Emerging Practices in Medicaid Primary Care Case Management Programs. Populations Enrolled


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.

State Program Total Enrolled
(Latest Figures)
Populations Included in Mandatory Managed Care Enrollment
Chart P:
Alabama Patient 1st 355,000 (Oct 1) TANF38, SOBRA children, SSI, Aged, CHIP
Florida MediPass 580,000 (Oct 1) TANF, SSI, foster care children, CHIP
Iowa MediPASS 47,000 (Oct 1) TANF, CHIP
Maine Maine PrimeCare 71,677 (Oct 1) TANF and related, CHIP (Medicaid expansion)
MaineNET/ Partnership MaineNET: 40; Partnership: 40 (Oct 1) Enrollment not mandatory
North Carolina ACCESS I 413,702 (Oct 1) TANF, SSI, Aged/Blind/Disabled (ABD)
ACCESS II 137,305 (Oct 1)
ACCESS III 28,112 (Oct 1)
Oklahoma SoonerCare Choice PCCM Model 140,336 (Oct 1) TANF, SSI, Aged, CHIP (Medicaid expansion)
Texas Texas Health Network 209,000 (Oct 1) TANF
STAR+PLUS 6,000 (Oct 1) SSI children, certain MH/MR
Virginia MEDALLION 127,828 (Aug 31) TANF, SSI, Aged, CHIP

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.)

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