Emerging Practices in Medicaid Primary Care Case Management Programs. Member Services


Services designed to facilitate membership are essential components of high quality health care. Some member services are offered in all the case-study states - complaint and grievance processes, member help lines run internally or by enrollment brokers, enrollee interpreter/translation services, new member handbooks and materials, and the provision of lists of participating PCPs to new members. Chart N lists some of the member services offered in the case-study states.

State Program Member Services Included
Chart N:
Member Services
Alabama Patient 1st Member hotline, grievance/complaint process, targeted case management for medically at-risk or non-compliant patients, enrollee interpreter/translation services
Florida MediPass Member hotline, grievance/complaint process, disease management, enrollee interpreter/translation services
Iowa MediPASS Member hotline, grievance/complaint process, newsletter mailings, member handbook and Medicaid guide routinely sent to members, enrollee interpreter/translation services
Maine Maine PrimeCare Member hotline, grievance/complaint process, enrollee interpreter/translation services
MaineNET/ Partnership MaineNET: PRA-Plus screen, preventive health screen complaint/grievance process, enrollee interpreter/translation services
Partnership: above, plus local care coordinator works with physician
North Carolina ACCESS I Member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
ACCESS II Incentives for members to see PCCMs, member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
Oklahoma SoonerCare Choice PCCM Model Member services department, nurse advice hotline, grievance/ complaint process, case management, member handbook, enrollee hotline, information mailings on benefits and preventive health topics, enrollee interpreter/translation services
Texas Texas Health Network Nurse advice hotline, customer service help line, prenatal care line for new pregnant members, utilization management help line, grievance/complaint process, ombudsman program (Harris service area only), case management, outreach workers link with health-related and socioeconomic community resources, community-based member health education, community I&R database, case management staff coordinate care for all members who meet criteria, member education materials, newsletter, enrollee interpreter/translation services
Virginia MEDALLION Member hotline, grievance/complaint process, enrollee interpreter/translation services

Additional efforts made by the case-study states include:

  • Special hotlines: Oklahoma and Texas have 24-hour/7-day nurse advice lines, in addition to member services hotlines. In Oklahoma, members calling the hotline to determine whether to seek emergency room care are triaged by the nurse, who faxes the state a copy of the recommendation he/she made to the caller. Oklahoma's nurse advice line also calls 10 percent of new members monthly to orient new members; the state plans to increase this to 100 percent of new members in Spring 2001. Oklahoma has a specially dedicated member services department. In Texas, the nurse advice line promotes coordination of care through a faxed summary of the call to the PCP for members who are triaged to emergent or urgent care. Texas also has a 24-hour/7-day utilization management help line for precertification and authorization and a prenatal care line to facilitate appointment setting for newly enrolled pregnant women.
  • Incentives: Some of the networks in North Carolina's ACCESS II and III programs offer incentives for members to make and keep appointments. These incentives include diapers and gasoline coupons. Oklahoma has an EPSDT bonus payment system (discussed in greater detail in the Finance section of this report).
  • Newsletters: Iowa, Maine, and Texas send quarterly newsletters to all PCCM members. These newsletters include healthy promotion messages; Texas' (which is printed in English and Spanish) includes a cartoon character designed to appeal to children. Iowa also sends letters to beneficiaries to provide education about the appropriate use of the health care system. Maine's enrollment broker distributes the newsletter as well as handles member requests for information.
  • Special education efforts: In both the Texas Health Network and STAR+PLUS, Texas gears educational efforts to the needs of the community (as identified in the annual health needs assessment). Outreach staff employed by the plan administrator in each service area conduct new member orientations, EPSDT education, and follow up when a member is overdue for a screen or has sought services inappropriately from an ER. Outreach and education activities occur in places frequented by Medicaid beneficiaries, including their homes. These staff also work with community based organizations to link members to nonmedical services, such as GED classes, housing, child care, and donated housewares. One current project is the Reach Out and Read Program, which distributes books through PCPs' offices. Maine's enrollment broker conducts community outreach and education efforts to increase members' understanding of managed care and EPSDT.

Oklahoma does extensive outreach to newly eligible Aged/Blind/Disabled (ABD) Medicaid beneficiaries, including outbound telephone calls, direct mail, and enrollment fairs. Exceptional Needs Coordinators and other state medical staff complete health profiles of these new members whenever possible. Each profile is sent to the enrollee's chosen PCP, in order to provide that PCP with a medical history of his/her new patient

  • Ombudsman program: In the Harris County service area of Texas, STAR+PLUS members can obtain help from the Client Advocate program. The program is designed to represent the beneficiary's interests and facilitates communication between the beneficiary and the provider. Special attention is given to SSI members.

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