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Title: Florida Medicaid managed care : analysis of enrollment procedures and choice counseling
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Title: Florida Medicaid managed care : analysis of enrollment procedures and choice counseling
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Language: English
Creator: Florida Center for Medicaid Issues, University of Florida
Publisher: Florida Center for Medicaid Issues, University of Florida
Place of Publication: Gainesville, Fla.
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Full Text



Florida Center for Medicaid Issues


Letter 2

Appendix I 14


Agency for Health Care Administration
Health Care Financing Administration
Health Maintenance Organization
Supplemental Security Income
Temporary Assistance to Needy Family


March 30, 2001

Mr. Bob Sharpe
Assistant Deputy Director for Medicaid
Agency for Health Care Administration

Dear Mr. Sharpe:

As the State of Florida struggles with the double-digit increases in
Medicaid costs and tighter state budget conditions, the Florida
Legislature and the Agency for Health Care Administration
(AHCA) are seeking to increase efficiency in the Medicaid
program. The Legislature has proposed amendments to Florida
Statutes that would eliminate the requirement for AHCA to
provide choice counseling to Medicaid recipients who are
mandated to enroll in Medicaid Options, Florida Medicaid's
Managed Care Program; Medipass, Health Maintenance
Organizations (HMO), or Provider Service Networks (PSN). In
addition, amendments have also been proposed to limit enrollment
in Medipass to those counties that have fewer than two HMO
choices. The stated intent of this amendment is to "emphasize, to
the maximum extent possible, the delivery of health care through
entities and mechanisms which are designed to contain costs, to
emphasize preventive and primary care, and to promote access and
continuity of care."1

These amendments have the potential to effect AHCA's enrollment
policies and procedures for the Medicaid program. In an attempt
to assess the impact of these changes, we have reviewed the
enrollment process currently in place in Florida Medicaid and
enrollment data for Medipass and contracted HMOs. We have also
reviewed enrollment procedures used by other state Medicaid
programs that have mandatory managed care enrollment for

ProposedAmendment FS Section 409.9121.


Florida statutes currently mandate individuals in specific Medicaid
eligibility categories (TANF 'Temporary Assistance for Needy
Families' and SSI-without Medicare 'Supplemental Security
Income') to enroll in managed care. The legislated requirement to
provide choice counseling to Medicaid recipients was intended to
assist individuals in making a voluntary choice of managed care
plans. The reality is that efforts to assist individuals in choosing a
plan have been largely unsuccessful with Florida reporting a
voluntary enrollment rate of 26% in 19982. Although recent
enrollment data shows that this percentage may have increased to
as much as 40%, a majority of individuals are still being assigned
to a managed care plan after failing to choose within the specified
time limit.

The proposal to eliminate the requirement to provide choice
counseling could provide AHCA with more flexibility in the
enrollment process. There is concern, however, that the
elimination of the choice counseling will lead to more confusion
about plan choices, and even fewer individuals actually choosing a
plan. In evaluating the enrollment processes of other states with
mandatory managed care, there is great variability in the rate of
voluntary enrollment and the mechanisms used to provide
recipients with information on managed care plan choices.

Although the use of enrollment brokers has become the most
common method among states to educate and disseminate
information to Medicaid recipients required to enroll in managed
care, there are states that successfully use other practices. The
enrollment processes for the states of Oregon and Wisconsin have
been reviewed in-depth for this report because of their use of
innovative models to enroll recipients in managed care programs
and the effectiveness of these models.

The state of Oregon has achieved 100% voluntary enrollment of
mandated populations in its managed care plans without the use of
an enrollment broker or contracted agent. Oregon's Medicaid

2 Mandatory MedicaidManaged Care-Plan and Enrollee Perspectives on the
Enrollment Process in the Kaiser Commission on Medicaid and the Uninsured
(this report was prepared by Kathleen A. Maloy, JD, PhD of the George
Washington University Center for Health Services Research Policy, October

program, Oregon Health Plan (OHP), requires individuals to
choose a managed care plan in its application for eligibility.
Because OHP requires individuals to choose a plan as a
precondition of eligibility, there is an additional benefit; there is no
lag time in which recipients are in traditional fee for service plans.

Although Florida requires all TANF and SSI-without Medicare
eligibles to enroll in managed care, the 90-day window allows
these recipients to remain in the fee for service plan until a
managed care plan has been chosen or assigned. Because of this
situation, Florida only averages approximately 85% enrollment of
mandatory populations in any given month.

