Kaiser Family Foundation Survey on State Medicaid Managed Care ...

traded, and whether it is a local or national (i.e., multi-state) company.Overall, in FY 2011, 63 percent of Medicaid enrollees in MCOs were in plans that specialize in servingMedicaid. For-profit health plans accounted for a little over half of all Medicaid MCO enrollment (53percent). Non-publicly traded plans accounted for 58 percent of enrollment. Medicaid MCO enrollmentwas distributed about equally between national and local plans (Figure 2). 8Appendix 3 provides state-by-state detail on MCO contracts, plan characteristics, and enrollment.Most states require Medicaid MCOs to be licensed as HMOs. Federal regulations generally requirethat Medicaid MCOs meet state solvency standards established for private HMOs, or be licensed orcertified by the state as a risk-bearing entity. 9 The vast majority of the 33 states responding (of 36states with MCOs) reported that they require Medicaid MCOs to be licensed as HMOs or otherwiselicensed by the state insurance regulatory body, with specified, limited exceptions. Two states(Arizona and Maryland) indicated that they have no insurance licensure requirements. Six statesreported that they allow exemptions from state solvency requirements for Medicaid HMOs aspermitted by federal law, or for Provider Service Networks or Provider-Sponsored Organizations(PSNs/PSOs), or Health Insuring Organizations (HIOs).More than a third of states with MCOs provide for an external appeals process for MCO enrollees.Fourteen states with MCOs (of 34 responding) reported that, in addition to the state fair hearingprocess required by federal regulations, they provide for an external appeals process for MCOenrollees. 10Outreach, marketing, and health plan selectionMost states allow MCOs to conduct permissible outreach and marketing activities. A total of 28 states(of 34 responding) allow MCOs to conduct outreach and marketing to Medicaid beneficiaries withinfederal rules, while six states do not allow plans to conduct outreach or marketing.A substantial majority of states with MCOs 11 use enrollment brokers. Twenty-five states (of 35responding) reported that they contract with a third-party enrollment broker to provide planinformation to beneficiaries and assist them in choosing an MCO. Vendors listed by more than one stateinclude Maximus (11 states), Automated Health Systems (five states), ACS (three states), and HPEnterprise Services (two states).States’ auto-assignment algorithms typically reflect both beneficiary-based considerations and statepolicy objectives vis-à-vis MCOs. States prefer that beneficiaries make a choice from the health plansoffered. However, Medicaid programs with any mandatory managed care must have a system forassigning Medicaid beneficiaries who do not select a plan within the required timeframe (although thestates allow these beneficiaries an opportunity to opt out of the assigned MCO and into a different one).8 MCO enrollment information was not reported for Kansas or Nebraska.9 See 42 CFR §438.116. Exceptions apply to federally qualified HMOs, public plans, plans that are (or are controlledby) one or more federally qualified health centers, and those whose solvency is guaranteed by the state.10 The 14 states are California, Colorado, Delaware, DC, Florida, Hawaii, Illinois, Indiana, Michigan, New Jersey,Pennsylvania, Rhode Island, Washington, and West Virginia.11 Only states with MCOs were asked to report on enrollment broker arrangements.20 00