Defining 'fair'.

PURPOSE: In the USA, private businesses and the federal government contract with health plan companies to arrange and provide for specific health benefits and services. Most contracts are designed around acute care services for people without disabilities. We wanted to design a health benefit programme tailored to the needs of people with disabilities. METHOD: We convened two expert panels. The first, comprised of experts on government programme payments and benefit design, identified key services of a programme providing care for people with disabilities. The second panel, comprised of representatives of health plan companies, simulated the contract evaluation process. RESULTS: Model health benefit programmes for people with disabilities are similar to programmes for people without disabilities, but should provide and pay for care co-ordination, non-medical benefits, and unlimited therapy while incorporating self-directed care. As existing health plan companies consider whether or not to sign a contract to provide these programmes, operational issues carry as much weight as financial factors. CONCLUSION: Purchasers seeking to contract with health plans to provide innovative programmes for people with disabilities must be willing to consider pilot projects, and to give the health plan companies projected utilization and cost data so they can predict their financial risk.

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PubMed2003

Willing and able. Supreme Court ruling forces HMOs to open networks to any willing provider; some say it may wound managed-care industry.

In a decision some say could help end traditional managed care, the U.S. Supreme Court ruled that states have the power to force HMOs to open their networks to any healthcare provider willing to abide by the plans' terms. Elizabeth Johnson, left, counsel for the Kentucky Department of Insurance, says the decision will let states take on key healthcare issues that Congress has never been able to resolve.

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