C O F a c t S h e e t . p d f [ F < ~ . . / . . / . . / . . / L o c a l S e t t i n g s / T e m p o r a r y I n t e r n e t F i l e s / O L K 1 / % 0 d h t t p : / - - w w w . c m s . h h s . g o v - P r o m i s i n g P r a c t i c e s - D o w n l o a d s - n y m l t c . p d f 9 > h t t p : / / w w w . c m s . h h s . g o v / P r o m i s i n g P r a c t i c e s / D o w n l o a d s / u t i n h . p d f 6 9 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / t r e n d s 0 4 . p d f A @ 3 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / 1 9 1 5 b c . a s p 0 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 / d e f a u l t . a s p k " - 8 h t t p : / / w w w . c a l o p t i m a . o r g / i n d e x . a s p ? c o n t e n t = s e n i o r s e l e c t t * 8 h t t p : / / w w w . f i n d a r t i c l e s . c o m / p / a r t i c l e s / m i _ m 0 7 9 5 / i s _ 1 _ 2 2 ( N ' 0 h t t p : / / w w w . f i n d a r t i c l e s . c o m / p / a r t i c l e s / m i _ m 0 7 9 5 [ G $ = h t t p : / / w w w . d a d . s t a t e . v t . u s / 1 1 1 5 w a i v e r / f i n a l M e d W a i v e r R e g s . p d f 0 w ! h t t p : / / w w w . d a d . s t a t e . v t . u s / A : h t t p : / / w w w . a h c c c s . s t a t e . a z . u s / S e r v i c e s / P r o g r a m s / A L T C S . a s p J Q h t t p : / / w w w . d p w . s t a t e . p a . u s / H e a l t h / A c c e s s H e a l t h C a r e / S u p p S e r v W a i v e r s / 0 0 3 6 7 1 6 3 5 . h t m G h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / i n d e x . h t m l ^ I S h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / d h s _ i d _ 0 0 8 6 6 6 . h c s p ^ I S h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / d h s _ i d _ 0 0 8 6 6 6 . h c s p = x 8 h t t p : / / w w w . h h p . u m d . e d u / A G I N G / M M I P / g r a n t e e s / F l o r i d a . h t m l i ( > h t t p : / / a h c a . m y f l o r i d a . c o m / M e d i c a i d / l o n g _ t e r m _ c a r e / i n d e x . s h t m l J C - h t t p : / / w w w . n a s m d . o r g / w a i v e r s / 1 9 1 5 b c c h a r t . h t m ' / 8 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / e r 0 4 n e t . p d f A @ 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / 1 9 1 5 b c . a s p J C - h t t p : / / w w w . n a s m d . o r g / w a i v e r s / 1 9 1 5 b c c h a r t . h t m stuff from martin Martin.Kitchener@ucsf.edu Kitchener, Martin
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_AuthorEmail _AuthorEmailDisplayName _ReviewingToolsShownOnce A [ G r = h t t p : / / w w w . d a d . s t a t e . v t . u s / 1 1 1 5 w a i v e r / f i n a l M e d W a i v e r R e g s . p d f } ! o 4 h t t p : / / w w w . d h s . s t a t e . u t . u s / p d f / T h e O l m s t e a d - P l a n . p d f # } l + h t t p : / / w w w . k f f . o r g / m e d i c a i d / 2 2 3 6 - i n d e x . c f m G i Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 4 1 E f Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 1 3 4 5 3 ' & c , h t t p : / / w w w . u r b a n . o r g / U p l o a d e d P D F / o c c a 1 1 . p d f J ` Q h t t p : / / w w w . d p w . s t a t e . p a . u s / H e a l t h / A c c e s s H e a l t h C a r e / S u p p S e r v W a i v e r s / 0 0 3 6 7 1 6 3 5 . h t m 3 > ] R h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / D H S _ i d _ 0 1 7 4 9 3 . p d f I Z S h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / p d f / m l t c _ i n t e r _ r e p . p d f 5 " W 3 h t t p : / / w