Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Voluntary and Mandatory Enrollment in Risk-Based Managed Care

07/01/2012

re is substantial variation within and across states with regards to whether enrollment in risk-based managed care programs is mandatory or voluntary. Typically, managed care enrollment requirements vary by enrollee category.

Medicaid TANF-Related Beneficiaries. Figure 2 shows whether a state had mandatory or voluntary enrollment in risk-based Medicaid managed care for 2010 in the 20 study states for adults and children whose eligibility for Medicaid is related to their eligibility for the Temporary Assistance for Needy Families (TANF, or cash assistance) program or who meet other poverty-related eligibility criteria (called "TANF-related" enrollees throughout the remainder of the report). The figure shows states according to whether they require TANF-related groups to enroll in risk-based managed care on a statewide basis or only in certain regions, or whether risk-based Medicaid managed care enrollment is only voluntary in all of the state.


Figure 2: Type of Medicaid Enrollment in Risk-Based Managed Care for TANF and
Poverty-Related Adults and Children in Study States, 2010

US States: Type of Medicaid Enrollment in Risk-Based Managed Care for TANF and Poverty-Related Adults and Children in Study States, 2010

Source: Documents and interviews with state officials.


As of 2010 in the study states, risk-based managed care enrollment for TANF and poverty-related adults and children is mandatory statewide in ten (Arizona, Connecticut, Delaware, Maryland, Minnesota, New Jersey, New Mexico, Ohio, Rhode Island, and Tennessee ), mandatory by geographic region in nine (California, Florida, Minnesota, New York, Pennsylvania, Texas, Virginia, Washington, and Wisconsin ), and voluntary in one (Massachusetts). Massachusetts has chosen to allow TANF-related enrollees to select a Primary Care Case Management (PCCM)4 program as an alternative to risk-based managed care statewide, and approximately 40 percent do so.

Medicaid SSI-Related Beneficiaries. As shown in Figure 3, there is a different pattern of enrollment for non-institutionalized, nonelderly Medicaid enrollees with disabilities whose Medicaid eligibility is based on their eligibility for the Supplemental Security Income (SSI) program or who meet other disability-related eligibility criteria (called "SSI-related" throughout the report). While half the states mandate enrollment for SSI-related groups, either statewide or by region, six states (Massachusetts, Minnesota, Ohio, Texas, Washington, and Wisconsin) have voluntary enrollment for all SSI-related beneficiaries.5 In addition, four states have different enrollment requirements for SSI-related adults and children, as follows:

  • Connecticut: Enrollment for SSI-related children is mandatory statewide, but SSI-related adults are excluded completely from risk-based managed care.
  • Ohio: Enrollment for SSI-related children is voluntary, while SSI-related adults are mandatorily enrolled statewide.
  • Texas: Enrollment for SSI-related children is voluntary, while SSI-related adults are mandatorily enrolled by region.
  • Washington: SSI-related children are excluded completely, while SSI-related adults are enrolled on a voluntary basis in one county, and excluded in others.

Figure 3: Type of Medicaid Enrollment in Risk-Based Managed Care for SSI Adults and Children in Study States, 2010

Source: Documents and interviews with state officials.

Note: 1 SSI-related children differ from adults; see text for explanation

 

Figure 3: Type of Medicaid Enrollment in Risk-Based Managed Care for SSI Adults and Children in Study States, 2010
State TANF Children TANF Adults SSI Children SSI Adults

Source: Documents and interviews with state officials.

Note: SSI-related children differ from adults; see text for explanation

Arizona MS MS MS MS
Connecticut MS MS MS EXCL
California MR MR MR MR
Delaware MS MS MS MS
Florida MR MR MR MR
Maryland MS MS MS MS
Massachusetts V V V V
Michigan MR MR MR MR
Minnesota MS MS V V
New Jersey MS MS MR MR
New Mexico MS MS MS MS
New York MR MR MR MR
Ohio MS MS EXCL MS
Pennsylvania MR MR MR MR
Rhode Island MS MS MS MS
Tennessee MS MS MS MS
Texas MR MR V MR
Virginia MR MR MR MR
Washington MR MR EXCL V
Wisconsin MR MR V V

 


Informants in several states noted that advocacy groups play an important role in determining whether SSI-related enrollees are offered a choice regarding enrollment in risk-based Medicaid managed care. In some cases (e.g., recently in Massachusetts), advocates have been supportive of the improved coordination of care that managed care can bring, and in some (e.g., Connecticut and New Jersey) they have been opposed because of the potential for reduced access.

Advocates were concerned with managed care organizations being able to handle and understand the SSI-related population, since MCOs were more used to a commercial population. (State Official)

CHIP Beneficiaries. While not shown separately, the pattern of mandatory and voluntary enrollment for CHIP children follows that of TANF-related Medicaid enrollees in most study states. The seven states cited above with very separate Medicaid and CHIP risk-based managed care programs all mandate enrollment in CHIP managed care on a statewide basis, except for Virginia, where mandatory enrollment follows the Medicaid pattern geographically. Two of the states (California and Florida) exclude children with special health care needs from mandatory enrollment, but the others do not.

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