Emerging Practices in Medicaid Primary Care Case Management Programs. Third Party Contracting


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 Functions
Alabama 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

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

Virginia MEDALLION Enrollment, prior authorizations, quality improvement


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