States' Efforts to Educate and Enroll Beneficiaries in Managed Care

HEHS-96-184: Published: Sep 17, 1996. Publicly Released: Oct 29, 1996.

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Pursuant to a congressional request, GAO provided information on state efforts to enroll Medicaid beneficiaries in managed care, focusing on: (1) the role of managed care organizations (MCO) in marketing and expanding managed care participation; (2) the types of marketing and enrollment abuses that have occurred and states' efforts to curb these abuses and ensure that beneficiaries are informed about their health plan options; and (3) state efforts to measure the effectiveness of their education and enrollment approaches.

GAO found that: (1) to boost enrollment in their Medicaid managed care programs, especially where participation is voluntary, some states have allowed MCOs to use various direct-marketing strategies, including door-to-door marketing, to encourage beneficiaries to sign up with their plan; (2) however, some MCOs and their agents have engaged in unscrupulous practices to maximize beneficiary enrollment, and thereby maximize plan revenues and commissions; (3) these practices include bribing public officials to obtain confidential information on beneficiaries, paying beneficiaries cash and other incentives to sign up, deliberately misinforming beneficiaries about access to care, and enrolling ineligible beneficiaries; (4) to address or avoid these marketing problems, many states have banned or restricted direct-marketing activities by MCOs and have retained responsibility for enrolling or disenrolling Medicaid beneficiaries; (5) as part of their enrollment programs, these states devote considerable efforts to facilitating beneficiaries' difficult transition from fee-for-service to managed care; (6) to do this, they have developed strategies to help beneficiaries understand the principles of managed care and make the often complex decisions involved with selecting an MCO; (7) despite their common emphasis on using the enrollment process as an opportunity to promote beneficiary understanding of the program and selection of an MCO, the four states GAO visited varied in their specific approaches, in part, due to their goals and circumstances; (8) these four states' education and enrollment efforts are also often augmented by community groups, such as maternal and child health advocates, and by MCOs, who are contractually required to inform enrollees on a continuing basis of plan services and operations; (9) although community groups in the four states generally believe that their states' education and enrollment efforts have facilitated beneficiaries' transition or introduction to managed care, methods used to measure the effectiveness of these approaches have been limited; (10) state officials and experts GAO contacted consider the best current measure to be the rate at which beneficiaries select their own health plan, rather than being assigned to one by the state; (11) while these states attempt to reach voluntary selection rates of 80 percent or higher, their actual experience has ranged from 59 to 88 percent; and (12) as general measures of the overall operation of their Medicaid managed care programs, these states also track other indicators, but none of these was designed or analyzed to specifically measure the effectiveness of the education and enrollment process.

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