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.
State | Program | Model |
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Alabama | Patient 1st | Mandatory |
Florida | MediPass | 1/3 of Medicaid beneficiaries in PCCM, 1/3 in MCOs, 1/3 institutional/other; PCCM members in 6 counties also enrolled in BHO |
Iowa | MediPASS | PCCM in 92 (of state's 99) counties; choice of MCO or PCCM in 43 counties; behavioral health organization (BHO) |
Maine | Maine PrimeCare | PCCM is the only managed care delivery system (as of December 2000) — will be statewide by 2001 |
MaineNET/ Partnership | MaineNET: PCCM; Partnership: PCCM with external care coordination entity | |
North Carolina | ACCESS I |
1 county - mandatory MCO; 5 counties - choose between MCO/PCCM (default to PCCM); rest of 99 counties - PCCM only ACCESS II and III build upon ACCESS I, have all ACCESS I features |
ACCESS II | ||
ACCESS III | ||
Oklahoma | SoonerCare Choice PCCM Model | PCCM in rural areas; MCO in urban areas |
Texas | Texas Health Network | In STAR, can choose between MCO or PCCM (Texas Health Network); one area has BHO; one area has partially capitated PHP being phased out |
STAR+PLUS | Choose between MCO/PCCM | |
Virginia | MEDALLION | PCCM and MCO in different areas (PCCM in more rural areas) |
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Third Party Contracting
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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.
State Program Functions Chart I:
Third Party Contract FunctionsAlabama 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
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Endnote
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23. The PCP receives $3.00 for the first 250 patients on his/her panel and $2.50 per patient thereafter.
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