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Case Study 1: Background

This state has had a risk-based managed care program for children and parents since the 1990s (Healthy Families) but older persons and persons with disabilities are not eligible for the program.  It has been through several procurement cycles, and the Medicaid agency’s Managed Care Division has refined its contract management and quality improvement processes over the years.  

Marcia Mellen

Marcia Mellen, the Medicaid Director believes that the Healthy Families program has improved value for beneficiaries and for tax payers and wants to expand the approach to include all populations and Medicaid services, including LTSS. The legislature, responding to the concerns of stakeholders, has directed the department to proceed slowly, authorizing a voluntary pilot program in up to 3 counties. It has also made it clear that it does not want to include Medicare in the program. 

James Towne
James Towne is a Medicaid Policy Manager assigned responsibility for planning, designing and implementing the pilot.  He is leading a team known as the Core Planning Team (CPT) in developing the program design. The CPT is a small group of internal managers, including representatives from the divisions of Elderly Services, Disability Services and Medicaid Financial Services.


As a first step the CPT decided to draft a program goal statement and high-level approach. Once approved, this became the document that was disseminated internally and externally to introduce the pilot effort. 

Question Mark

If you were the CPT, how might you describe this state's goals? You can use Worksheet 2.3 to help.

Next we'll see the Goals proposed by James and the CPT.


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