A Report from Families USA
October 1997

Promoting Consumer Choice in Medi-Cal Managed Care

NOTE: The original version of this report contains tables which are not posted in this on-line version. For further information regarding print copies of this report contact Families USA.

Table of Contents

EXECUTIVE SUMMARY

INTRODUCTION
Section I: OUTREACH AND ENROLLMENT:HOW OTHER STATES PROMOTE MANAGED CARE PLAN SELECTION

Allow Time to Educate the Community about the New SystemProvide Both Written and Oral Information that Explains the Enrollment Process and Helps People Choose PlansEnsure that Information is Culturally and Linguistically Appropriate, and that Materials and Counseling Are Available to Blind and Hearing Impaired Persons.Use Neutral Counselors to Advise Beneficiaries of Plan ChoicesLessons Learned From Conducting Enrollment Through Brokers or Counselors

Section II: ENROLLMENT IN CALIFORNIA'S TWO-PLAN MODEL

Enrollment Procedures in California Two-Plan CountiesWhen Only One Plan is OperationalWhen Both Plans Are Operational

ENROLLMENT RECOMMENDATIONSENDNOTES

EXECUTIVE SUMMARY

California is in the midst of moving 3.4 million Medi-Cal beneficiaries in 12 counties into a new managed care delivery system, called the "Two-Plan Model." Under this system, most families with children who receive Medi-Cal must enroll in a Health Maintenance Organization (HMO). They can choose between at least two HMOs for their care. As in other states and counties that require Medicaid beneficiaries to enroll in managed care, California gives Medi-Cal beneficiaries a certain amount of time to select a health plan; if they do not make a selection within this time, the state assigns them to a managed care plan by default. In 1996, the federal government found default assignment rates as high as 80 percent in Alameda County, meaning that only 20 percent of Alameda Medi-Cal beneficiaries affirmatively selected their managed care plan. In August 1997, default assignment rates in fully operational Two-Plan Model counties ranged from 71 percent in Fresno to about 29 percent in San Joaquin County.High default assignment rates are often an indicator of serious enrollment problems. The U.S. General Accounting Office in a 1996 report pointed out that although there are some differences in state methodologies for calculating assignment rates, "assignment rates appear to be the best available indicator for measuring the effectiveness of a state's education and enrollment activities." Default assignees may experience disruptions in treatment when they do not follow their treating physicians into health plans. People who are assigned to plans by default tend to use services less than those who select their own plans, resulting in state payments to plans that are providing few services.States that have mandated managed care enrollment for Medicaid beneficiaries have had varying experiences with enrollment. Some have minimized default assignment rates to about 10 percent. Although California faces perhaps the most difficult enrollment task due to its sheer size and its geographic and linguistic diversity, lessons from states that have made fairly smooth transitions to Medicaid managed care can help inform California's enrollment process.Based on a review of literature and enrollment contract provisions and interviews with state officials, advocates, and enrollment contractors in a number of states, the Medi-Cal Community Assistance Project offers the following recommendations for California:1. California should set a goal for voluntary choice of 80 percent. California should suspend default assignments (allowing beneficiaries who do not select a plan to stay in fee-for-service Medi-Cal), and increase outreach in any county exceeding a 20 percent default rate. A number of states have now achieved voluntary selection rates exceeding 80 percent; some states have achieved voluntary selection rates close to 90 percent.2. California and its enrollment contractor, Maximus, should work with community organizations to enhance outreach. California should establish workgroups of "stakeholders" (including community groups and Medicaid beneficiaries) regarding enrollment in all counties. Community-based organizations can assist with education, outreach, and follow-up to nonrespondents. A "stakeholders" group has now been formed in Los Angeles regarding the enrollment process and community-based organizations are increasingly involved in outreach and education. Similar workgroups should be required in all Two-Plan Model counties.3. California should aggressively follow up to reach Medi-Cal beneficiaries who have not responded to mailings with enrollment information and have not chosen a plan. In some states, six or more attempts are made to reach beneficiaries by mail to encourage them to make a choice. Additionally, some states and enrollment brokers have developed plans to track undelivered mail, call or hand-deliver notices to nonrespondents, and utilize community-based organizations in outreach. When California defaults a Medi-Cal beneficiary into a plan not of his or her choosing, the beneficiary may unwittingly go back to a former provider the next time care is needed. In these cases, California should pay the provider for one visit and the provider should advise the beneficiary to contact an enrollment counselor. The Counselor should advise the beneficiary about the assigned managed care plan, enrollment choices, and disenrollment rights.4. The Two-Plan enrollment form and all enrollment materials should be speedily translated into all threshold languages and field-tested prior to use. Until the enrollment form is available in all threshold languages, California should halt default assignments. The enrollment form is the vehicle by which Medi-Cal beneficiaries select both a plan and a provider. It is not yet available in languages other than Spanish and English. The lack of a translated enrollment form is a major obstacle for populations who have no ability to complete forms in Spanish or English. They risk being assigned to inappropriate health plans by default.5. Before mandatory Medi-Cal managed care enrollment begins in a county, California should provide outreach and education for a designated period. The Department of Health Services should encourage community groups and consumers to review proposed public education campaigns and incorporate their suggestions, field-test all public education materials, send multiple notices to beneficiaries, and implement intensive outreach plans at least four months before default assignments begin. States that report high voluntary plan selection rates have allowed from 4 to 18 months for outreach before making default assignments.6. California should revise its default assignment methods to protect beneficiaries. When beneficiaries do not select a plan, California should use information about beneficiaries' previous providers to assign beneficiaries to both a plan and a primary care provider. This information is available through claims data.7. California and Maximus, the state's enrollment broker, should evaluate staffing needs to ensure that the enrollment contractor will have sufficient staff and phone lines to counsel beneficiaries about plan choices during peak enrollment periods. Several states experienced serious enrollment problems when enrollment brokers were unable to respond to higher-than-anticipated volumes of calls. California and Maximus should carefully evaluate staffing needs in counties that will have a large number of Medi-Cal beneficiaries in managed care and should be prepared to add staff and phone lines quickly if demands on the enrollment broker exceed expectations.8. California should improve its written materials and oral presentations about managed care for Medi-Cal beneficiaries. Following examples set by other states, California should consider developing comparative charts that would help beneficiaries choose plans, and lists of questions that beneficiaries might consider in comparing plans. California should field-test all written materials in all threshold languages, and improve the Health Care Options presentation.9. Maximus or the State of California should provide evening and weekend phone service to answer enrollment questions.10. California should finalize procedures for expedited and retroactive disenrollments and educate beneficiaries, advocates, social services providers, and community-based organizations about these procedures. Medi-Cal beneficiaries who need to disenroll quickly include people who need services not covered under managed care; foster care children; long-term care beneficiaries; people who have moved; people under the continuing care of a provider not available through their plan; people assigned to distant primary care locations; and people who rely on specialists, pharmacies, and hospitals not in their assigned plans.

