Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 8: Enrollment

State Medicaid programs include several eligibility groups in their PCCM programs. With the exception of the MaineNET/Partnership program, the eight case-study states require mandatory participation of certain eligibility groups. Most states selected AFDC/TANF eligibles and related eligibility categories for initial enrollment in their Medicaid managed care initiatives. As they developed more experience, states added those populations considered to be more challenging for a managed care environment. Among the eight case-study states, six include eligibility groups in addition to TANF/related in mandatory enrollment. These eligibility categories include SSI disabled children and adults, aged beneficiaries, and children in foster care. Under the BBA, states are permitted to mandate managed care enrollment as a state option for most beneficiaries without obtaining 1915(b) or 1115 waivers. States must still seek a waiver from HCFA(now known as CMS) if they require mandatory enrollment of certain Medicare beneficiaries, American Indians/Alaska Natives, and special needs children.³⁷  Since the advent of the State Children's Health Insurance Program (SCHIP), all of the study states except North Carolina and Texas have incorporated CHIP members into their PCCM programs. North Carolina provides CHIP coverage outside the Medicaid program. Chart P lists the populations included in mandatory managed care enrollment, as well as total numbers of people enrolled.

The MaineNET/Partnership is a voluntary program for Medicaid beneficiaries in the SSI and Aged eligibility categories. If they receive long-term care services at home as part of the Home and Community-based Services (HCBS) waiver program, they are eligible to receive Partnership services as well. Beneficiaries who reside in a nursing home or a facility for people with mental retardation, or who are enrolled in the HCBS waiver for persons with mental retardation, are excluded from enrollment.

States often make exceptions to their mandatory enrollment requirements for certain individuals and groups who may be better served outside the state's managed care delivery system. These individuals may enroll in the PCCM program but are not required to do so. Alabama, Florida, Maine, Iowa, and Virginia exempt persons with special needs and medical conditions on a case-by-case basis if it appears that their health needs can be better met in a fee-for-service system. American Indians/Alaska Natives are not exempt from participation in the Maine PrimeCare program, North Carolina ACCESS, and Texas Health Network, because they may receive their health care from providers (such as the Indian Health Service) who do not participate in the state's PCCM program. Maine enrolls pregnant women with primary care providers and tells the women that they can choose their own providers for pregnancy-related OB care. North Carolina makes participation voluntary for pregnant women.

States also identify a range of Medicaid eligibility groups who are excluded from participating in their managed care programs. These are often populations who, because of medical or residential needs, or their dual eligibility status, would be difficult to serve effectively in a managed care environment. States commonly exclude dual eligibles (Medicaid beneficiaries who are also eligible for Medicare), children who are in the state's foster care and subsidized adoption programs, and those individuals who reside in nursing facilities or other residential care. (Please refer to Appendix C for a complete listing of enrollment exemptions and exclusions in the case-study states.)

The enrollment process is fairly standard from state to state, and PCCM programs face similar issues and challenges in developing systems that provide adequate information and notification to members. States are increasingly using private vendors to conduct enrollment and other functions for their managed care programs. Six of the eight case-study states contract with an enrollment broker; Alabama and North Carolina do not. Several of these states (Florida, Virginia, and Iowa) initially conducted enrollment services internally, then converted to contracting with an outside vendor for this function. Maine used an enrollment broker for the first year and a half of its managed care programs, then brought the enrollment function into the state agency using welfare to work participants as enrollment staff. The state subsequently decided to contract with an enrollment broker again; the current contractor has hired some of these workers.

Among the states using enrollment brokers, officials appear to be satisfied with the performance of their contractors and the collaborative relationships they have developed. They report that they work with their respective contractors on a nearly daily basis, thereby preventing problems before they occur.

Regardless of whether a state uses an enrollment broker or retains enrollment as a state-administered function, there are certain issues that are intrinsic to Medicaid managed care enrollment. Informing prospective members about Medicaid managed care and its requirements is one of the most challenging tasks, according to state officials, yet one of the most critical for the success of the program. As one state official noted, the top issue is whether members really understand and agree/comply with what it means to enroll with a PCP and how to access services. States use a variety of strategies to inform beneficiaries about their managed care choices, including

• informational materials and instructions about how to enroll;
• group educational sessions;
• 1-800 help lines; and
• individual face-to-face counseling, in some instances.

In general, enrollment staff, whether employed by the state agency or by an enrollment broker, have limited personal contact with the prospective member unless the member calls for further information. Maine has tried to counter that limited contact with phone outreach to prospective members. The state's enrollment broker works with the regional eligibility determination staff to get the most current telephone numbers of Medicaid beneficiaries in order to call and encourage them to choose a PCP. State staff believe that their voluntary choice rate of 85 percent is due, in part, to their success in reaching prospective members by telephone.