Another state using unique enrollment mechanisms is Wisconsin.
Although Wisconsin uses several contracted agents to perform
various functions in the enrollment process, they are not the first
step in the process. All Medicaid recipients in the mandatory
eligibility categories are auto-assigned to a managed care plan as
soon as eligibility is determined. Recipients are notified by mail of
their eligibility status and the managed care plan to which they
have been assigned. The hotline for the enrollment broker is
provided to recipients on the eligibility/enrollment notice for those
who do not want to accept the assigned managed care plan or who
want to learn more about the plans/choices. The auto-enrollment
process serves as an incentive for recipients to make a choice if
they are not satisfied with the assigned plan.

The mechanisms used by these states allow their Medicaid
programs to achieve the maximum cost-saving benefits of
mandatory managed care while preserving the opportunity for
Medicaid recipients to choose a plan.

BACKGROUND As mandatory enrollment in managed care plans has become more
prevalent in Medicaid programs throughout the United States over
the last decade, the importance of information and choice for
enrollees has grown. "The enrollment process provides an
important opportunity for states and managed care plans to educate
beneficiaries about the concept of managed care, how to access
services, [and] how to 'navigate' the Medicaid Managed care
system". Since the concept of managed care is so different from

the concept of traditional Medicaid Fee For Service plans,
providing the necessary information to recipients is key to the
success of managed care's cost containment strategies. The best
way to provide this information to recipients, however, has been

Many state legislatures and watchdog groups believe there to be a
conflict of interest for HMOs/health plans to provide the
information directly to potential enrollees. Predatory marketing
tactics by some managed care organizations have led many states
to restrict this type of direct marketing.3 Some states shifted this
responsibility to the eligibility counselors and found that many did
not have the necessary knowledge of managed care to educate
recipients, resulting in the need for additional training for
eligibility staff.4 Increasingly, states, like Florida, have chosen to
contract out these services to enrollment brokers. According to a
survey by the National Academy for State Health Policy, the
number of states using enrollment brokers increased by 55%
between 1996 and 19984. Based on the data available, however,
states using enrollment brokers have not necessarily been more
successful in achieving higher voluntary enrollment rates. States
with enrollment process similar to that used in Florida, report
voluntary enrollment rates ranging from 50% in Michigan, 60% in
Maryland, and over 70% in some areas of California. As a result,
state Medicaid programs are still searching for the most effective
and efficient mechanisms to achieve voluntary managed care
enrollment for mandated populations.

ENROLLMENT BROKERS Since the inception of Medicaid managed care programs, State
governments and Medicaid programs have faced many challenges
in enrolling Medicaid clients into managed care plans or primary
care case management. Some of the difficulty arises from
voluntary verses mandatory enrollment requirements, lack of
adequate managed care delivery systems and the demographics of

3 '.. ' '. -, s Choice: Lessons From ManagedMedicaid in the Health Affairs
(by Irene Fraser, Elizabeth Chait, and Cindy Brach, \,. t,, !.. ctober, 1998).
4Medicaid Managed Care Enrollment and Disenrollment: The Experience of
Four States in the National Academy for State Health Policy (prepared under a
contract with Cornell University ;hi. .,hi a grant from The Pew Charitable
Trusts by Deborah Curtis, July 1999).

the population being served. In hopes of acquiring economies of
scale and expertise in educating consumers, many states have
contracted with enrollment brokers to handle their enrollment

There are many obstacles for enrollment brokers to overcome in
providing their mission of educating, motivating, and voluntarily
enrolling Medicaid clients into managed care plans. Lack of
sufficient and correct information is a major hurdle for enrollment
brokers. For example, in the electronic transmission of new
Medicaid eligibility information from the state to the enrollment
broker, client telephone numbers are often not included or are
incorrect. This delays efforts to expeditiously contact new
recipients to initiate enrollment proceedings.

In addition to telephone efforts, enrollment staff send letters to
"new eligibles" with guidelines on choosing a managed care plan
and instructions for contacting the enrollment broker within
required time frames.

Mandatory assignments or auto-assignments to managed care plans
are made if new Medicaid members fail to make a choice. In some
states, the state is responsible for making the mandatory
assignment even though an enrollment broker has been contracted
to handle the enrollment process.

