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

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and Medicare is billed fee-for-service for Medicare services. Cost
sharing for out-of-network services is not covered.
Other states have responded to the need for coordination by limiting their programs
to allow dual eligibles to retain freedom of choice to receive Medicare benefits from
any certified provider. For example, Tennessee enrolls dually eligible beneficiaries
in plans only for services that are not covered by Medicare. In this State, the
Tenn<strong>Care</strong> Bureau notifies plans as new members enroll and identifies new
members who have Medicare coverage. <strong>Medicaid</strong>-only members receive a member
handbook and membership card. However, as previously discussed, dually eligible
beneficiaries are not required to use network providers and do not receive member
handbooks. Instead, they receive membership cards and materials explaining how
to access their pharmacy benefits and other benefits that are not covered by
Medicare.
Tracking Enrollment of Dually Eligible Beneficiaries
In order to coordinate <strong>Medicaid</strong> enrollment decisions with Medicare, state
enrollment systems must be able to identify beneficiaries that have enrolled in a
Medicare HMO. A number of states receive regular information from HCFA or
health plans themselves to track Medicare HMO enrollment. Arizona, California,
Florida, Kentucky, Louisiana, Massachusetts and Texas indicated that tapes are now
being received from HCFA. A memorandum of agreement is pending between
HCFA and Maryland to share enrollment information. Ohio has requested on-line
access to the information. Alabama and Illinois receive monthly lists from the
Medicare HMOs. Generally, most states have not requested these tapes, or are not
aware that HCFA will make them available.
Disenrollment
Critics of managed care are concerned that financial incentives to enroll healthy
members (biased selection) may lead to disenrollment of members who are hard to
serve and have high utilization patterns. Given the wide variation in costs between
individual members of special populations this concern becomes even more acute
in those programs that serve the elderly and persons with disabilities.
Partially in response to this concern, <strong>Medicaid</strong> agencies in Arizona and Oregon
approve all disenrollments to ensure that plans are not encouraging difficult to
serve or costly members to leave the plan. In these two states, state staff track
disenrollment rates as a quality improvement measure and to determine whether
disenrollment is voluntary or whether plans may be forcing people with high
utilization or complex needs out of their plan. Most disenrollments in Oregon have
been members with substance abuse conditions who are noncompliant. Health
plans send documentation to OMAP concerning what services and interventions
were planned and how they were implemented. State officials may consult with the
plan and recommend further interventions before disenrollment is approved.
The National Academy for State Health Policy e © 8/97 IV-60