INTRODUCTION

This report examines strategies other states have used successfully to encourage Medicaid beneficiaries to select managed care health plans, thereby minimizing default assignments. The purpose of this report is to inform policymakers, administrative agencies, contractors, advocates, and community organizations, based on other states' experiences, of ways to improve the education and enrollment of Medi-Cal beneficiaries to ensure a smooth transition to managed care.California is in the midst of moving 3.4 million Medi-Cal beneficiaries in 12 counties into a new managed care delivery system, called the "Two-Plan Model."1 In the 12 Two-Plan Model counties?Alameda, Contra Costa, Fresno, Kern, Los Angeles, Riverdale, San Bernadino, San Francisco, Joaquin, Santa Clara, Stanislaus, and Tulare?Medi-Cal beneficiaries will have a choice of at least two HMOs: a "Local Initiative Plan" and a "Commercial Plan." The Commercial Plan is a private sector health plan selected by California's Department of Health Services. The Local Initiative is a managed care plan organized by the county. If a county does not establish or sponsor a Local Initiative, the state will contract with a second commercial plan.In California's Two-Plan Model counties, as in many other states and counties that require Medicaid beneficiaries to enroll in managed care plans, beneficiaries are given a certain amount of time to select a health plan. If they do not affirmatively make a selection, the state (through its contractor) assigns them to a managed care plan by "default."Through strong outreach and careful enrollment procedures, a number of states have been able to minimize default assignments to about 10 percent of the enrolled population. Put another way, about 90 percent of Medicaid beneficiaries have affirmatively selected managed care plans. By contrast, during 1996, enrollment problems plagued many California counties that implemented the Two-Plan Model. The federal Health Care Financing Administration (HCFA) found default assignment rates as high as 80 percent in Alameda County (that is, only 20 percent of Medi-Cal beneficiaries selected managed care plans).2Recent statistics show widely varying default rates among fully operational Two-Plan Model counties. In the month of August 1997, default assignments ranged from 71 percent in Fresno County to about 29 percent in San Joaquin County.3The Problem with High Default AssignmentsHigh default rates are a problem for three reasons. First, high default assignment rates indicate that beneficiaries do not understand a new managed care system. In order for managed care to fulfill its promise of promoting continuous preventive care and coordinating health care services, beneficiaries must understand how to use their new health plans. They need to know how to obtain primary care services, when to seek referrals, how to get specialty care, and how to get health services that are provided outside of the managed care system. Beneficiaries who affirmatively select plans usually do so after reading materials about their choices or listening to a presentation about managed care. Default assignees include many people who have not heard managed care presentations or read plan materials. Without understanding the change in their health care, beneficiaries may go to the same clinics they have always used?only to learn that they have been assigned to a managed care plan that does not include these providers.Second, default enrollments can seriously disrupt ongoing treatment. One of the purposes of managed care is to promote continuous relationships with primary care providers so that people will get good preventive care and doctors will know their medical histories. When they choose their plans, Medicaid beneficiaries who have established relationships with physicians in the past are often able to follow their current providers into managed care plans. Beneficiaries who are assigned to plans by default usually are unable to continue with their physicians. In order to re-establish care with their former physicians, default assignees must often disenroll from the health plan to which they were assigned and re-enroll in another. Default enrollments may also lead to inappropriate assignments to physicians located far from beneficiaries' homes or to children in the same family assigned to different plans or providers.Finally, states pay capitated rates to managed care plans based on the number of people enrolled, regardless of how many people actually use the plans' services. People who are assigned to plans by default tend to use services less than those who select their own plans, resulting in state payments to plans that provide few services.4 Therefore, in order to use Medicaid dollars effectively, states must ensure that enrollment brokers have effectively minimized default assignments.Two-Plan Model Enrollment ProblemsCalifornia's task of moving beneficiaries into managed care is more difficult than the task many states have faced both because of California's sheer size5 and geographical diversity and because of the cultural and linguistic diversity of its Medi-Cal population. While in many states the great majority of Medicaid beneficiaries speak either English or Spanish, California's Medi-Cal beneficiaries include members of at least 18 major ethnic groups.A previous report by the Medi-Cal Community Assistance Project, Rush to Managed Care: The California Two-Plan Model for Medi-Cal, outlined some of the problems California experienced with enrollments in 1996. According to community groups, problems resulted from insufficient notice to beneficiaries about enrollment choices, rapid enrollment schedules, inadequacies in enrollment counseling and informational materials, default assignments into plans and providers that were not geographically accessible, the lack of translated written materials, errors and backlogs in processing enrollments, problems assigning people to primary care providers once they were enrolled in a plan, and the lack of rapid or emergency disenrollment procedures for people defaulted into managed care plans. Due in part to the enrollment problems, HCFA halted default assignments in Los Angeles County.California is taking a number of steps to improve enrollment in the Two-Plan Model. According to state officials, California will try some of these new approaches in Los Angeles, and if successful, will implement them in other Two-Plan Model counties as well.About This ReportThis report begins with a look at other states' enrollment processes. California is using some, but not all, of the approaches that have worked in other states. The second section of this paper describes California's enrollment process in Two-Plan Model counties. We conclude with recommendations for California, based on the experiences of Two-Plan Model counties and of other states. The Medi-Cal Community Assistance Project shared a draft of this report with the California Department of Health Services and with the federal Health Care Financing Administration, and we have made revisions in response to their comments.

Section I

OUTREACH AND ENROLLMENT:

How Other States Promote Managed Care Health Plan Selection

This section presents the Medicaid managed care enrollment experiences of selected states. These experiences can inform discussions now taking place among state officials, health plans, consumers and community organizations in California about how to improve beneficiary education in Two-Plan Model counties. The state experiences portrayed in this section are gathered from the literature, a review of contracts and requests for proposals for enrollment brokers in 13 states, and interviews with advocates, enrollment contractors, and state officials.Other states have minimized default assignment by:

allowing time to educate the community about the managed care system;

providing both oral and written information such as videos on managed care and written plan comparison charts to explain the enrollment process and to help people choose plans;

ensuring that oral and written information is culturally and linguistically appropriate and that material and counseling are available to beneficiaries who are blind or hearing-impaired;

using neutral benefits counselors and ensuring that staff and phone lines are adequate to counsel beneficiaries about plan choices; and

establishing standards for enrollment brokers, including
-financial incentives to achieve high voluntary selection rates,
-clear responsibility to assist with primary care provider as well as plan selection,
-standards for phone counseling that require phone service during daytime, evening, and weekend hours,
-mandatory follow-up by phone or in person with nonrespondents, and
-requirement that enrollment contractors work with community groups and initiate and implement outreach plans.

If people still do not choose plans, states can minimize enrollment problems by:

correcting any problems in the education and enrollment process;

considering beneficiaries' needs in making default assignments?matching them, for example, with plans that include their previous providers or with providers who are geographically close and with plans that can meet their language needs; and

providing for expedited and retroactive disenrollments.

Allow Time to Educate the Community about the New System

A successful managed care enrollment process requires significant lead time so Medicaid beneficiaries, community organizations, and health providers can be informed about the move to managed care. States that report high voluntary plan selection rates have allowed between 4 and 18 months for outreach before making default assignments. Firms that contract with states to provide outreach and enrollment assistance also recommend beginning community outreach several months before managed care enrollment begins. Outreach techniques include:

sending many written notices to Medicaid beneficiaries,

educating community agencies and providers that serve Medicaid beneficiaries,

counseling beneficiaries during Medicaid recertification appointments,

making presentations at health fairs,

conducting media campaigns,
door-to-door canvassing by local community groups, and

using videos.

Community Education Prior to Enrollment

-Initially, Utah Medicaid beneficiaries could choose between primary care doctors who were paid fees for each service (PCCM) and HMOs. During the 18-month transition period, most doctors who served patients with Medicaid coverage signed up with HMOs, making it possible for these patients to continue seeing their regular doctors under capitated managed care.- In Rhode Island, the state sent notices with families' welfare checks for three consecutive months before enrollment in a new managed care system began. Actual enrollment took place over the course of a year. People usually enrolled in managed care plans at the time they re-certified for Medicaid.- During the first phase of its mandatory program, New Jersey's Medicaid agency and its enrollment broker, Foundation Health Federal Services, spent four months educating communities generally about the transition to managed care. The broker then sent notices to beneficiaries about the need to select managed care plans and gave them another four months to make selections before auto-assigning them.* As reported by the State Medicaid Bureaus.

In addition to informing Medicaid beneficiaries about the new managed care program, states should educate community agencies that counsel Medicaid beneficiaries. They should also educate the provider community. Most states require only part of their Medicaid population to enroll in managed care?for example, families with children but not older persons or persons with disabilities. If a doctor's receptionist does not understand who is and is not required to enroll in managed care, the doctor's office may mistakenly turn away patients who still have the right to fee-for-service care. Educating providers also helps to maximize the number of doctors who will contract with managed care plans to serve Medicaid patients.