In a study conducted by the Kaiser Commission on Medicaid and
the Uninsured, beneficiaries reported that the single most
important factor in selecting a Medicaid managed care plan is the
make-up of the primary care physician provider network.1 Even
though recipients state that this is their highest priority, the process
is so complex that confusion is often the result. In some states, this
decision is made during the application process with the governing
agency. Other areas use enrollment brokers to coordinate this
selection process. In Florida, Medicaid members must contact
their chosen managed care plan to select their primary care
physician. This selection is sometimes delayed due to lack of
phone service, difficulty in comprehending the managed care
process and/or lack of interest. If printed provider directories are
distributed to new enrollees, the information may not be reliable
due to constantly changing provider networks. Since health plans

are often required to supply printed materials in advance, it is not
feasible to maintain accurate information.


The state of Florida operates its Medicaid managed care program
through a 1915(b) waiver obtained from the Health Care Financing
Administration (HCFA) in 1991. In 1998, the state decided to
contract with Benova, Inc. to provide enrollment services and
choice counseling to Medicaid beneficiaries. The three year
agreement commenced on 7/1/98 and the term ends on 6/30/01.
The total contract amount is $39,687,206 and payment is cost-
based reimbursement. Thus far, payments made to Benova, Inc.
were $11,993,530 for work completed 7/1/ 98 to 6/30/99 and
$13,643,530 for work completed 7/1/99 to 6/30/00.

Under this contract, Benova, Inc. is responsible for the initial
choice counseling contact with new Medicaid eligibles in both
mandatory and voluntary enrollment categories. Once an
applicant is determined to be eligible for Florida Medicaid,
information is electronically transmitted to the broker. These
updates are provided to the broker daily. Within five days of
receipt of this information, the broker sends voluntary and
mandatory enrollment packets to recipients as appropriate. In the
packet, information on the available plans, a hotline phone number
for more information, and enrollment forms are included.
Recipients that are required to enroll in managed care have ten
days in which to respond to the initial contact. If no response is
received, a reminder letter is sent. After 45 days (from the initial
eligibility date) with no response another letter is sent. If a
response is still not received, the broker attempts to contact the
individual by phone. If the 90-day time limit expires with no
choice made, the information is returned to AHCA. AHCA retains
the responsibility of making mandatory enrollment assignments
when recipients fail to choose a plan within the allotted time frame.

Benova's Florida Community Development and Outreach section
is charged with the mission of reaching Florida's Medicaid
recipients, encouraging them to learn about managed care, and
teaching them to how to select a managed care plan, choose a
primary care physician and to enroll in a plan of their choice. The
outreach staff conducts outreach sessions throughout the state of

Twenty-five field choice counselors and four field supervisors are
based in North Florida-Tallahassee, Central Florida-Tampa and
South Florida-Miami and work with in collaboration with
community-based organizations. The primary goal of this outreach
is to increase the targeted population's awareness of the need to
make a voluntary choice. In addition to community presentations,
enrollment staff will meet face-to-face with recipients to assist in
the managed care plan selection process. However, as a Benova
representative in Miami explained that although some beneficiaries
wanted a "face-to-face interaction...the vast majority of people, if
they have a choice, look for a fairly businesslike discussion over
the phone."5

Benova reports that some information problems create difficulty in
contacting recipients. For example, when eligibility lists are
transmitted electronically to the enrollment broker, client telephone
numbers are not included in the information sent. For three years,
the Agency for Health Care Administration has attempted to have
this information included in the eligibility transmittals, but have
been unsuccessful in doing so. If this information could be
included, initial contact efforts would be expedited, and the cost of
staffing resources spent in getting phone numbers would be greatly

In addition, enrollment efforts are hampered by the fact that some
recipients are not capable of comprehending the printed enrollment
materials mailed to them. Some households do not have
telephones and have to rely on the good will of neighbors or other
family members to communicate or receive information. Lack of
interest and unresponsiveness by Medicaid clients continue to
impede enrollment goals.

5 Communwealth Fund Field Report-E. hI. i,,.n Medicaid Beneficiaries About
Managed Care: Approaching 13. Sue A Kaplan, Jessica Greene, Chril Molnar,
Abby Bernstein, and Susan Ghanbapou. May, 2000.

OREGON HEALTH PLAN A more in-depth look at the Oregon Health Plan reveals a strong
commitment to the use of managed care. The enrollment
procedures and eligibility policies are focused on the purpose of
enrolling all recipients in managed care and providing stability of
enrollment for both recipients and health plans. Separate cost data
for the enrollment portion of Oregon's Medicaid program is
unavailable since the process is integrated with all other functions
of the program.

