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West Virginia's Medicaid Redesign: Mountain Health Choices

West Virginia has redesigned its Medicaid program to offer alternative benefit packages that create incentives for beneficiaries to take responsibility for their own health and health care. Other states, including Kentucky and Idaho, are considering or have already begun similar reforms.

Through a State Plan Amendment, permitted under the Deficit Reduction Act of 2005, West Virginia has launched Mountain Health Choices, offering an Enhanced Plan to healthy children and adult beneficiaries who agree and comply with a member agreement, and a more limited Basic Plan to those who fail to do so.[1] The benefit redesign is intended to provide incentives that encourage members to take greater responsibility for their health, with positive financial consequences for the state. According to Shannon Riley, executive assistant to the West Virginia Commissioner of the Bureau for Medical Services, "Everyone realizes that short-term cost containment is not the answer. If we can improve health, we can reduce the long-term growth of the Medicaid program."

The Member Agreement
Joining and remaining in the Enhanced Plan requires that members comply with a set of responsibilities, including:

  • selecting a medical home;[2]
  • doing one's "best to stay healthy" and adhering to health improvement programs as directed by the individual's medical home;
  • going to (or taking one's child to) their medical home for check-ups and when sick;
  • keeping and arriving on time for appointments;
  • using the hospital emergency room for emergencies only; and
  • complying with prescribed medications.
The state will track compliance through claims data. In the first year, the state will monitor adherence to recommended screenings and health improvement programs, missed appointments, and medication compliance. Monitoring the other responsibilities will be phased in later.

Basic and Enhanced Plans
For children, the main difference between the Basic and Enhanced plans is that the former limits prescription drug coverage to four scripts per month, while the latter does not have this limit and will continue to adhere to the state's traditional Medicaid guidelines. Officials say that the state will make exceptions to the four-script limit on a case-by-case basis. Under both plans, children will continue to receive all medically necessary care.[3]

For adults, there are stronger incentives to comply with the member agreement and gain access to the Enhanced Plan. The Basic Plan will provide federal and state mandatory services, but will have a four prescription per-month limit. Only adults in the Enhanced Plan will have access to services such as weight management classes, nutritional counseling, tobacco cessation programs, and others to be announced.

Further, children and adults in the Enhanced Plan who meet certain health goals will receive reward points on a quarterly basis. The health goals will be determined by health care providers in cooperation and consultation with their patients. Beginning in 2007, the points can be used in exchange for additional benefits, which are currently being determined through discussions between the state and the Centers for Medicare and Medicaid Services.

Mountain Health Choices will be implemented in three counties in late 2006 or early 2007. It will eventually expand to include about 160,000 healthy children and adults statewide, representing about two-thirds of Medicaid beneficiaries but a much smaller portion of Medicaid spending. No time frame has been established at this point, because the state wants to ensure that the program is running smoothly and successfully in the three counties before expansion.

The personal responsibility model being pursued by West Virginia, Kentucky, and Idaho and considered by others has raised concerns among some physicians, patient advocates, and experts. In a recent commentary in the New England Journal of Medicine, the authors suggest that the West Virginia plan is unfair because it places responsibility on patients for factors, such as public transportation, that may be out of their control; children must depend on their parents or guardians to comply with the rules; and the most vulnerable individuals—i.e., Medicaid beneficiaries—are held to a standard of behavior not required of others.[4] Other observers, such as Judith Solomon at the Center for Budget and Policy Priorities, contend that the plan could lead to poorer health for some beneficiaries because those in the Basic Plan would not have access to critical health services such as diabetes care and mental health services or all needed prescriptions.[5]

Program planners point out that the program is being piloted in order to test its functioning and gauge the impact on beneficiary behavior. Ultimately, they hope to learn what best motivates beneficiaries to change their behavior in ways that improve health. State officials will closely monitor the program's effects, intending to learn from mistakes and build on success.

[1] This program will not apply to individuals with disabilities or children in foster care. Parents sign the agreement on behalf of their eligible children.
[2] The agreement defines a "medical home" as a physician, clinic, or health plan that will be a member's source of primary care and coordinate their services.
[3] The state maintains that all children enrolled in Medicaid will be provided with early and periodic screening, diagnostic and treatment services when medically necessary. Unlike the Enhanced Plan, the Basic Plan for children will not include podiatry or chiropractic care.
[4] G. Bishop and A. C. Brodkey, Personal Responsibility and Physician Responsibility—West Virginia's Medicaid Plan, New England Journal of Medicine, August 24, 2006, 355 (8): 756–758.
[5] Judith Solomon's analysis is available on the Center on Budget and Policy Priorities site.

For More Information
Contact: Nancy Atkins, Commissioner, West Virginia Bureau for Medical Services, West Virginia Department of Health and Human Resources, [email protected]

See: West Virginia Medicaid Redesign Site
West Virginia State Plan Amendment

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