Videos can help alert the community to a coming change in Medicaid. Several states use videos to describe plan choices. Videos can also help to educate consumers about potential problems under managed care and their solutions.Community-based organizations can both help states identify gaps in beneficiaries' understanding of managed care and assist with outreach. For example, the Community Service Society of New York interviewed 421 Medicaid beneficiaries in income support centers about their knowledge of and experiences with managed care.6 The Society found significant gaps in Medicaid beneficiaries' understanding of managed care and enrollment options. For instance, most managed care enrollees chose the first plan that approached them rather than considering other options. Although at the time of the survey, enrollment in Medicaid managed care was voluntary, 31 percent of respondents said they were told they had to sign up for a plan to remain eligible for Medicaid. Only 63 percent of respondents in managed care reported that they were told they could only use the network providers. Just 45 percent reported that they were told how to get specialty care and 18 percent that there were restrictions on using emergency rooms. Few were informed of plans' complaint procedures. The Community Service Society has launched its own managed care education project to address these problems. It has produced Your Health Plan Handbook: How to get the health care your family needs from a managed care plan (1996), offers workshops on managed care, and has sent trained volunteers to community-based organizations.California's Community OutreachCalifornia has not adopted a statewide plan regarding pre-enrollment outreach in Two-Plan Model counties. According to the state's approved waiver, the state is supposed to mail enrollment packages to beneficiaries three months before full implementation of the Two-Plan Model in a county. However, in its pre-implementation review of the waiver program in Santa Clara County, HCFA found that this condition had not been met in January 1997.7In early 1997, the state conducted a brief public education campaign. As part of that effort, the state will continue to distribute brochures, posters, and videos. In May 1997, after HCFA halted default assignments in Los Angeles, California drafted a further beneficiary education campaign for Los Angeles. The campaign would include a media campaign and increased outreach presentations (to be offered both by the enrollment broker and by contracting community-based organizations). The state also asked managed care plans to step up provider education activities in Los Angeles, and worked directly with provider organizations to reach providers not participating in health plans. Consumer groups have asked for field-testing of all educational materials, more definition of the outreach campaign in Los Angeles and work with community-based organizations on other aspects of outreach and education.8 Pre-enrollment outreach campaigns are needed in other counties as well.Provide Both Written and Oral Information that Explains the Enrollment Process and Helps People Choose Plans

Prior to enrollment, beneficiaries need written information explaining whether they will need to select a managed care plan, how they can continue seeing their current providers, who is not required to select a plan (if some people are exempt from mandatory participation), whether they will be assigned to a plan if they do not make a selection, and what to do and where to call or go for more information. As discussed below, states should not rely only on written notices for this information?the enrollment process is smoothest when it is coordinated with the periodic appointments required to re-certify eligibility for Medicaid and when states or brokers offer face-to-face counseling and follow-up phone calls. If people do not schedule an enrollment appointment or select a plan after their first notice, they should receive further notices and additional time to select plans. If the state then assigns people to plans, the assignees need further notice about the assignment, about how to use managed care, and about their rights to change plans.To aid in enrollment, states can compile materials submitted by plans or they can produce materials comparing the various plans themselves. Rhode Island provides enrollees with a table comparing plans. Enrollment counselors in Rhode Island help people complete a worksheet listing each family member's doctors and pharmacies and the plans that include each.Written information should include:

• the names, locations, specialty areas, language capabilities, and qualifications of providers that serve Medicaid beneficiaries under a plan (this information should be updated regularly);
  
• the number to call to find out whether a primary care provider's practice is accepting new Medicaid enrollees;
  
• a list of hospitals affiliated with each plan;
  
• an explanation of how to get medicines and the locations of HMO pharmacies, if applicable;
  
• any differences in the drugs covered by the plan if the state permits variation;
  
• procedures for getting specialty services;
  
• a list of any services not provided through the plan itself but that members may still obtain under Medicaid and an explanation of how to get those services;
  
• any additional benefits provided by the plan such as van transportation to doctor appointments or child care during doctor appointments;
  
• procedures for getting urgent and emergency care;
  
• a simple explanation of how managed care plans differ in structure, etc.;
  
• an explanation that people may receive family planning and reproductive health services at the provider of their choice unless the state has been granted an 1115 waiver by the federal government that specifically waives this choice (California has not);
  
• complaint and grievance procedures;
  
• where to call with questions; and
  
• where to call for help.

Community groups can aid in preparing written materials. In Maryland, the enrollment broker contracts with local community-based organizations to write materials about managed care issues for special populations. For example, Advocates for Children and Youth, in Baltimore, Maryland, has written both short fact sheets and a booklet of questions concerning managed care for children with special needs.Partners in Health, with funding from the Maryland Developmental Disabilities Council, published a workbook on managed care for people with disabilities, which includes questions people with disabilities should ask in comparing plans.9California's Written InformationWe reviewed an enrollment packet used in Los Angeles, California in 1997. It includes provider directories, which show specialties and language capabilities of each provider as well as admitting hospitals. The directories do not mention the possibility that some providers will not accept new patients. Instructions explain how to complete enrollment forms and where to call for help. The enrollment packet does not include any simple explanation about what it means to be in a managed care plan; how the process for obtaining specialty care, pharmacy services, or other medical services will change; or how (other than locating a provider) someone might choose among available plans. Information about emergency care and grievances is in an enclosed booklet entitled "Problems with Medi-Cal?" Plans subcontracting with LA Care have produced individual charts listing hospitals and plan features, but these are not compiled into a comparative chart.Ensure that Information is Culturally and Linguistically Appropriate and that Materials and Counseling Are Available to Blind and Hearing-Impaired Persons

Some states have insisted that enrollment counseling staff speak the languages of Medicaid beneficiaries and that written materials be easily readable. Massachusetts, for example, requires that enrollment counseling staff reflect the cultural, demographic, and physical diversity of its Medicaid population. Enrollment materials in Pennsylvania and New York must be written on a fourth-grade reading level. Some states pretest written materials or ask a committee of Medicaid beneficiaries to review them. Materials must be in large print in Georgia and in Braille in West Virginia.California Linguistic RequirementsCalifornia requires linguistic services if the population speaking a particular language is more than 3000 in the service area, more than 1000 in one zip code area, or more than 1500 in two contiguous zip code areas. Linguistic groups of these sizes are called "threshold" language groups. Failure to translate written materials and to produce materials at appropriate reading levels continues to be a problem. In 1996 and early 1997, only some of the information in enrollment packets was translated. California has taken steps to remedy this problem by augmenting existing contracts to revise, translate and field-test the enrollment materials. As of July 1997, the enrollment form itself is still only available in English and Spanish, presenting a major barrier to enrollment for speakers of other languages. Ironically, the English form asks in question two, "What language do you read?" The state says that all enrollment materials except for the form have now been translated into appropriate threshold languages and field-tested. A state official reports that a contractor will translate the enrollment form in the future.10Use Neutral Counselors to Advise Beneficiaries of Plan ChoicesAt least 12 states use private "enrollment brokers" or "health benefits counselors" to advise Medicaid beneficiaries about their managed care plan choices and to assist them in enrolling in a plan. Other states that ban direct marketing or enrollment by health plans use human services agency staff as neutral benefits counselors.Is it better for a state to contract with an enrollment broker firm or to hire enrollment counselors directly? That answer depends partly on the state's capabilities. If the Medicaid agency does not normally perform outreach well, does not have adequate phone systems for handling inquiries, and does not have good computer systems that can match Medicaid beneficiaries with accessible plans and providers, a contract with an enrollment broker may be a better approach. On the other hand, if states have performed outreach well in the past and can assign enough staff to act as enrollment counselors during heavy enrollment periods, it might be better for state agencies to counsel and enroll Medicaid beneficiaries in managed care plans.Duties of counselors or brokers vary from state to state. In some states, they are charged with one-on-one counseling. In other states, they hold group sessions to tell Medicaid beneficiaries about their managed care options, or they show the group a video and then answer questions. In still other states, they conduct enrollment primarily by phone and mail.The states' experience with neutral enrollment brokers provide a number of lessons for other states moving to Medicaid managed care.Lessons Learned From Conducting Enrollment Through Brokers or Counselors:Lesson 1. Use trained, responsive staff.Whether contractors or state agency staff counsel beneficiaries, it is important that they have good skills in communicating with beneficiaries. States and contractors should look for culturally diverse staff, reflective of the Medicaid population in a particular state. States and contractors often recruit brokers or counselors through community-based organizations and welfare-to-work programs. Brokers and counselors should be well-trained and patient. They should know the differences between available plans, the criteria that people should consider in making their choices, issues confronting special populations under managed care, problem resolution techniques, and how to use the computer system for processing enrollments. Foundation Health, the enrollment contractor for Massachusetts and New Jersey, holds three-week training sessions for counselors. (Foundation does not operate as a health plan in these two states but serves only as an enrollment contractor.)California Training RequirementsCalifornia contracts with Maximus as its enrollment broker. The RFP specifies topics on which counseling staff must be trained.Lesson 2. Plan for adequate staffing.Opening enrollment without adequate numbers of staff can cause many problems. Here are some questions that will help guide planning for staff to handle enrollment:

• Will brokers or counselors be stationed in each site where beneficiaries report periodically to have their eligibility for Medicaid reassessed? How many sites are there?
  