Oregon operates its Medicaid managed care program through a
HCFA 1115 waiver. Their application for Medicaid eligibility
requires all applicants to choose a managed care plan in advance of
the eligibility determination. In order to assist individuals in
making this choice, the state provides printed guides explaining
managed care and comparison charts of the available plans. The
guides provide information on the basic services all plans are
required to provide and survey data on satisfaction and quality for
each plan. On a county by county basis, a comparison chart is
included in the brochure which explains the basic differences
between plans, such as which hospitals and pharmacies are
available and any extra or optional services provided by the
planss. Oregon strictly prohibits direct marketing to individuals
by health plans. In the event that an applicant has additional
questions, toll-free phone numbers for each plan are provided in
the brochure. Individuals may also discuss plans and options with
eligibility counselors at regional offices. If an applicant fails to
make a choice on the application, the application is denied and
returned to the individual with an explanation of the reason for
denial. Oregon reports that this occurs with approximately 5% of

Oregon has implemented other policies to ensure health plan
stability and continuity of care for recipients. Once an individual
chooses a health plan (before eligibility is even determined), they
are locked-in to that plan for a minimum of six months. Recipients
are made eligible for six-month intervals and are not allowed to
change plans, except in rare circumstances. The state provides an
open enrollment period bi-annually in which recipients can change
plans. These policies provide health plans with stability of
enrollment, while simultaneously providing recipients with
continuity of care.

WISCONSIN MEDICAID The Medicaid managed care program in the state of Wisconsin is
operated with a 1915(b) waiver obtained through HCFA.
Although Wisconsin uses an enrollment broker for some functions
in the enrollment process, it is not the traditional model used by
other states contracting with a broker. Wisconsin did not provide
data on the contract costs associated with its enrollment processes.

Wisconsin's Medicaid program has divided up the enrollment
process among the state's Department of Health and Family
Services and two contracted agents. The Department of Health
and Family Services is responsible for the application process and
eligibility determination. Once individuals are determined to be
eligible, the state provides that information to its fiscal agent. The
fiscal agent is responsible for sending out the enrollment
information to recipients. The system used by the fiscal agent, pre-
determines the auto-assignment of individuals to plans. The auto-
assignment system is random to ensure that each plan gets a "fair
share" of enrollees.

The enrollment information provided to recipients states the plan
name to which they have been auto-assigned. Recipients are given
a toll-free number to contact the enrollment broker if they wish to
change their assignment or learn more about the plans. Recipients
are allowed 30 days in which to make a change and are locked-in
to the auto-assigned or chosen plan for 9 months. Eligibility is
redetermined on an annual basis.

The auto-assignment mechanism in Wisconsin's Medicaid
managed care program informs recipients of the predetermined
plan selection and allows them to choose another plan if preferred.
This process provides Wisconsin's Medicaid program with an
efficient enrollment process for getting recipients into managed
care plans.


The design of the enrollment process is a key factor determining
the ultimate success and effectiveness of Medicaid managed care.
Both Wisconsin and Oregon have designed their managed care
enrollment processes to be closely integrated with eligibility
determination. This feature allows the programs to minimize
communication problems and delays, and enroll recipients into
plans efficiently.

No matter how the program is designed, another important
component is effective information systems. All participants in the
Medicaid managed care enrollment process; state agencies,
contracted agents, health plans, and recipients, need accurate and
up-to-date information in order to perform their roles. When
participants do not have access to needed information, the whole
process is delayed and becomes ineffective.


The information in this report is intended to provide insight into
innovative and successful enrollment procedure that could enhance
Florida Medicaid's ability to benefit from its managed care
program. Although the states examined in detail may face
different challenges than Florida, their experience provides
examples of alternative policies that could be useful in dealing
with the elimination of the requirement to provide choice

Copies of this report will be made available to others at your

If you or your staff have any questions about this report, please call
me at (352) 392-0675. This report was prepared by Ms. Renee
Dubault and Ms. Smaro Bloodworth.

Robert G. Frank, Ph.D.
Director, Florida Center for Medicaid Issues
College of Health Professions
University of Florida

Appendix I


To determine the enrollment processes used by other states we
examined state policy literature on Medicaid Managed Care from
health care journals, state policy organizations, and other various
sources. Internet sites from several states provided additional
detailed information on Medicaid policies and procedures.

In-depth interviews were conducted with staff from Florida's
Agency for Health Care Administration (AHCA). Florida's
enrollment broker Benova, Inc., Oregon Health Plan, and
Wisconsin's Medicaid program to determine details not available
through published materials.

Analysis of enrollment data for Florida's Medicaid's managed care
plans and Medipass was conducted to determine enrollment rates
for mandatory enrollment categories and overall enrollment

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