Emerging Practices in Medicaid Primary Care Case Management Programs. Enrollment Process


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 1st or the 15th 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.

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