• If group counseling sessions are planned, how many people can each site accommodate for such sessions? Groups should probably not be larger than 12 people.
  
• How much time will it take to present information, either individually or through group sessions, and then answer individual questions and process the enrollments? Some enrollment firms allow 40 minutes for the group presentation with additional time if translation is needed.
  
• How many people does the state plan to enroll and over what time period?
  
• Will the state or contractor provide a toll-free number for enrollment and disenrollment questions? Will that hotline also handle beneficiaries' problems and questions about HMO services? What are its hours?

It is not possible to say exactly what staffing levels are ideal. States do not yet have much experience using enrollment brokers or counselors, and enrollment methods have varied from state to state. New Jersey's enrollment contractor used 23 health benefits advisors at a phone center and 26 advisors in field offices to counsel and enroll over 180,000 households over one year (roughly one advisor for every 3,700 households). As of June 1996, 303,000 Medicaid beneficiaries in New Jersey were enrolled in managed care, a population over twice the size of Alameda County's mandatory managed care enrollees. Some of the advisors were temporary employees, used only during peak enrollment periods. Rhode Island hired 21 enrollment counselors to enroll 30,000 households over one year (about one counselor for every 1,400 households). As of June 1996, 71,000 Medicaid beneficiaries in Rhode Island were enrolled in managed care, a population comparable in size to the population of mandatory managed care enrollees in Tulare County or Stanislaus County. In addition to processing enrollments, Rhode Island's counselors assist beneficiaries with a baseline survey of their health status, help get medical records from previous providers, and reach out to homeless Medicaid beneficiaries.11As evidenced by initial problems in Connecticut and problems in California, it is important for brokers to quickly add both staff and phone capability when enrollment demands are higher than firms expect.Lesson 3. Phase in enrollment, synchronizing enrollment
with Medicaid recertification schedules.Most beneficiaries come into Medicaid or public assistance offices periodically to be "re-certified"?that is, to have their eligibility reassessed. During re-certification appointments, eligibility workers can remind people about the importance of choosing a managed care plan and refer them to enrollment brokers or counselors for counseling. Because re-certification appointments are staggered, tying enrollment to recertification allows for a gradual enrollment schedule, giving the state time to correct initial problems and avoiding the disruption that has accompanied enrollments of large groups of Medicaid beneficiaries all at once.California Enrollment ScheduleIn California, the intent was to phase in mandatory managed care starting with new eligibles, then beneficiaries re-certifying for Medi-Cal, and finally mass-converting existing caseloads of Medi-Cal beneficiaries who did not have re-certification appointments during the time that a county implemented mandatory enrollment. However, there have been county-to-county variations in this schedule because the two plans are not always simultaneously operational. In addition, the benefits of using this phase-in schedule were undermined in two ways. The timetable for implementation of the Two-Plan Model was too short, so some counties converted large caseloads to managed care before the state corrected problems identified from enrolling newly eligible and re-certified beneficiaries. Second, there was and is inadequate coordination between eligibility workers and the enrollment contractor. The eligibility workers are not being trained or educated about the conversion to managed care and are not able to answer questions. Also, they are not effective at encouraging people to participate in the enrollment presentations. Even presentations at the welfare offices are poorly attended. In some counties, the welfare departments have been uncooperative in providing space for the contractor.Lesson 4. Plan for adequate phone lines and monitor the experience of reaching enrollment counselors by phone.Whenever the state sends out notices about managed care, many beneficiaries call for information. In order to control the volume of inquiries, states can mail to just part of the target population at a time. Enrollment broker firms plan for phone lines to handle a typical volume of calls and often use a phone back-up system, where calls are forwarded to a central or county office, during enrollment spurts. Even with these precautions, some states and firms have underestimated phone demands, and it has taken weeks to correct problems. Piloting managed care enrollment in a small geographical area first might help states and firms to better estimate phone and staffing needs for the entire state.California Phone StandardsCalifornia's contract with Maximus includes standards for phone service, including busy signals and hold times.Lesson 5. Offering enrollment by phone, by mail, and in person may increase response rates.Recently, states such as Oklahoma and Connecticut have allowed Medicaid beneficiaries to enroll in managed care by telephoning an enrollment broker instead of coming in for an appointment or mailing back information. Enrollment counselors in Connecticut follow a 20-minute phone script to present information about plan choices over the phone. Seventy percent of Connecticut managed care enrollees have used telephone enrollment.12While certainly a convenient and popular option, it is not clear that beneficiaries always receive enough information to make informed decisions over the phone. Also, many beneficiaries do not have telephones.California Enrollment MethodsCalifornia does not allow telephone enrollment in Two-Plan Model Counties. Beneficiaries can enroll by mail or in person.Lesson 6. Help beneficiaries enroll with a provider when they select their managed care plan.Some states assist beneficiaries with enrollment in a managed care plan and then require the plans themselves to assist beneficiaries with provider selection or assignment. This arrangement causes many problems. First, new enrollees may be denied access to any services until the plan assigns them to a physician, which often takes more than a month. Second, if the plans are handling assignment of providers, the states will not know when most of a plan's doctors have stopped taking new patients and the plan should be closed to new enrollees. Medicaid beneficiaries are counseled to choose plans based on the providers they wish to use; they may learn only after enrolling that the doctor they wanted is not accepting new patients.States have solved some of these problems by encouraging Medicaid beneficiaries to select their primary care physicians at the time they enroll in a plan. To do this, the state (or enrollment contractor) must keep automated records of the providers participating in each plan, and the plans must regularly update provider information. (States must also allow providers sufficient time to contract with plans before requiring enrollees to join?otherwise, states "put the cart before the horse" and make it impossible for enrollees to follow their providers.) Some beneficiaries may wish to continue using community clinics as their providers but have not identified particular doctors within those clinics as their primary care physicians. States should therefore ensure that enrollment forms allow beneficiaries to select clinics as primary care providers.When beneficiaries do not select providers (whether they have selected plans or have been assigned to them), states should set a deadline for the plans to assign Medicaid recipients to physicians. To ensure that beneficiaries have prompt access to primary care physicians, states should put that deadline in their contracts with managed care plans.California Provider SelectionCalifornia allows beneficiaries to select primary care providers on the enrollment form. However, some of the plans have made it difficult for the enrollment contractor to process the selection of a clinic by not assigning clinics a provider identification number. When beneficiaries select plans but not providers, plans have 40 days to assign them to a provider.13Lesson 7. Use a good computer system.The computer system should contain Medicaid eligibility information, enrollment information, and updated information on the location and specialty areas of providers accepting new Medicaid patients. Ideally, either the state or its contractor should be able to search fee-for-service claims data to locate beneficiaries' most recent providers so that beneficiaries who do not choose plans can be matched with previous providers who have joined managed care networks.California Claims InformationCalifornia has recently agreed to require its fiscal intermediary (the contractor who processes Medicaid claims) to search claims data and produce information on previous providers. However it is raw data, containing every provider who has filed a claim. The state is providing it to the plans and urging them to use it to assign a primary care provider. To date, the state has declined to provide a mechanism to use the data to identify a primary care provider that could be used by the enrollment broker in place of arbitrary default.Lesson 8. Look at beneficiaries' needs for special services when matching them with plans.For some beneficiaries, continued relationships with mental health providers, home care workers, or other specialized providers will be even more important than continuity with a primary care provider. Advocates in both Delaware and Rhode Island reported that serious problems arose for people with mental illness when they followed primary care providers into plans but had to find new mental health providers. Especially in states that mandate enrollment of persons with disabilities in managed care, enrollment brokers or counselors should consider needs for such specialized services.14Mental Health in CaliforniaIn California, mental health services are carved out, and there is a separate mental health managed care program. There have been some problems in coordination of care, but it is too soon to assess the impact.Lesson 9. Consider adding staff during peak enrollment times and reassigning enrollment staff when enrollment demands are low.Demands on enrollment counselors will be heaviest when a new managed care system begins. After most Medicaid beneficiaries have enrolled in managed care plans, fewer staff will be needed to process requests for plan changes and to enroll new Medicaid beneficiaries. States that use their own employees as enrollment counselors may need to reassign some employees to other jobs after the initial enrollment period. Rhode Island outstations enrollment counselors at hospitals to do general public benefits outreach when managed care enrollment is slow.Adding Enrollment Staff in CaliforniaAlthough we have not reviewed the staffing plans, there have been no major reported problems this year. California reviews and authorizes the staffing plans for county enrollment programs and at call centers. The original contract with Maximus anticipated that conversion would be almost fully implemented at the time they took over from Benova, the previous contractor. When this turned out not to be the case in January, the state authorized the enrollment contractor to increase staffing due to the increased enrollment workload.Lesson 10. In states contracting for enrollment brokers, put standards in requests for proposals (RFPs) and contracts.In RFPs and enrollment broker contracts, states have an opportunity to specify duties of enrollment brokers, set performance standards, and provide financial incentives for brokers in order to avoid default assignments. Without adequate contract standards, states pay for counseling sessions that may not help people choose appropriate health plans.Some states have set particular qualifications for benefits counseling staff through RFPs:

• New Jersey requires "adequate" staffing levels, staff with customer service experience and college degrees or equivalent experience, and registered nurses to review whether people should be exempt from managed care based on their health status.
  
• Massachusetts requires staff to reflect the cultural, physical, and demographic nature of the beneficiary population.
  
• Delaware seeks counselors with knowledge of community resources and public transportation.
  
• Missouri requires the contractor to hire a specified percentage of its staff from work and training programs for welfare recipients.15

States vary in how they pay for enrollment broker contracts. They may pay based on a fixed-price budget or reasonable cost, based on a competitive bidding process, or pay a fee for each enrollee. Some states penalize contractors if the default assignment rate goes above a certain standard, and some states pay a higher fee per enrollee when greater numbers of people select plans.These payment mechanisms have some potential pitfalls. Because enrollment broker contracts are still relatively new, states that do not invite price bids may need to do considerable research to determine a reasonable price. If a state asks brokers to compete for contracts based on cost, the contract will go to the lowest bidder that meets the state's requirements, which may or may not be capable of actively providing the best outreach and counseling. States that allow beneficiaries to switch HMOs after 30 days should be cautious about paying brokers on a per-enrollment basis. Under such a payment system, brokers could get paid higher rates when many people disenroll from one plan and re-enroll in another. Rapid plan switches indicate dissatisfaction with initial enrollment choices and possible problems in enrollment counseling.Minimum standards for plan selection, with either penalties for high percentages of default assignments or bonuses for low default assignment rates, seem useful. Based on the experience of several states, enrollment brokers should be able to achieve default assignment rates well under 25 percent.16Some "best practices" include:

• Ensuring appropriate reading levels for enrollment materials, making sure materials are translated and are provided in large print and Braille, and pre-testing materials with consumers;
  
• Assigning responsibility to the broker for furnishing updated information about participating providers in each managed care plan, so that the broker enrolls beneficiaries with a chosen primary care provider at the time the person enrolls in a plan;
  
• Following up on returned mail and using multiple methods to reach nonrespondents. For example, in some states, brokers must devise a plan to reach nonrespondents, such as making phone calls to them or contacting them through their current health providers;
  
• Providing evening and weekend phone service;
  
• Requiring brokers to initiate vigorous community outreach strategies including ways to involve existing community organizations in outreach and provide "floating" workers to enroll homeless or homebound Medicaid beneficiaries;
  
• Placing enrollment staff in public assistance offices (or nearby, if there is no space) to provide counseling at the time of Medicaid re-certification;
  
• Requiring brokers to have sufficient computer capacity to process enrollments and ensuring that those computer systems work;
  
• Detailing topics on which the enrollment brokers' staff will be trained and ensuring that the state's welfare and Medicaid workers are also trained to answer Medicaid managed care questions;
  
• Establishing cultural and linguistic requirements;
  Ensuring that the counseling staff meets cultural and linguistic requirements;
  
• Paying brokers higher rates when default assignments are minimized and when rapid disenrollment requests are low;
  
• Ensuring that managed care complaints received by the broker are also registered with the department charged with resolving grievances; and
  
• Testing whether Medicaid beneficiaries understand the basics of managed care after hearing an enrollment presentation.

Enrollment Standards in CaliforniaCalifornia has not set any standards or goals for maximum default rates and does not provide for incentive payments to the contractor for low default rates or low rapid disenrollment rates. The contractor is paid based on the number of enrollments/disenrollments processed, minutes of direct assistance provided to beneficiaries, and the number of enrollment service representatives employed. The appendix shows how other aspects of California's enrollment contract compare with other state enrollment broker requirements.

Delay Default Assignments until Most Beneficiaries Select Plans

States should do a number of things to protect beneficiaries who fail to select plans and therefore must be assigned to one. They should send beneficiaries several notices urging them to select plans before resorting to making assignments by default. Outreach workers or enrollment brokers or counselors can call Medicaid beneficiaries who do not respond to notices and go door-to-door in neighborhoods with low sign-up rates. In some states, where less than 70 percent of the target population selected their own plans, advocates have succeeded in delaying default assignment dates until states did better outreach.

In making default assignments, consider beneficiaries' needs

When states do assign people to managed care plans, they can use claims data to assign families to the plans that include doctors they have recently used. They can also use zip codes and addresses to assign families to plans with nearby doctors. North Carolina and New Jersey are among many states that consider geographic accessibility in making assignments. Maryland and Virginia are among states that consider previous providers in making default assignments; each has an algorithm that takes into account other factors as well, such as benefit packages, geographic accessibility or family relationships. Both Maryland and Virginia previously used primary care case management for Medicaid beneficiaries?that is, beneficiaries named a doctor who was responsible for providing referrals to specialty care. Thus, it was clear from the claims data which doctors provided primary versus specialty care and could potentially be named as Primary Care Physicians under new health plans. In states that did not use primary care case management before moving beneficiaries into HMOs, the task of searching claims data is more complicated; states may still be able to identify recent providers used by a patient or providers most frequently used by a patient, but states may have to take an added step to determine which of these provided primary care.States must have a mechanism for assessing plan capacity. In the best cases, states consider plans' primary care and specialist provider capacity and stop new assignments when most providers within a primary or specialty area have reached maximum caseloads. New Jersey looks at the capacity of specialists, primary care providers, hospitals, durable medical equipment providers, etc., and determines plan capacity based on the "weakest link" in the plan's network. New Jersey stops auto-assignments to a plan when it has reached 80 percent of capacity. This ensures that enrollees will have choices of providers within the plan and that the plan has room to accommodate, for example, newborn children in enrolled families.California Default AssignmentsIn a fully operational Two-Plan Model county, where fee-for-service is not an option, default assignment is done by a formula that is weighted to favor the Local Initiative until the Local Initiative reaches its minimum enrollment levels. The contractor and the state do not consider previous providers in making default assignments. The health plans are responsible for monitoring provider capacity. In assigning a primary care provider, the plans are supposed to consider geographic proximity and whether the provider is accepting new patients and has the language capacity to serve beneficiaries.Provide for expedited and retroactive disenrollment

