Table Of Content

3</-tf7-03-T.JK>/3*.., I-E3 HEALTHECONOMICSRESEARCH,INC. 4W1al1tWhaavme,rlMeAy0O2a4k5s2-R8o4ad1,4Suite330 (781)788-8100 (781)788-8101-FAX Enrolling Elderly and Disabled Beneficiaries in Medicaid Managed Care: Lessons Learned from the Oregon Health Plan m CMSLibrsn/ C2-07-13 7500Secun FinalReport Baltimore,MD2124^ Preparedby: JanetB.Mitchell,Ph.D. HealthEconomicsResearch,Inc. and PaulSaucier,M.A. MuskieSchoolofPublicService UniversityofSouthernMaine August24,1999 iS^U JUL JanltB.Mitchell,Ph.D. Gregory^.Pofie,M.S. ProtectDirector ScientificReviewer TBhobeerne,seParrocjhecptreOfsfeincteerd.inThtehisstraetpeomretnwtasscopnetrafionremdedinutnhdiesrreHpeoarlttharCeasroeleFliyntahnocsienogfAtdhmeinaiustthorrastiaonnd(nHoCeFnAd)orCsoentmreancttbNyo.HC50F0A-9o4r-0A0S5P6E,Psahuoluldbe inferredorimplied. n ! TableofContents Page ExecutiveSummary E-l Background 1 Statewide§1115ProgramsforAllAges 1 SignificantManagedCareInfrastructure 1 Cost-SharingPolicyforDuallyEligibleBeneficiaries 2 BroadParticipationofPlansFostered 2 ScopeofCapitatedServices 3 FocusofReport 4 EnrollmentChoices 4 EnrollmentChoicesGenerally 4 ChoicesforDuallyEligibleBeneficiaries 5 TheEnrollmentProcessforPhaseII 9 WhoPerformstheEnrollmentFunction 10 HowDoesEnrollmentTakePlace 13 EnrollmentProtections 23 ExceptionalNeedsCareCoordinators(ENCCs) 24 ContinuityofCareReferralForms 25 ExemptionsProcess 27 DisenrollmentProvisions 29 OHPSuccessinManagedCareEnrollment 30 ProgresstoDate 30 ImplicationsforOtherStates 33 AppendixA OregonHealthPlanComparisonChart AppendixB Forms7208and7208A AppendixC ContinuityofCareReferral(CCR)Forms HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare:i oreg2/enrolIrpt/loc.wpd/nd TableofTables Page Table1 Medicare-MedicaidCombinationsforDuallyEligibleBeneficiaries 7 Table2 TrendsinMedicareHMOEnrollmentforDuallyEligibleandNon-Medicaid EligibleMedicareBeneficiaries: U.S.vs.Oregon(percentenrolled) 8 Table3 TrendsinOHPManagedCareEnrollment: DuallyEligiblevs.OHP-Only Beneficiaries 28 Table4 DistributionofDuallyEligibleandOHP-OnlyBeneficiariesAcrossManaged CarePlans,1998 32 Table5 DistributionofDuallyEligibleBeneficiariesbyTypeofManagedCare Arrangement 33 HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare:ii oreg2/enrollrpt/toc.wpd/nd EnrollingElderlyandDisabledBeneficiariesin MedicaidManagedCare: LessonsLearnedfromtheOregonHealthPlan ExecutiveSummary OregonlaunchedtheOregonHealthPlan(OHP)inFebruary1994,enrollingbothits traditionalAFDCandnewexpansionpopulationsintomanagedcare. Exactlyoneyearlater, theStatebeganenrollingitselderlyanddisabledbeneficiaries,includingthoseduallyeligible forbothMedicareandMedicaid. Bytheendof1995,themajorityoftheelderlyand -I disabledwereenrolledinFullyCapitatedHealthPlans. Byearly1998,thisfigurehad 1 climbedto75percent,withanadditional6percentenrolledwithaprimarycarecase manager. Theremainingbeneficiariesremaininfee-for-service,manyofthemspecifically exemptedbecauseofathird-partyresource(suchassupplementalMedi-Gapinsurance). Oregon'sexperiencewithelderlyanddisabledbeneficiariesprovidessomevaluable lessonsforotherstatesthatmaybeconsideringenrollingthispopulationintomanagedcare. PlanningforEnrollment • Specialtimeandattentionshouldbegiventotheenrollmentofelderly anddisabledbeneficiaries. InOregon,Stateofficialsdidnotenrollthis population until a full year after enrolling TANF and expansion beneficiariesintomanagedcare. ThisgavetheStateadditionaltimeto resolveany"start-up"problemsbeforeattemptingtoenrollthemore vulnerablePhaseIIbeneficiaries. • When planning a managed care program for elderly and disabled beneficiaries,significanttimeshouldbeallowedtodevelopconsensus amongkeyconstituents. TheStateworkedwithadvocacygroupsto developspecialenrollmentproceduresandconsumerprotectionspriorto