Aijaz Monisa, Song Paula H, Lewis Valerie A, Shea Christopher M
University of North Carolina at Chapel Hill, USA.
Virginia Commonwealth University, Richmond, USA.
Med Care Res Rev. 2025 Oct;82(5):387-398. doi: 10.1177/10775587251324974. Epub 2025 Mar 18.
Empowering beneficiaries to choose a health plan that meets their health needs during the transition to Medicaid managed care is critical to promote informed decision-making. This study uses North Carolina's transition under the 1115 waiver to examine the role of the state, health plans, and providers in informing beneficiaries about the transition. We reviewed policy documents and interviewed 43 individuals representing provider practices and 10 representing the State Department of Health and Human Services and health plans between December 2020 and September 2021. Interviewees from the state described strategies to encourage beneficiaries to select a health plan. Participating practices shared that their patients were unaware or confused about the transition. These concerns led practices to engage beneficiaries and contract with all health plans to ensure continuity of care, contributing to administrative burdens. While the state made significant efforts to engage beneficiaries, the interaction between beneficiaries and providers was still critical.
在向医疗补助管理式医疗过渡期间，让受益人能够选择满足其健康需求的健康计划对于促进明智的决策至关重要。本研究利用北卡罗来纳州根据第1115号豁免权进行的过渡，来考察州政府、健康计划和医疗服务提供者在向受益人通报过渡情况方面所起的作用。我们查阅了政策文件，并在2020年12月至2021年9月期间采访了43名代表医疗服务机构的人员以及10名代表州卫生与公众服务部和健康计划的人员。来自州政府的受访者描述了鼓励受益人选择健康计划的策略。参与的医疗服务机构表示，他们的患者对过渡情况不知情或感到困惑。这些担忧导致医疗服务机构与受益人进行接触，并与所有健康计划签约以确保医疗服务的连续性，从而增加了行政负担。虽然州政府为让受益人参与做出了重大努力，但受益人与医疗服务提供者之间的互动仍然至关重要。