Several Medicaid staff commented that they would like to see the agency responsible for Medicaid eligibility determination take a role in educating the beneficiary about managed care. Iowa provides training about its managed care programs to income maintenance workers who determine eligibility in the county offices so that they can reinforce managed care information for new members. In Maine, state eligibility workers previously provided information about PCCM to TANF beneficiaries during their orientation, but the Bureau of Family Independence (the state agency responsible for eligibility determination) decided to eliminate this task from the workers' duties. According to state Medicaid staff, this change in policy has resulted in new members not knowing anything about PCCM when asked to choose a provider. They often call their caseworkers at the Bureau for Family Independence for information about the program, creating more work for eligibility staff.

States also struggle with the challenge of enrolling new members in managed care as soon as possible after their initial Medicaid eligibility determination. Officials comment that they often lose contact and continuity with prospective members between the time they are found eligible for Medicaid and the time they are asked to enroll in PCCM; the mobility of Medicaid beneficiaries presents a considerable challenge. Maine enrolls PCCM members on either the 1^st or the 15^th of the month, whichever gives the new member at least a five-day notice. The state previously did daily enrollment, but this constant flow of information was too difficult for physician practices to administer. Virginia is in the process of reducing the window for prospective members to select a managed care option from 60 days to 30 days. Staff believe that the longer time frame resulted in many missed opportunities to provide appropriate health care, particularly for pregnant women.

Several of the case-study states have implemented lock-in requirements, mandating that the member stay with a PCP for a certain period of time. The case-study states, including those without lock-in provisions, report minimal disenrollment in their PCCM programs; few members elect to change their PCP when given the opportunity.

• Florida has a 12 month lock-in provision for both its PCCM and MCO systems.
• Iowa has the Extended Participation Program, which requires members to stay with their PCP in the PCCM program or their MCO for six months.
• Virginia also has a six-month lock-in provision, but state officials note that members are permitted to change their PCP within the lock-in period. When they have legitimate reasons for requesting a different PCP, their requests are approved.
• Oklahoma initially had a lock-in requirement but, as of July 1999, permits members to change their PCP up to four times a year.

A few of the case-study states have made specific accommodations in their enrollment processes for special needs populations. The practices of Alabama and Oklahoma are of particular interest.

Alabama pays close attention to the enrollment of individuals with special needs. As the state proceeds with enrollment county by county, it works with community agencies in the particular county to identify subpopulations of individuals with special needs. The state makes sure that specific providers who serve persons with special needs are recruited as PCPs before proceeding with mandatory enrollment. When bringing on a county with a fairly large population of Russian Medicaid beneficiaries, state agency staff contacted a physician in the community who speaks Russian and serves the population. The physician assisted the state by helping prospective members understand the program and how to enroll.

Oklahoma began enrolling the Aged, Blind, and Disabled (ABD) populations in its PCCM and MCO programs in January 2000. The state adopted several strategies to facilitate the enrollment of these individuals.

• Staff education: The Medicaid agency worked closely with regional eligibility determination staff to educate them about the particular needs and concerns of the ABD members and about their managed care options.
• Enrollment fairs: The Medicaid agency staff (including Exceptional Needs Coordinators) conducted health fairs and informational events at sites accessible to the targeted populations to help them understand how their health care delivery was going to change.
• Transportation: The state enlisted the transportation contractor to transport prospective members to the enrollment fairs. The state ensured that the contractor was aware of the particular needs of the ABD populations.
• Exceptional needs coordinators (ENCs): The state has identified nurses and social workers with case management experience to serve as ENCs for the PCCM members. (The state has required its contracted MCOs to hire ENCs for their special needs members as well.) The ENCs work with community service agencies and other providers to coordinate resources and services for special needs members.
• Targeted outreach: During initial enrollment of the ABD populations, the ENCs make phone calls to those Medicaid beneficiaries who have high utilization of services, based on their claims history. The purpose of the phone call is to inform members about upcoming changes in their coverage, explain managed care, and to complete a profile to identify their outstanding health needs. The ENC also helps the prospective member select a PCP who can best meet their needs. The health information about the member is then forwarded to the selected PCP so that the provider is aware of the new member's health needs.

37. Specifically, the BBA exempts the following populations from mandatory enrollment in Medicaid managed care; dual Medicare-Medicaid eligibles; American Indians/Alaska Natives who are members of federally recognized tribes; and children who are eligible for SSI, in home and community-based settings, in foster care or other out-of-home placement, receiving foster or adoption assistance, or receiving services through a family-centered, community-based coordinated care system receiving Title V grant funds.

38. In general, TANF refers to other poverty-related populations in addition to TANF beneficiaries. However, Alabama makes a distinction between SOBRA women and SOBRA children; SOBRA children are mandatorily enrolled; SOBRA adults are not eligible.