implementation. Whileplanningandconsensusbuildingmaynotappear HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare:E-l oreg2/enrollrpt/execsumm.wpd/nd ExecutiveSummary innovative,somestatesattemptingsimilarprogramsfailedtodoso(and encountereddifficulties,e.g.,Tennessee). ! = InvolvementofOtherPublicAgencies • Gainingthecooperationofsisteragenciesatboththestateandlocal r levelswaskeytothesuccessfulenrollmentofelderlyanddisabled beneficiariesinOregon. OMAPworkedcloselywiththeagencywith traditionalresponsibilityforthesepopulationsintheState:theSeniorand Disabled Services Division(SDSD). Becausethey feltpartofthe process, SDSD staff cooperated with, rather than resisted, the implementationofmanagedcarefortheirpopulations. • Givingitssisteragencyaroleintheenrollmentofelderlyanddisabled beneficiariesintomanagedcareplanswaskeytogainingitspolitical support.Becausethisagencywaswidelyperceivedasanadvocateforthe elderlyanddisabled,advocateswerereassuredthatcontinuityofcarewas lesslikelytobedisrupted. ConsumerProtections • Consumer advocacy and enrollment responsibility need not be inconsistent. BydelegatingtheenrollmentfunctiontolocalSDSDor AreaAgencyonAging(AAA)offices(ratherthantoanindependent broker),theStatehelpedensurethatchoicecounselingwasperformedby theworkersmostknowledgeableabouttheirclients. Localcaseworkers werebestsuitedtohelpensurecontinuityofcare,andweregiventhe authoritytoexemptindividualsfrommanagedcareonacase-by-case basis. Thetransitionofelderlyanddisabledbeneficiariestomanagedcarecan beeasedbytheintroductionofspecialprotections.InOregon,these included the use of Continuity of Care Referral Forms (written communicationsfromenrollmentworkerstomanagedcareplans)and ExceptionalNeedsCareCoordinators(ENCCs),astaffpositioncreated withinplansspecificallytoaddresstheneedsofthePhaseIIpopulation. HealthEconomicsResearch,IncJEnrollingtheElderlyandDisabledinMedicaidManagedCare:E-2 oreg2/enrollrpt/execsumm.wp(l/nd ExecutiveSummary DecentralizationandLocalControl • Instateswithstrongcountyorotherlocalgovernmentsinvolvedin ij servicedeliveryforelderlyanddisabledbeneficiaries,itispossibleto decentralizetheenrollmentfunctionandstillimplementastate-wide managedcareprogram. Becausedecentralizationmayintroducesome I inconsistenciesinenrollmentpracticesacrossareas,stateswillneedto provideongoingtrainingandothersupportstothelocalentities. • Local controloftheenrollmentanddisenrollmentfunctionsproved criticaltothe"buy-in"byadvocatesandothersofmanagedcarefor elderlyanddisabledbeneficiaries. Dissatisfiedbeneficiariesareableto changeplanssimplybycontactingtheirlocalworkers. Iflocalofficescurrentlycarryingouteligibilityandcasemanagement functionshavesufficientflexibilitytoallocatetheirstatefunds,theymay alsobeabletoperformtheenrollmentfunctionwithoutsignificantnew resources(atleastoncetheinitialwaveofenrollmentiscompleted). TheSpecialChallengeofDuallyEligibleBeneficiaries • Enrollmentofduallyeligiblebeneficiariesisextremelycomplexand time-consuming. Despitethe considerable amountoftime Oregon devotedtothistask,theState,theplans,andlocalenrollmentofficesall agreedthatthechallengehadbeengrosslyunderestimated. • Statesmustrecognizethatenrollmentofduallyeligiblebeneficiariesinto MedicareHMOsfortheirMedicarebenefits(whereappropriate)isa parallel,butseparate,processfromMedicaidmanagedcareenrollment. Coordinationofthesetwoproceduresremainsthegreatestsourceof frustrationamongOHPplans. ChoiceofPlans • Manyfactorsmayinfluenceplanchoicesamongelderlyanddisabled beneficiaries. The principal deciding factor appears to where the beneficiary's primary care provider participates. However, the recommendationofresidentialstaff(atgrouphomes, forexample), familymembers,surrogates,andenrollmentworkersalsocaninfluence