States, with Centers for Medicare & Medicaid Services (CMS) approval, can require Medicaid beneficiaries to enroll in a managed care plan to obtain some or all Medicaid benefits, or they may make such enrollment voluntary. Many states mandate managed care enrollment for certain Medicaid beneficiaries and make it voluntary for others. States may also create mandatory programs in some geographic areas and voluntary programs in other areas, depending on the number of managed care organizations (MCOs) available.
There are a number of statutory authorities through which states can allow or require Medicaid beneficiaries to receive services through a managed care delivery system. However, all Medicaid managed care programs must adhere to the requirements in Section 1932 of the Social Security Act (the Act) and Section 438 of title 42 of the Code of Federal Regulations (42 CFR 438), including the provisions relating to the processes and policies for mandatory and voluntary enrollment.
There are few statutory requirements regarding the managed care enrollment process other than a provision that allows enrollees in a mandatory managed care program the right to change plans without cause within 90 days of enrolling in the plan, and every 12 months thereafter. Enrollees may also change plans for cause at any time (§1932(a)(4)(ii)(I) of the Act). In addition, if a state requires Medicaid beneficiaries to enroll in an MCO, enrollees must be given a choice of at least two plans, with the exception of enrollees in certain rural areas who must be given a choice of providers within an MCO (§1932(a)(3) of the Act).
Most federal requirements regarding Medicaid managed care enrollment processes are described in 42 CFR 438. Prior to 2016, there were few federal regulations governing the enrollment process and substantial variation among states in the time frames and processes to inform Medicaid beneficiaries about plan choices and enroll them into MCOs. The rules were updated in 2016 to expand the federal oversight role, standardize the expectations for states across all managed care authorities, and update program standards to reflect the current scope of Medicaid managed care programs. The new regulations establish additional standards for voluntary and mandatory managed care enrollment processes to create more consistency among states. However, states still have flexibility in designing Medicaid managed care programs and enrollment processes within these federal guidelines, and can develop enrollment procedures to support the state program design.
Each state contracts independently with managed care plans; the number of plans that an enrollee can choose from may vary by county, region, or metropolitan area within that state. States must allow new enrollees a period of time to choose either a managed care or fee-for-service (FFS) delivery system (if managed care enrollment is voluntary) or MCO (if enrollment in managed care is mandatory). If an enrollee does not make a choice, the state may assign the enrollee to an MCO but must allow the enrollee to change to a different MCO or to FFS. States must also provide enrollees with supporting information and enough time for enrollees to use the information to make an informed choice.
Many states use an independent enrollment broker to help beneficiaries with the plan choice and enrollment process; since July 2018, all states have been required to provide independent choice counseling services for all new managed care enrollees and all enrollees who are changing health plans. In addition, states may use community-based organizations to assist enrollees with the enrollment process.
To help ensure that enrollees understand how and where to access services, there are numerous federal rules regarding marketing, outreach, and communication. Federal rules allow states and MCOs to communicate with enrollees through a number of mechanisms including the mail, phone, and various electronic communication methods including texts, email, and websites. States must ensure that information is accessible to individuals with limited English proficiency by providing access to interpretation services or written translations. States must also provide alternative formats for the visually impaired. MCOs must routinely update their provider directory information and make this available both on paper and on a plan website so that enrollees and potential enrollees can have up-to-date and accurate information about available providers. MCOs are required to include, for most providers, the provider’s address, phone number, specialty, whether he or she is accepting new patients, the provider’s cultural and linguistic capabilities, and whether the provider’s office or facility has accommodations for people with physical disabilities.
States must also consider the need to minimize disruption in any ongoing course of treatment when enrollees transition from FFS to managed care or between MCOs. To improve health outcomes and beneficiaries’ overall care experience, the updated regulation sets standards for care coordination, assessments, and treatment plans. It requires that Medicaid and State Children’s Health Insurance Program managed care plans coordinate to ensure that individuals are able to make smooth transitions between settings of care to enhance access to services, and new beneficiaries complete an initial health risk assessment within 90 days of enrollment.
Additionally, managed care plans must assess enrollees with special health care needs who also may be using long-term services and supports (LTSS), develop a treatment plan based on the assessment, and ensure that the plan is regularly updated. States often require plans to allow a transition period during which an enrollee can continue treatment with a given provider for a given period of time, regardless of whether or not the provider is within the plan’s network. This helps to ensure continuity of care until the managed care plan can develop a transition plan and identify appropriate providers within the network to meet the enrollees’ needs, or to include the enrollees’ providers in the plan’s network. Federal rules also address specific enrollment processes for managed LTSS programs, including a provision that enrollees will be permitted to disenroll from their current managed care plans if they experience a disruption in employment or residence due to a change in their provider of residential or institutional supports.
Medicare and Medicaid have different statutory provisions, administrative procedures, and payment policies, which can complicate coordination of services and payments for dually eligible low-income seniors and people with disabilities who are dually eligible for both Medicaid and Medicare, services and benefits may be coordinated to different degrees under current law.Unlike Medicaid, federal Medicare law requires that a beneficiary’s enrollment in managed care must be voluntary (§1802 of the Social Security Act). State policies therefore determine whether persons dually eligible for both Medicaid and Medicare have the option to enroll in Medicaid managed care, whether enrollment is voluntary or mandatory, and whether certain services such as behavioral health and LTSS are provided by the managed care plan or through FFS. See Medicaid and Medicare Plan Enrollment for Dually Eligible Beneficiaries for more information on managed care enrollment for dually eligible beneficiaries.
CMS has implemented the Financial Alignment Initiative, a demonstration project to improve care and reduce program costs for low-income seniors and people with disabilities who are dually eligible for both Medicaid and Medicare. This demonstration includes a managed care model in which CMS, a state, and an MCO enter into a three-way contract with a blended capitated rate for the full continuum of Medicaid and Medicare benefits for dually eligible enrollees. As of December 2017, 13 states participate in the Financial Alignment Initiative either under a capitated model, a managed FFS model, or an alternative model, with approximately 404,000 individuals enrolled. See Financial Alignment Initiative for Beneficiaries Dually Eligible for Medicaid and Medicare for more information on the overall design of the initiative and information on enrollment, plan and state participation in the demonstration.