In some states, Medicaid beneficiaries are allowed to move from one managed care plan to another (or, if managed care enrollment is voluntary, from managed care to fee-for-service) at any time. In other states, Medicaid beneficiaries are "locked-in" to managed care plans for certain periods of time, such as six months, but allowed to change plans during the first month of enrollment and at other times for good cause.17 Usually, disenrollments take time. In many states, it takes until the first of the month following a beneficiary's request for a change to a new plan to be effective. Certain beneficiaries, however, need speedier disenrollments, and some states have responded to their needs. For example, a person in ongoing care who is assigned through default enrollment procedures to a plan that does not include his or her provider, risks interrupted care unless he or she can immediately disenroll or Medicaid can "retroactively" pay the person's current provider while the person disenrolls from his or her assigned health plan. For a number of years, Medicare has successfully used a retroactive disenrollment process for beneficiaries who joined a Medicare HMO without understanding what enrollment meant.Unfortunately, in many cases, emergency disenrollment procedures have been vague. In the District of Columbia, emergency disenrollment has been handled on a case-by-case basis rather than through written procedures. A District Medicaid beneficiary undergoing treatment for a stroke found her care disrupted through an erroneous auto-assignment; when she called the HelpLine to report her problem, she was told that it would take a month for her to disenroll and resume care with her treating provider. About a week later, the District discovered a massive enrollment error resulting in erroneous auto-assignments for many beneficiaries. The District permitted immediate disenrollments only for those who called after the mistake was discovered.New York City is among places that provide for expedited disenrollments for those misinformed at enrollment regarding any aspect of a managed care plan and for enrollees who have a medical emergency that requires immediate disenrollment.18Expedited Disenrollment in CaliforniaCalifornia advocates have been working with the state to improve and publicize expedited disenrollment procedures. The Department of Health Services has drafted, but not finalized, regulations regarding expedited disenrollments.Section II
ENROLLMENT IN CALIFORNIA'S TWO-PLAN MODELThe following discusses the current enrollment process in California's Two-Plan Model and, based on an assessment of what has worked in other states, offers suggestions for improving the enrollment process.Enrollment Procedures in California Two-Plan Model Counties