w w . n p a o n l i n e . o r g / w e b s i t e / s r t i c l e . a s p ? i d = 7 1 Z _ T ) h t t p : / / w w w . n a s m d . o r g / w a i v e r s / w a i v e r s . h t m 7 & Q : h t t p : / / w w w . s p a n n j . o r g / f a m i l y w r a p / m e d i c a i d _ f a c t _ s h e e t s . h t m K N Y h t t p : / / w w w . k f f . o r g / m e d i c a i d / l o a d e r . c f m ? u r l = / c o m m o n s p o t / s e c u r i t y / g e t f i l e . c f m & P a g e I D = 2 8 3 5 9 % * K 0 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 1 1 5 / k s w o r k . a s p S R H 9 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / 1 1 1 5 1 2 0 4 . p d f E 2 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / f l a l z f s . p d f $ B < h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / n s s t a t e o a 0 4 . p d f p s ? D h t t p : / / w w w . c m s . h h s . g o v / r e s e a r c h e r s / d e m o s / M a s s H e a l t h S C O F a c t S h e e t . p d f [ F < ~ . . / . . / . . / . . / L o c a l S e t t i n g s / T e m p o r a r y I n t e r n e t F i l e s / O L K 1 / % 0 d h t t p : / - - w w w . c m s . h h s . g o v - P r o m i s i n g P r a c t i c e s - D o w n l o a d s - n y m l t c . p d f 9 > h t t p : / / w w w . c m s . h h s . g o v / P r o m i s i n g P r a c t i c e s / D o w n l o a d s / u t i n h . p d f 6 9 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / t r e n d s 0 4 . p d f A @ 3 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / 1 9 1 5 b c . a s p 0 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 / d e f a u l t . a s p k " - 8 h t t p : / / w w w . c a l o p t i m a . o r g / i n d e x . a s p ? c o n t e n t = s e n i o r s e l e c t t * 8 h t t p : / / w w w . f i n d a r t i c l e s . c o m / p / a r t i c l e s / m i _ m 0 7 9 5 / i s _ 1 _ 2 2 ( N ' 0 h t t p : / / w w w . f i n d a r t i c l e s . c o m / p / a r t i c l e s / m i _ m 0 7 9 5 [ G $ = h t t p : / / w w w . d a d . s t a t e . v t . u s / 1 1 1 5 w a i v e r / f i n a l M e d W a i v e r R e g s . p d f 0 w ! h t t p : / / w w w . d a d . s t a t e . v t . u s / A : h t t p : / / w w w . a h c c c s . s t a t e . a z . u s / S e r v i c e s / P r o g r a m s / A L T C S . a s p J Q h t t p : / / w w w . d p w . s t a t e . p a . u s / H e a l t h / A c c e s s H e a l t h C a r e / S u p p S e r v W a i v e r s / 0 0 3 6 7 1 6 3 5 . h t m G h t t p : / / w w w . h e a l t h . s t a t e . n y . u s / h e a l t h _ c a r e / m a n a g e d _ c a r e / m l t c / i n d e x . h t m l ^ I S h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / d h s _ i d _ 0 0 8 6 6 6 . h c s p ^ I S h t t p : / / w w w . d h s . s t a t e . m n . u s / m a i n / g r o u p s / h e a l t h c a r e / d o c u m e n t s / p u b / d h s _ i d _ 0 0 8 6 6 6 . h c s p = x 8 h t t p : / / w w w . h h p . u m d . e d u / A G I N G / M M I P / g r a n t e e s / F l o r i d a . h t m l i ( > h t t p : / / a h c a . m y f l o r i d a . c o m / M e d i c a i d / l o n g _ t e r m _ c a r e / i n d e x . s h t m l J C - h t t p : / / w w w . n a s m d . o r g / w a i v e r s / 1 9 1 5 b c c h a r t . h t m ' / 8 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / m a n a g e d c a r e / e r 0 4 n e t . p d f A @ 1 h t t p : / / w w w . c m s . h h s . g o v / m e d i c a i d / 1 9 1 5 b / 1 9 1 5 b c . a s p J C - h t t p : / / w w w . n a s m d . o r g / w a i v e r s / 1 9 1 5 b c c h a r t . h t m