Enrollment - Key Considerations

Voluntary vs. Mandatory Enrollment

One of the first decisions states will need to make about the enrollment function is whether or not the program will have voluntary or mandatory enrollment. Note that if enrolling Medicare-Medicaid beneficiaries, Medicare enrollment must always be voluntary. Beneficiaries and advocates may argue for voluntary enrollment in order to preserve beneficiaries’ freedom of choice.  MLTSS contractors will argue for mandatory enrollment in order to ensure sufficient enrollment for a viable and robust program. 

Mandatory programs not only guarantee higher enrollment, they also make it more possible for MLTSS contractors to build a strong network.  If you do decide on mandatory enrollment, beneficiary choice is required at the plan level.  In general, with some exceptions for rural areas, beneficiaries must be offered a choice of two plans.

Managing the Enrollment Function

States will also need to determine who should perform the enrollment function. States with existing Medicaid managed care programs may want to consider extending or modifying existing enrollment capacity to include the MLTSS program. Options include:

• Contracting with a third party enrollment broker
• Having the entity that conducts eligibility (e.g., county or regional office) conduct enrollment

Enrollment Counseling

States should provide enrollment counseling to beneficiaries to help them understand their options. When determining who will provide the counseling, you should ensure that the entity is free from conflicts of interest. If your state is using an enrollment broker or an Aging and Disability Resource Center (ADRC) to perform the enrollment function, this entity may be a natural choice to perform the enrollment counselor function, since it is already involved with enrollment and does not have a financial stake in the beneficiary’s choice.

Level-of-Care Assessments

Payments are likely to be tied to the level of care needed, so it is vital that states guard against conflicts of interest in the care assessment process. Possible options include:

• Third party vendor. Have a third party complete the level-of-care assessments. It may be appropriate to consider having the same vendor that completes the level-of-care assessments under FFS also perform the assessments for the MLTSS program.
  
  
• Approval/audit function. If you determine that you want the MLTSS contractor to complete the level-of-care assessments, consider implementing a robust approval/audit function. This could be completed by the state or contracted out if the state cannot perform this function.

Enrollment Periods

Except for Medicare-Medicaid beneficiaries, Medicaid managed care authorities allow up to a one-year lock-in period. Members who are eligible for both Medicaid and Medicare have the right to change their health plan options on a monthly basis.

Marketing Protections

When designing an MLTSS program, your state will have to consider Medicaid guidelines associated with marketing practices; and if your program will include the dually eligible, Medicare guidelines also apply.

• Medicaid. When writing your MLTSS contract, your state must make sure MCOs meet the federal Medicaid guidelines for marketing protections among managed care plans as described in the Code of Federal Regulations (42 CFR 438.104). The section specifies that plans must:
  
  
  1. first obtain state approval to distribute materials,
  2. distribute materials to enrollees in the entire service area,
  3. ensure enrollees receive oral and written materials upon enrollment,
  4. refrain from activities that would influence enrollment through incentives or disincentives, and
  5. refrain from engaging in door-to-door marketing activities.

In addition to the federal Medicaid regulations, your state may have adopted additional marketing rules. If such rules exist, your Medicaid managed care division will be familiar with them.

• Medicare. Medicare guidelines additionally address general marketing practices and require plans to provide potential enrollees with written information about benefits, services, and rules and procedures associated with the plan. The Code of Federal Regulations (42 CFR 417.428) also prohibits certain marketing practices among plans, including: discriminatory practices, activities that mislead or confuse beneficiaries, practices that incentivize enrollment through gifts or payment, door-to-door solicitation, and practices that result in dissemination of marketing materials prior to a 45-day wait period.

 

 

 

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