The Medical Coverage Decision-Making Work Group

How do health insurers and other payers define medical necessity? What criteria do they use to allow benefit exceptions or experimental procedures?
The Medical Coverage Decision-Making Work Group’s goal is to improve understanding of how payers decide when and whether to cover medical services.

The Work Group systematically gathered information on coverage decision-making across the state. Their products are designed to educate families and providers about how decisions are made, and to show the avenues for reconsideration and influence.

The Group developed a set of case vignettes of children with special health care needs that highlight specific issues and service needs. They used these vignettes in structured interviews with health plan decision-makers to discuss how coverage decisions would proceed in each example. See a link to findings at right.

Information gathered from these interviews were used to develop resource materials for families and providers to clarify the types of criteria used in medical decision-making and offer guidelines to caregivers for maximizing medical coverage. See Making the Case for Coverage: Tips for Helping Children and Families Get the Benefits They Need from Their Health Plans: A Guide for Clinicians and Advocates

The membership of the group included representation from commercial and Medicaid health plans, other purchasers, families and providers.

The History
The Medical Coverage Decision-Making Work Group began its work in 2003 with support from the Maternal and Child Health Bureau within the Health Services and Resources Administration, U.S. Department of Health & Human Services.

Co-Chairs:

James Glauber, MD
Neighborhood Health Plan


Nancy Turnbull
Harvard School of Public Health

Reports:

Adequacy of Health Care Financing for Children with Special Health Care Needs in Massachusetts
This background brief assesses the current status of, opportunities and strategies for achieving adequate health care financing for this population.
January 2002

How Massachusetts Health Plans Make Coverage Decisions: A Report on Interviews with Nine MA Health Plans
February 2006

Medical Coverage Decision-Making Work Group Overview
February 2004


Additional Resources:

For articles, educational materials, and links to further information about health care financing, please visit our Resource Center.

Other Work Groups:

Care Coordination

Family Participation

Medical Home

Transition