California contracts with a private enrollment broker to counsel and enroll Medi-Cal beneficiaries in managed care. California calls its outreach and enrollment process "Health Care Options" (HCO) counseling. As the Two-Plan Model began, California continued an existing contract with the firm Benova to enroll beneficiaries. In January 1997, a new Health Care Options contract went into effect with another firm, Maximus.Many problems have been documented with enrollment in California. Responsibility for various aspects of enrollment is shared among the state, the enrollment contractor, and health plans. The state has retained responsibility for public relations related to implementation of the Two-Plan Model, for developing enrollment materials and information packets, and for arranging with county Departments of Social Services for HCO presentations. Benova, and later Maximus, were responsible for answering enrollment questions by phone; providing HCO presentations and counseling according to the state's specifications, and processing enrollments, default assignments beginning in July 1996, and disenrollments. Health plans are responsible for assistance in Primary Care Provider (PCP) selection if clients request information beyond what is in the plan's printed directory and for assignment of PCPs for beneficiaries who do not make a choice of PCP or who are assigned to a plan.The process for enrolling in a health plan varies, depending on whether the Commercial Plan and Local Initiative are both operational in a Two-Plan Model county or whether the Model is still being phased in and only one of the two plans is operational.When Only One Plan is OperationalDuring the phase-in of the Two-Plan Model, when only one plan is operational, all Medi-Cal beneficiaries have the right to remain in fee-for-service Medi-Cal. Under procedures that went into effect July 1, 1996, new Medi-Cal applicants and beneficiaries scheduled for redeterminations of their eligibility are assigned by "default" into the operational managed care plan if they do not indicate a fee-for-service choice.19 The enrollment process, as described in California's contract with Maximus, is supposed to work as follows:New applicants for Medi-Cal and Medi-Cal beneficiaries scheduled for an annual redetermination of their eligibility are targeted for enrollment. The Department of Social Services informs applicants of where they can receive enrollment materials and information from the HCO contractor. The HCO contractor mails enrollment packets to families whether they choose to attend an enrollment presentation or not. The packets, which are developed by the state, describe available plans, list participating providers, list phone numbers to call for assistance (both for English speakers and for speakers of "threshold" languages), and include an enrollment form. Materials are supposed to be sent in primary languages.These new applicants and beneficiaries complete enrollment forms indicating whether they want to enroll in the operational plan, another existing HMO, or remain with a fee-for-service provider. Targeted beneficiaries have a total of 30 days to make a choice. If a beneficiary does not promptly return an enrollment form after attending an HCO presentation or receiving a mailed enrollment packet, the contractor sends a reminder notice in 10 days stating that the beneficiary will be assigned to the operating plan if he or she does not return the form. The notice also instructs beneficiaries on how to prevent this assignment.If the beneficiary still does not complete an enrollment form within 30 days, she/he is assigned to a managed care plan and receives notice as to how to disenroll.When Both Plans Are OperationalWhen both the Local Initiative and the Commercial Plan are fully operational in a county and when HCFA has declared both plans ready to accept enrollments and default assignments through a "readiness review," most families with children are required to enroll in one of the plans and no longer have the option to remain in fee-for-service.The contractor sends a notice to all beneficiaries required to enroll telling them they soon will have to choose between the two plans. Beneficiaries who already are enrolled in one of the two plans are sent a notice that the other plan is now available should they desire to switch.20The contractor mails full enrollment packets to beneficiaries sometime before both plans are fully operational. The schedule for sending these packets is determined county-by-county, but, according to the approved waiver, packets must be mailed three months before full implementation of the Two-Plan Model. If beneficiaries do not return enrollment forms, they are sent another notice 10 days before the enrollment deadline stating that they will be assigned to a plan by default; this notice instructs them as to how to prevent default assignment by returning enrollment forms before the deadline.After 30 days, beneficiaries who do not return enrollment forms are assigned to plans based on a "weighted assignment" method: The plan must have a primary care service site within the beneficiary's zip code area; family members are usually assigned to a plan as a group; and the plan must include a primary care provider with the capacity to accept new patients and the ability to meet the beneficiary's language needs. The Local Initiative is given preference in the assignment process. This process is designed to protect safety-net health providers (such as community health clinics) because the Local Initiative must contract with such providers.Medi-Cal beneficiaries must select or be assigned to a primary care provider, as well as to a plan. Some indicate their choice of a provider on their initial enrollment form. Others may enroll in a plan (or be assigned to a plan) before they select a provider. In these cases, the plan must complete the process of primary care provider assignment. The plan notifies the beneficiary that she or he may choose a provider but is required to assign a provider within a specified time period if the beneficiary has not made a selection.ENROLLMENT RECOMMENDATIONS1. California should set a goal for voluntary choice of 80 percent. California should suspend default assignments and increase outreach in any county exceeding a 20 percent default rate. This goal should be incorporated into future enrollment broker contracts.Default assignments have been delayed in other states in order to increase voluntary choice rates. A number of states now have voluntary selection rates exceeding 80 percent; the best states have achieved voluntary selection rates close to 90 percent. Even without a new enrollment broker contract, California could establish goals for voluntary selection, stopping default assignments and increasing outreach efforts in any county that does not reach the voluntary selection goals.21Other states have included in their enrollment broker contracts a number of standards and goals to promote effective enrollment (see appendix). In future contracts or through amendments to the existing contract, California should incorporate, for example, a goal for voluntary choice of 80 percent, incentive payments for both low default assignment rates and few requests for managed care disenrollments or managed care plan changes within the first months of plan selection, maximum allowable default rates, and penalties if the broker's phone or computer system fails.2. California and Maximus should work with community organizations to enhance outreach. California should establish workgroups of "stakeholders" (including community groups and Medicaid beneficiaries) in all counties.In other states, community organizations have subcontracted to provide both outreach and education for the general population and to write educational materials geared to specific populations with special needs. California should also utilize the skills of its community-based organizations to educate Medi-Cal beneficiaries about the transition to managed care.The Department of Human Services and Maximus should meet with community-based organizations in each county to identify ways they might enhance outreach and then enter into appropriate subcontracts.Recently, in Los Angeles County, the state circulated a letter of interest for community-based organizations to provide enrollment broker services under subcontract with Maximus. While involving community-based organizations is a step in the right direction, the specified duties and enrollment targets may be beyond the scope of many community-based organizations. Advocates comment that many community-based organizations can more appropriately assist with education, outreach, and follow-up to nonrespondents rather than actual enrollment.22In Los Angeles, the Department of Health Services has begun holding monthly "stakeholders" meetings regarding its enrollment process. The Department should make a clear commitment to respond to "stakeholder" proposals and should establish similar workgroups in other counties to assess and improve enrollment throughout California.3. California should aggressively follow up to reach Medi-Cal beneficiaries who have not responded to mailed enrollment information and have not chosen a plan.Currently, Maximus sends a "notice of intent to assign" to people who do not make enrollment choices. In some other states, brokers are required to develop plans for reaching nonrespondents. For example, in Massachusetts, the broker tracks undelivered mail and uses data from other state agencies in second attempts to contact beneficiaries and information furnished by current medical providers to contact disabled nonrespondents. New Jersey sends multiple reminder notices to nonrespondents. In urban areas where there are high concentrations of Medicaid beneficiaries, New Jersey's enrollment broker subcontracts with community-based organizations that hand-deliver enrollment forms when beneficiaries do not respond to mailed enrollment information.California should develop aggressive methods to reach beneficiaries who do not respond to mailed information. At a minimum, California should target follow-up to special populations or geographical areas that have low response rates.When they are assigned by default to plans, many Medi-Cal beneficiaries still go to former health providers because they do not understand the change in their health care. Beneficiaries may incur bills, pay out of pocket for care, or may be turned away from care. The state should establish a mechanism to pay these former providers for one visit, so that care will not be disrupted. Providers can then refer beneficiaries to their new plans and providers for future care and can refer beneficiaries to enrollment counselors regarding options to re-enroll in plans that include their current providers.4. The enrollment form and all materials should be speedily translated and field-tested prior to use. California should halt default assignments until the enrollment form is available in all threshold languages.The enrollment form is the crucial vehicle by which Medi-Cal beneficiaries select both a plan and a provider. It is not yet available in languages other than Spanish and English. The lack of a translated enrollment form is a major obstacle for populations who have no ability to complete forms in English and Spanish and who may therefore be defaulted into inappropriate health plans. No default assignments should be made in any county until the form is available in all of the county's threshold languages.Under a subcontract, the state says that all other enrollment materials have now been translated and field-tested. Advocates and community-based organizations applaud this step but have not yet seen the translated materials in the hands of beneficiaries. Community groups in Los Angeles recently surveyed some non-English speaking Medi-Cal beneficiaries by phone and learned that they had not yet received translated enrollment packages.235. Before mandatory Medi-Cal managed care enrollment begins in a county, California should provide additional outreach and education for a designated period. Responsibility for pre-enrollment education should be clearly delineated.The October 1996 contract between the state Department of Health Services and Maximus does not assign responsibility for pre-enrollment outreach or set forth a schedule for community outreach before enrollment begins. Under the State's Medicaid waiver, beneficiaries are supposed to receive enrollment packets three months before full operation of the Two-Plan Model. In January 1997, the Department of Health Services conducted a brief "Medi-Cal Managed Care Public Education Campaign," distributing some posters and bus billboards; brochures and a videotape will soon be distributed. The department is in the process of contracting for additional public education in Los Angeles County.California should designate a period for pre-enrollment outreach in all affected counties before mandatory enrollment in managed care and should undertake public education campaigns in all counties. The department or its contractors should encourage input from community groups and consumers about proposed public education campaigns. The department or its contractors should also field-test all public education materials in all threshold languages, determine how public education campaigns can successfully reach targeted groups, and evaluate and modify public education techniques as needed.Some other states have sent multiple notices to beneficiaries, contracted with community groups for outreach, and implemented intensive outreach plans at least four months before default assignments began. California should undertake similar efforts to educate consumers, community groups, social service agency staff, and providers about managed care before actual enrollment begins.6. California should revise its default assignment methods to protect beneficiaries.California's weighted assignment method is designed to ensure that plans to which beneficiaries are assigned have the capacity to serve them and have geographically and linguistically accessible providers; it is also designed to protect the safety net by giving the Local Initiative, which must contract with safety-net providers, preference in the assignment process.24 The goals of protecting beneficiaries' interests and of protecting safety-net providers' interests through the default assignment formula may be in conflict. The current assignment method accomplishes neither goal. It fails to protect beneficiaries because the assignment method does not consider continuity with existing providers. Many beneficiaries assigned to plans experience disruptions in their care. The assignment method also does not adequately protect safety-net providers. If the Commercial Plan becomes operational first, it may receive the vast majority of auto-assignments, leaving the Local Initiative with too few auto-assignments to guarantee its survival. In San Francisco, Blue Cross became operational about one year before the Local Initiative, contributing to the fact that San Francisco Health Plan cannot reach the number of default assignments it was originally guaranteed. On the other hand, in some counties, the great majority of traditional and safety-net providers contract with both plans, raising questions as to whether weighted assignments to plans have any effect on the safety-net.Other states have handled default assignments differently. For example, some states require all participating plans to contract with safety-net providers. Several states that began with Primary Care Case Management systems for Medicaid beneficiaries and then moved the beneficiaries into HMOs have required brokers to identify previous primary care case managers using claims data. Then they have assigned beneficiaries by default to the plan that includes their former provider. Since providers may participate in more than one plan, default assignment algorithms may choose between these plans based on which one provides enhanced benefits or which scores best in a bidding process. To the extent that default assignments are not serving Medi-Cal beneficiaries well now, California should look to other states for guidance in revising its default assignment method.A state official reports that the Department of Health Services is now revising its system in Los Angeles County so that it can provide information to plans about assignees' previous fee-for-service providers. In the future, plans will be able to consider that information when they assign new enrollees to primary care providers. However, plans will not be required to use this information. Since the information about previous providers is not used to make default assignments to plans, a beneficiary may still be defaulted to a plan that does not include his or her previous providers.California should furnish information about previous providers (available through its fiscal intermediary's claims data) to the enrollment broker and amend the contract to require the enrollment broker to assign people to plans including their most frequently used recent providers. Also, plans throughout California should receive data about previous providers in a readily usable form and should be required to use this information in assigning primary care providers to people who have not selected their providers.Some Medi-Cal beneficiaries want to continue using community clinics but cannot identify a particular primary care provider within those clinics. The state and contracting health plans should provide identification numbers to clinics, and revise provider directories and enrollment forms so that beneficiaries can readily select clinics as their primary care providers.7. The enrollment contractor should have sufficient staff and phone lines to counsel beneficiaries about plan choices. California and Maximus should evaluate potential staffing needs when, for example, the Two-Plan Model is fully implemented in Los Angeles.Besides evaluating staffing needs based on experience with staffing ratios in the counties that are fully operational and based on other states' experiences, the state and its Contractor should have a plan in place for quickly adding staff and phone lines if demand exceeds expectations and for adding staff who speak threshold languages.8. California should improve its written materials and oral presentations about managed care.Most written materials and the content of enrollment presentations are currently the responsibility of the California Department of Health Services. Plans furnish provider directories and descriptions of their services, which the state includes in enrollment packets. Following examples set by other states, California should develop comparative charts and questions that would help beneficiaries choose plans and field-test all written materials in all threshold languages. In its HCO presentations, Maximus is required to follow a script developed by the state. According to its contract, Maximus may make "enhancements to the HCO presentation." The state should evaluate the effectiveness of the HCO presentation, getting input from both beneficiaries and community groups, and revise it as appropriate.9. California or Maximus should provide evening and weekend phone service to answer enrollment questions.Many states contract with enrollment brokers to provide such evening and weekend as well as daytime phone service.10. California should finalize procedures for expedited and retroactive disenrollments and educate beneficiaries, advocates, social service providers, and community-based organizations about these new procedures.In December of 1996, the state Department of Health Services drafted, but did not finalize, a letter to health plans regarding emergency disenrollment procedures for certain default-assigned beneficiaries?people needing services not covered under managed care, foster care children, long-term care beneficiaries, incarcerated beneficiaries, people who have moved?and others with "reasonable cause." This spring, the department published draft regulations regarding disenrollment. Advocates report continuing problems in obtaining emergency disenrollments for pregnant women and others who have established relationships with providers. The draft regulations need to be finalized and implemented. Reasons for emergency disenrollment should be expanded to include errors made by the HCO contractor, and cases in which the beneficiary is under continuing care of a provider not available through the plan; primary care locations exceed a geographical distance of 10 miles or 35 minutes; or the beneficiary's pharmacy, specialists, or choice of hospitals are not in the beneficiary's assigned plan. As of September 1997, legislation is pending to address these issues.

