The Roots and Branches of the Medical-Legal Partnership Approach to Health: From Collegiality to Civil Rights to Health Equity

This Article traces the roots of the medical-legal partnership (MLP) approach to health as a way of promoting the use of law to remedy societal and institutional pathologies that lead to individual and population illness and to health inequalities. Given current forces at work - the medical care and public health systems\u27 foctis on social determinants of health, the increased use of value-based medical care payment reforms, and the emerging movement to train the next generation of health care and public health professionals in structural competency - the time is ripe to spread the view that law is an important lens through which we should view health promotion, disease prevention, and overall well-being

Designing a Complaint and Grievance System and Other Member Assistance Services Under Medicaid Managed Care

Medicaid beneficiaries enrolled in managed care arrangements have two basic sets of procedural protections when benefits are denied. The first set consists of the right to timely and adequate notice of any action affecting [a] claim for medical assistance, as well as a fair hearing in the case of any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness. The second is the right to internal grievance procedures to challenge the denial of coverage *** or payment [of medical] assistance. The Health Care Financing Administration (HCFA) is expected to delineate the specific elements of each of these procedural safeguards in a managed care environment -- as well as how the two sets of protections relate to each other -- in forthcoming regulations implementing the Balanced Budget Act (BBA) of 1997. This Issue Brief examines how state Medicaid agencies approach the issue of grievances and appeals in their contracts with managed care organizations (MCOs) furnishing comprehensive services. The source of information for this Issue Brief is the MCO contract data base maintained by the Center for Health Services Research and Policy and supported in part by the Substance Abuse and Mental Health Services Administration. As a result, this Issue Brief focuses on grievance and appeals procedures for enrollees of managed care organizations and does not address the procedural protections available to individuals who are enrolled in other forms of managed care, such as primary care case management systems

Coverage Decision-Making in Medicaid Managed Care: Key Issues in Developing Managed Care Contracts

Coverage provisions are the most complex part of any managed care contract. This is particularly true for Medicaid agencies, because of important differences between Medicaid and insurance. This Issue Brief identifies general issues that should be addressed as managed care contracts are developed and drafted, and it specifically explores the challenges faced by public purchasers when drafting managed care coverage provisions

Pegram v Herdrich: Implications for Consumer Protections in Managed Care

This Report, prepared for the Substance Abuse and Mental Health Services Administration, provides a brief overview of the United States Supreme Court\u27s landmark decision in Pegram v Herdrich (hereinafter referred to as Herdrich). This report begins with a brief overview of the debate in the courts over how to distinguish between legal challenges to the conduct of managed care companies in which all state remedies are preempted by ERISA and those that may proceed under state law. It then summarizes the facts of the Herdrich case and the Court\u27s holding. The report concludes with a discussion of the implications of the decision for federal and state consumer protection legislation. A point of caution should be raised. The Herdrich decision is so new, and its implications so potentially far-reaching, that legal scholars, policy makers, lawyers, and judges undoubtedly will be pondering and debating its meaning and reach for years. However, in light of the enormous attention now focused on managed care accountability, the decision will attract a great deal of attention. Consequently, at least a preliminary analysis is warranted

Cultural Competence in Medicaid Managed Care Purchasing: General and Behavioral Health Services for Persons with Mental and Addiction-Related Illnesses and Disorders

This Issue Brief explores cultural competence. Employing the data base from the large-scale Medicaid contract analysis conducted annually by the Center for Health Services Research and Policy (CHSRP) (now CHPR), we examine the approaches that state agencies take in implementing the concept of cultural competence in the design and implementation of their managed care systems

Coverage Decisions Versus the Quality of Care: An Analysis of Recent ERISA Judicial Decisions and Their Implications for Employer-Insured Individuals

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the evolution of this framework for analyzing health claims emanating from the conduct of ERISA-covered managed care arrangements and considers its implications for the provision of treatment for mental illness and addiction disorders. Both studies and anecdotal evidence suggest that managed care companies impose particularly rigorous controls over treatment for mental illness and addiction disorders. It is therefore perhaps not surprising that legal challenges to treatment decisions frequently involve individuals with these conditions. Consequently, to the extent that courts are in fact on the verge of re-conceptualizing their approach to analyzing managed care cases under ERISA, the implications for treatment of mental illness and addiction disorders may be especially significant

The Ticket to Work and Work Incentives Improvement Act of 1999: Implications for the Design and Support of Comprehensive Integrated Health Systems for Persons with Mental Illness and Addiction Disorder Disabilities

This report is designed to provide an overview of the Medicaid provisions of the Ticket to Work and Work Incentives Improvement Act of 1999, Public Law 106-170. This report considers the implications of the Act for the design and support of comprehensive, Medicaid-financed systems of health care for workers with severe disabilities and impairments, with a specific focus on persons with mental illness and addiction disorder disabilities. The Act, described by advocates for persons with disabilities as the most important piece of disability-related legislation since the enactment of the Americans with Disabilities Act of 1990, expands the availability of health care and employment preparation and support services for working-age adults with disabilitie