Enrollment

TMG Health provides enrollment services for Medicaid Managed Care Organizations (MCOs) that meet member and provider needs, and comply with government requirements for timeliness and accuracy. We are prepared to handle the continual turnover of enrollees, complexities of eligibility, and critical fi nancial reconciliation, to lay the foundation for subsequent claims, fulfi llment and other activities.

Under Healthcare Reform there will be a dramatic increase in the number of enrollees in Medicaid and/or Expanded Medicaid Managed Care. Managed Care Organizations will have new enrollment models to participate in, such as Exchanges and Accountable Care Organizations. TMG will be there to help. Our experience in working with the Medicaid population and understanding their special needs includes an emphasis on dual eligible servicing (Medicare and Medicaid) for the most vulnerable population of the poor, elderly and chronically ill.

The "Revolving Door"
Medicaid enrollment tends to be highly dynamic and volatile, as members move in and out of the plans due to changes in their eligibility, income thresholds, addresses, plan desirability, etc. Most states have open enrollment, which means that members can change MCOs and plans as often as monthly. Generally, after managed care is established in a state or region, there is a fairly low percentage of switching from plan to plan. However, in a new start-up (either when a totally new managed care program is introduced in a state, or when a new set of people are added, e.g., a new eligibility category or a new geographic region), a signifi cant amount of switching typically takes place until individuals get into the plan that they really want.

From an MCO perspective, while the total number of Medicaid enrollees may remain fairly stable, the actual individuals who are members may change signifi cantly from month to month. Eligibility must be re-established on a periodic basis (state-defi ned), usually every 6 to 12 months. Even in the states that have a longer timeframe, individuals frequently move on and off of Medicaid because of changes in their incomes or other situations affecting their eligibility. Many people on Medicaid are working poor, whose job history is sporadic and whose monthly income varies, so in a given month, they may not receive many hours, tips, etc. - and so their income is below the Medicaid threshold. In the next month they may get regular hours or some overtime, and as their income edges over the threshold, they lose their Medicaid eligibility.

We pride ourselves on responsiveness to member inquiries; timely production of member ID cards, HRAs and other materials; and member help "touch points" and proactive "reminders" of upcoming health needs and events via cell phone, PDA, etc.

Timelines and Accuracy
Timeliness and accuracy of enrollment fi les processing must meet strict federal and state guidelines. Delays and errors can impact members' ability to access treatment, as well as plan compliance. States have different schedules and frequency requirements for sending enrollment files to the MCO. All of the steps leading to accurate acceptance, reconciliation and processing of a file, including having it sent on to subcontractors, processed to determine who doesn't have a Primary Care Physician (PCP), and reviewed to identify any problems, need to be done quickly. Some states impose financial penalties if the standards aren't met.

Retroactive Eligibility
Another result of the dynamic nature of Medicaid eligibility is that individuals often become retroactively eligible or ineligible. This means that some claims may have to be paid or capitation issued retroactively. The reverse can also be true: i.e., the enrollment file triggers a need to review whether claims that have already been paid are now not Medicaid and the MCO's responsibility - and thus payment needs to be retracted from the provider.

A significant number of people actually become eligible for Medicaid while they are in the hospital. Depending upon the timing of their admission and the eligibility determination process, those situations can also create retroactive eligibility.

Financial Reconciliation
Enrollment files often need to be reconciled with a separate payment file so that an MCO can confirm that it is getting paid accurately by the state. This reconciliation includes not only ensuring that the plan's enrollment files match the state's payment for the enrollee. All of the variables mentioned above, as well as details such as partial month eligibility and category of eligibility (since these can change for an individual and have different payment rates from the state), need to be taken into consideration.

Eligibility Check
Physicians and other providers need to be able to quickly ascertain eligibility before they provide service. Since members can lose eligibility but still have a card from their previous Health Plan, most states tell providers that they should check eligibility prior to every visit/service. Many States have some type of automated system through which providers can check if the member is eligible, and under which MCO. However, those systems often don't show the PCP for the member. Some network providers may still want to check directly with the MCO.

In a broad sense, enrollment is the foundation of much of an MCO's subsequent work. An MCO wants to know that the eligibility file will be accepted from the state or the enrollment broker; be processed efficiently, with any potential errors found quickly; and be sent to subcontractors and other functional areas so that required actions can be taken to intake the new member, ensure that they have a PCP, etc. The information needs to be readily available throughout the plan and to providers, so that new members can get the services to which they are entitled. And the file needs to be scrubbed to ensure that it can be reconciled with payment from the state.

TMG Health has automated much of this process to keep costs in line. When TMG receives the 834 HIPAA-compliant membership files from the state Department of Health Services, we immediately validate the applications (or additions) against the state system to verify Medicaid eligibility. Valid enrollments are automatically directed to TMG's Managed Care Information System. If there are any issues, an Eligibility Query error is queued and directed to an enrollment processor for resolution. Unresolved eligibility files (members) are made available for resolution determination. Finally, TMG will automatically produce and submit the appropriate state Medicaid extract in the required state layout.

TMG's cost-effective, service-oriented solutions allow you to minimize your capital investment; eliminate ongoing system costs and IT resource requirements; greatly reduce costs for acquiring, training and maintaining staff; and enjoy constant access to state-of-the-art systems and best practices.

Newborn Eligibility TMG Health is prepared to handle the unique issues arising from Newborn Eligibility. Requirements vary from state to state, but essential steps include notification that a baby has been born, assignment/choice of an MCO and a PCP for the baby, and arrangements for the hospital to bill (and the MCO to pay) for the newborn’s stay in the hospital. This is a particularly important issue for Medicaid since many of these babies are born with medical issues

and stay in the hospital beyond the mother’s discharge date. Another common Medicaid scenario is that the mother is an undocumented alien and (in most states) not eligible for Medicaid. But the baby is an American citizen at birth and is often eligible for Medicaid.