Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 3: Organizational Structure and Administration

Several of the case-study states have made significant changes in the administration of their PCCM programs, creating organizational arrangements that more closely resemble contracted managed care networks. Whether state-administered or through contract agreements, these states have identified distinct functions for administration, such as enrollment, member services, provider network development, quality improvement, and medical management. In many instances, states are choosing to contract out for these program functions instead of administering them internally. The result is that PCCM programs have gained a new level of sophistication and importance as managed care delivery systems in state Medicaid programs. Chart H shows the range of delivery systems used in the case-study states.

• Third Party Contracting

  • Six of the eight case-study states contract with private entities to perform enrollment functions for PCCM. Alabama and North Carolina retain that function within their state and county governments. In each of the six states, the enrollment broker provides services for MCO enrollment as well. Maine's enrollment broker is also responsible for provider recruitment and member services. State officials in Maine combined these functions because they felt that it provided an opportunity for the broker to develop a comprehensive understanding of the community as the state rolls out its PCCM program from county to county. The broker learns the dynamics of the local delivery system as it recruits PCPs to participate. It then has a better knowledge and understanding of the community when it begins enrollment of Medicaid beneficiaries.

    As Chart I illustrates, each of the eight states operates its PCCM program a bit differently from the way the other states do, illustrating considerable variability in administration. For example, rather than having its enrollment broker conduct provider recruitment for PCCM, as Maine does, Florida has it fiscal agent provide that service. Oklahoma contracts with a separate entity to provide a 24-hour nurse advice line for members but has combined this function with those of the enrollment broker in one contract. Four of the states (North Carolina, Oklahoma, Texas, and Virginia) contract with independent entities to conduct quality improvement activities for PCCM Programs in Texas, North Carolina, and Maine provide three different examples of how states have structured the administration of their PCCM programs.

    Chart I:
    Third Party Contract Functions

    State	Program	Functions
    Alabama	Patient 1st	None
    Florida	MediPass	Fiscal agent, enrollment, pharmacy management, disease management
    Iowa	MediPASS	Fiscal agent
    Maine	Maine PrimeCare	Enrollment, policy institute at university does program development and evaluation
    	MaineNET/ Partnership	Medical eligibility, enrollment, care coordination, policy institute at university does program development and evaluation
    North Carolina	ACCESS I	Quality improvement
    	ACCESS II
    	ACCESS III
    Oklahoma	SoonerCare Choice PCCM Model	Enrollment, nurse advice line, quality improvement, encounter data verification
    Texas	Texas Health Network	Plan administrator to manage network and member services, enrollment, fiscal agent, quality improvement
    	STAR+PLUS
    Virginia	MEDALLION	Enrollment, prior authorizations, quality improvement

     

• State Variations in PCCM Administration

• Endnote

  • 23. The PCP receives $3.00 for the first 250 patients on his/her panel and $2.50 per patient thereafter.

View full report

Download

"report.pdf" (pdf, 314.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®