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Enrollment - Key Considerations

Voluntary vs. Mandatory Enrollment

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

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

Managing the Enrollment Function

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

Enrollment Counseling

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

Level-of-Care Assessments

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

Enrollment Periods

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

Marketing Protections

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

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




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