choices. HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare:E-3 oreg2/enrollipt/execsummwpd/nd ExecutiveSummary Overone-thirdofduallyeligiblebeneficiariesareenrolledinOHPplans withacomplementaryMedicareHMO.Thepercentofduallyeligible beneficiariesenrolledinMedicareHMOsskyrocketedfrom10percent in1994to32percentoneyearlater(whenPhaseIIwasimplemented). However,itisnotclearhowwellduallyeligiblebeneficiariesinOregon understandtheirMedicarechoices. * J oHreega2/lentrhollrEpct/oexnecosummmi.wcpds/ndResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagfeedCare:E-4 jf Background Statewide§1115ProgramsforAllAges InFebruary1994,OregonlaunchedtheOregonHealthPlan(OHP),itsinnovative Medicaidreformprogram. ThisprogramextendsMedicaideligibilitytouninsuredresidents withincomesbelowtheFederalPovertyLevel,enrollsallbeneficiariesintomanagedcare, andusesaprioritizedlistofhealthcareservicestodefinethebenefitpackage.Managedcare enrollmenttookplaceintwostages:PhaseIenrolledtheAFDC(nowTANF)andexpansion populationsattheoutset,whileenrollmentfortheremainingMedicaidbeneficiariesbegan ayearlaterasPhaseII(February1995). ThispopulationconsistedofSSIbeneficiaries (including dually eligible beneficiaries1) and foster children, totalling about 71,000 individuals. InthisreportwedescribetheprocessusedbyOregontoenrollelderlyand «i disabledbeneficiariesintomanagedcare. SignificantManagedCareInfrastructure Unlikemanystates,Oregonhasalong-standinghistoryofmanagedcareenrollment ; inbothMedicareandtheprivatesector. In1994,justpriortoPhaseIIimplementation, almostone-thirdofOregon'sMedicarepopulationwerealreadyenrolledinHMOs,including 10percentofthosewhowereduallyMedicare-Medicaideligible. AtotalofsixMedicare HMOs(bothTEFRAriskandcost-based)wereoperatingintheState,andOregonwas jj amongthetopfourstatesinthecountryforMedicareHMOenrollment. Theexistenceof 0^ amaturemanagedcaremarketinOregonundoubtedlyeasedthetransitiontomanagedcare 's 1 AlsoincludedwereasmallnumberofelderlyanddisabledbeneficiarieswhoarenotSSI-eligiblebutstillqualifyfor MedicaidinOregon. HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare: 1 oreg2/enroilrpt/newtextwpd/nd forMedicaidbeneficiaries. Atthesametime,itmarkedlycomplicatedtheOHPenrollment processforduallyeligiblebeneficiaries(aswewillseebelow). Cost-SharingPolicyforDuallyEligibleBeneficiaries Oregonisoneofonlythree§1115waiverstatesknowntohaveobtainedpermission n foranow-controversialfeaturethatmakesiteasiertoenrollduallyeligiblebeneficiariesin managedcare. InOregon,ArizonaandMinnesota,capitationratesforMedicaidmanaged careplansincludetheMedicarecostsharingtowhichduallyeligiblebeneficiariesare ' entitled, andthe plans arenotrequiredto pass onthese copaymentstoproviders if beneficiariesgooutofnetworkwithoutreferralforMedicareservices. Thisprovidesan incentiveforduallyeligiblebeneficiariestoreceiveMedicareserviceswithintheplans' networksevenwhentheyhavechosenMedicarefee-for-service.Thisfeaturegivesstate Medicaidprogramsgreatercontroloverthecaretheirduallyeligiblebeneficiariesreceive andhenceoverspendingaswell. Itisunclear,however,whetherHCFAislikelytoapprove similararrangementsforotherstatesseekingwaivers. «•• BroadParticipationofPlansFostered AlthoughOregondidhaveoneofthenation'shighestmanagedcarepenetrationrates priortothedevelopmentofOHP,thismanagedcareactivitywaslargelyconfinedtothe westernareaoftheStateandHMOsoperatedinonlyeightofOregon's36counties. The OfficeofMedicalAssistancePrograms(OMAP),theStateagencythatadministersOHP, tookanumberofstepstofostertheparticipationofmanagedcareplansinOHPthroughout theState.First,OMAPchosenottomakelicensurearequirementforcontractingwithplans. HealthEconomicsResearch,Inc. EnrollingtheElderlyandDisabledinMedicaidManagedCare:2 oreg2/cnrollrpt/newtext.wpd/nd