HEALTH MAINTENANCE ORGANIZATIONS AND CHILDREN WITH SPECIAL HEALTH NEEDS - A SUITABLE MATCH

Objective.-To address how well health maintenance organizations (HMOs) meet the needs of almost 700 000 children with disabilities due to ch ronic conditions enrolled in these plans. Design.-A cross-sectional su rvey. Measurements/Main Results.-Health maintenance organizations offe red better protection than conventional plans against out-of-pocket ex penses and were much more likely than fee-for-service plans to cover a ncillary therapies, home care, outpatient mental health care, and medi cal case management. In addition, few HMOs maintained exclusions for p reexisting conditions. Other aspects of HMO policies, however, were fo und to operate against the interest of families with chronically ill c hildren. In particular, HMOs commonly made specialty services availabl e only when significant improvement was expected within a short period . Also, HMOs typically placed limits on the amount and duration of men tal health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. Participants.-In dividual HMO plans. Selection Procedure.-A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. Interventions. -None. Conclusions.-Health maintenance organizations offer several adv antages over traditional fee-for-service plans for families whose chil dren have special health needs. However, the results also indicate tha t HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.