Medicaid Managed Care - U.S. Senate Special Committee on Aging

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Beyond identifying and contacting beneficiaries to educate them about the program
and the choices they must make to participate, procedures are required to help
beneficiaries, once enrolled, schedule needed appointments and ensure that they
access services. Educational activities undertaken through the counseling and
enrollment process, and by health plans once a member is enrolled, help
beneficiaries learn how to use the managed care system.
Several states report that enrolling beneficiaries, particularly in mandatory
programs, has been easier than educating new members about managed care.
Education efforts in several states with mandatory managed care programs have
shifted emphasis from choosing a physician or plan to educating about how to access
care and how to use the managed care system. States and plans report that they
have found that they cannot rely on physicians to educate members. One of the
major reasons it can be difficult to use physicians to convey information is that
physicians, for a number of reasons, often spend too little time with members
during office visits to engage in educational activities.
To assist provider's education efforts, some plans now locate their staffs in physician
waiting rooms to work with members. Also, Ohio uses a mentoring process for its
AFDC (TANF) population where enrollees themselves contact other members and
encourage prenatal visits and immunizations for children. Similar arrangements
could work to help members of special populations access services. Minnesota and
Ohio identified the importance of working with community social services
organizations and courts to educate staff of these organizations about how
beneficiaries use HMOs. For example, members were sometimes referred to
non-plan providers for court ordered treatment. If properly informed about
managed care, ancillary agencies, such as social service agencies, can help contact
and inform hard to reach beneficiaries about the importance of accessing health care
services.
State Enrollment Policy Choices
The enrollment and outreach processes should fit within the overall enrollment
structure of the program. In other words, the enrollment process needs to ensure
that beneficiaries understand their enrollment options. These options vary from
state to state. Important components of these options include:
* Will the program be voluntary or mandatory?
* Which subgroups within a mandatory population are excluded from or
may opt out of the managed care program?
States generally select one of three options for the mandatory or voluntary nature of
the program. (1) States may implement a mandatory program under which
beneficiaries that belong to the population served by the program must select a
health plan option. (2) States may implement a voluntary program under which
The National Academy for State Health Pohlcy * 8/97 IV-SO