Rosenbaum S, Teitelbaum J, Kirby C, Priebe L, Klement T
Issue Brief George Wash Univ Cent Health Serv Res Policy. 1998 Nov(2):1-11.
Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types of lawsuits: (1) those that challenge the practices of managed care companies under various federal and state laws that safeguard consumer rights, protect health care quality, and prohibit discrimination; and (2) suits that assert claims arising directly under the Medicaid statute and implementing regulations, as well as claims related to Constitutional safeguards that undergird the program. Lawsuits asserting claims arising under Medicaid tend to raise two basic questions: (1) the extent to which enrollment in a Medicaid managed care plan alters existing Medicaid beneficiary rights and state agency duties under federal or state Medicaid law; and (2) the extent to which managed care companies, as agents of the state, act under "color of law" (i.e., undertaking to perform official duties or acting with the imprimatur of state authority). Additionally, states might see an increase in litigation brought by prospective and current contractors who assert that they have been wrongfully denied contracts or improperly penalized for poor performance. These assertions may involve claims that are grounded in federal and state law, the Medicaid statute, and the Constitution. Moreover, in light of the consumer protection elements of the managed care reforms contained in the Balanced Budget Act, future managed care litigation may focus on the manner in which companies carry out states' obligations toward managed care enrollees. Resolution of Medicaid managed care cases involves the application of general principles of administrative and regulatory law. Thus, Medicaid managed care cases have implications for other public purchasers of managed care arrangements, including state mental health and alcohol and substance abuse agencies.
自1965年《医疗补助计划》颁布以来，各州可选择让受益人参加管理式医疗安排。随着强制性管理式医疗覆盖数以百万计的受益人（包括越来越多的残疾受助人），预计涉及医疗补助计划管理式医疗的诉讼数量和范围将会增加。对当前有关医疗补助计划管理式医疗的诉讼进行审查后发现有两种基本类型的诉讼：（1）那些依据各种保障消费者权利、保护医疗质量及禁止歧视的联邦和州法律，对管理式医疗公司的做法提出质疑的诉讼；（2）那些主张直接依据《医疗补助计划》法规及实施条例产生的权利主张，以及与该计划所依据的宪法保障相关的权利主张的诉讼。依据《医疗补助计划》提出权利主张的诉讼往往会引发两个基本问题：（1）参加医疗补助计划管理式医疗在多大程度上改变了联邦或州医疗补助法规定的现有医疗补助受益人权利及州机构职责；（2）管理式医疗公司作为州的代理人，在多大程度上是在“法律名义下”行事（即承担履行公职或在州政府授权下行事）。此外，各州可能会看到潜在承包商和现有承包商提起的诉讼有所增加，他们声称自己被错误地拒绝签订合同或因表现不佳而受到不当处罚。这些主张可能涉及基于联邦和州法律、《医疗补助计划》法规及宪法的权利主张。此外，鉴于《平衡预算法》中包含的管理式医疗改革的消费者保护要素，未来的管理式医疗诉讼可能会聚焦于公司履行各州对管理式医疗参保人义务的方式。医疗补助计划管理式医疗案件的解决涉及行政和监管法的一般原则的适用。因此，医疗补助计划管理式医疗案件对管理式医疗安排的其他公共购买者，包括州心理健康及酒精和药物滥用机构，都有影响。