ENDNOTES

1. In some additional counties, Medi-Cal beneficiaries are required to enroll in managed care through "County Organized Health Systems" or through "Geographic Managed Care."2.Default assignment rates are not completely comparable between states because of differences in methodologies for counting assignments. For example, California counts newborns assigned to their mothers' plans as default assignees, whereas New Jersey does not. We do not know what percentage of Two-Plan Model assignments in each county were newborns. Statewide, of all Medi-Cal beneficiaries in families with children, about 5 percent are under one year of age. Health Care Financing Administration, Medicaid Statistics, Fiscal Year 1995, Washington, D.C. (U.S. Department Health and Human Services, 1996).3.Report from Maximus, "Monthly Enrollment Summary, 7/26/97-8/25/97."4.See R. Hurley, and D. Freund, "Determinants of Provider Selection or Assignment in a Mandatory Case Management Program and Their Implication for Utilization," Inquiry, 25 (1988):402-10; T. McGlauglin, "Medicaid Contract Worth $190 Billion to 7 Insurers," St. Louis Business Journal, April 24-30,1995 at 13A; and J. Ferber, "Auto-Assignment in Medicaid Managed Care Programs," Journal of Law, Medicine and Ethics, 24 (1996):99-107.5.California will enroll 3.4 million Medi-Cal beneficiaries in managed care. Tennessee, the state with the second highest Medicaid managed care enrollment, had 1,180,000 enrollees in 1996.6.ristine Molnar, Denise Soffel, and Wendy Brandeis, Knowledge Gap: What Medicaid Beneficiaries Understand?and What They Don't?about Managed Care (New York, NY: Community Service Society, December 1996).7.Letter from Richard Chambers to J. Douglas Porter, January 22, 1997.8. "The Education and Outreach Plan for Los Angeles County," May 29, 1997 draft; letter from Community Health Councils, Maternal and Child Health Access, Legal Aid Foundation of Los Angeles, SF Valley Neighborhood Legal Assistance and Western Center on Law and Poverty to Ann-Louise Kuhns, Chief, Medi-Cal Managed Care Division, California Department of Health Services, June 5, 1997.9. Partners in Health, Opening the Window on Managed Care: A Workbook for People with Disabilities and Advocates (Millersville, MD: Partners in Health, The Coordinating Center), 1997.10. Information from Vivian Auble, Chief, Local Initiative Development, Los Angeles County, June 30, 1997; Medi-Cal Community Assistance Project, Rush to Managed Care (San Francisco, jCA: Medi-Cal Community Assistance Project, March 1997).11. Information from Laurie Facciarossa in New Jersey and Tricia Leddy in Rhode Island; HCFA, Medicaid Managed Care Enrollment, June 30, 1996; California Department of Health Services, Report of Eligibles for the 12 Two-Plan Model Managed Care Counties, May 1995, Sacramento.12. Information from Paul DiLeo, Benova, December 16, 1996.13. A Local Initiative Boilerplate Contract, Revised June 26, 1996.14. Information from Marti Rosenberg, Ocean State Action, December 1996 and Debbie Gottchalk, Community Legal Aid, Spring 1996; New York City Task Force on Medicaid Managed Care letter to Lu Zawistowich, Office of State Health Reform Demonstrations, HCFA, October 1995.15.Mary Kenneson, "Benefits Counseling Models and Issues," p. IV-19 in Horvath and Kaye (eds.), Medicaid Managed Care.16. In addition to New Jersey, Utah, Rhode Island, and Connecticut, mentioned elsewhere in this report, states with assignment rates below 25 percent include: Minnesota, 12 percent assignment; Missouri, assignment between 14 and 20 percent; Washington, assignment between 20 and 25 percent during initial implementation, but it crept higher when educational efforts were reduced. General Accounting Office, Medicaid: States' Efforts to Educate and Enroll Beneficiaries in Managed Care (GAO/ HEHS-96-184, September 1996).17. States that lock Medicaid beneficiaries into managed care plans for longer than a month handle disenrollments in various ways. Minnesota allows beneficiaries to change plans once during the first year for any reason and to make additional changes for cause. Missouri Consumer Watch drafted language for Missouri's pending 1115 waiver that would allow disenrollment from a plan on request within the first 45 days of assignment. In 1995, 21 states had general HMO laws that required HMOs to provide a contract cancellation period during which new enrollees could inspect and cancel their enrollment contracts for any reason. G. Dallek, C. Jimenez, M. Schwartz, Consumer Protections in State HMO Laws, (Los Angeles, CA: Center for Health Care Rights, November, 1995) p. 20.18. New York City Enrollment and Disenrollment Procedures, 1996.19. In some Two-Plan Model counties, default managed care enrollment procedures went into effect before either the Local Initiative or the Commercial Plan was operational. If they did not select a health plan or a fee-for-service provider, new applicants and Medi-Cal beneficiaries scheduled for annual eligibility redeterminations were defaulted into managed care plans with previous Medi-Cal contracts in a county.20.These procedures have not been consistently followed in all counties. See letter from Richard Chambers, Health Care Financing Administration, to J. Douglas Porter, Acting Deputy Director for Medical Care Services, January 22, 1997.21. After delaying default assignment and enhancing outreach, Missouri was able to achieve a voluntary choice rate of over 80 percent. Recently, the District of Columbia set a voluntary choice goal of 75 percent in its contract for enrollment education. Pursuant to an order in a class action lawsuit, Salazar v. District of Columbia, D.D.C., Civil No. 93-452 (GK), the District must report monthly default assignment rates exceeding 20 percent to the Court and act to reduce them.22. Letter from Maximus to Pamela Rich, "Proposal for Subcontracting With CBOs," May 13, 1997; letter from MCH Access, Consumers Union, SF Valley Neighborhood Legal Services, LA Managed Care Oversight Committee, Latino Issues Forum, Western Center on Law and Poverty, and Center for Health Care Rights to Ann Louise Kuhns and Ray Neilsom, June 6, 1997.23.Information from Lynn Kersey, Maternal and Child Health Access.24. According to the State's October 1996 contract with Maximus, when both plans are operational, the broker is supposed to consider geography, language capacity, and provider capacity in default assignments. In practice, assignment methods have varied county-by-county. In at least some counties, the above factors are not considered in defaulting beneficiaries to plans.

This report was written by Cheryl Fish-Parcham, Associate Director of Health Policy for Families USA, with assistance from Peggy Denker, Publications Director. The following people generously contributed their expertise to this report:Jeanne Finberg, Consumers Union; Lark Galloway-Gilliam, Community Health Councils; Lynn Kersey, Maternal and Child Health Access; Bruce Livingston, Health Access; Maryann O'Sullivan, Health Access; Lourdes Rivera, National Health Law Program; Guillermo Rodriguez, Latino Issues Forum; Laurie Soman, Children's Hospital, Oakland; Marjorie Swartz, Western Center on Law and Poverty.
This report and the Medi-Cal Community Assistance Project are supported by grants from:The California Wellness Foundation
The James Irvine Foundation
The Archstone FoundationMedi-Cal Community Assistance Project
942 Market Street, Suite 402
San Francisco, CA 94102
(415) 395-7959-voice
(415) 395-7956-fax
The Medi-Cal Community Assistance Project is a statewide effort to assure that the Medi-Cal Program operates as efficiently and effectively as possible for its intended beneficiaries. The Project has four major partners and many cooperating groups across California. Project Director: Maryann O'Sullivan, (415) 395-7959.

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