To control Medicaid budgets but also increase low-income families' access to quality
primary health care, sufficient momentum has gathered in many states over the last
…to move the focus of medical care from the emergency rooms and clinics of neighborhood
hospitals to alternative delivery sites, specifically to conveniently located community
clinics (linked to backup hospitals) and expanded health maintenance organizations...
As a result, and as the rationale behind states' commitment to Medicaid managed
care, many states
...have bolstered their efforts to successfully and effectively enroll a substantial
proportion of the Medicaid-eligible population in HMOs as a means of controlling
the steeply rising expenditures and improving the equality of care they receive.
To facilitate the change to this model of managed care, many states have launched
enrollment brokering initiatives to ensure the success of the transition away from
fee-for-service Medicaid or the PCCM approach. Serving as the link between the managed
care delivery system and Medicaid consumers, the enrollment broker (normally chosen
as the result of a competitive bid process) provides outreach, enrollment and education
services from a single, unbiased source to Medicaid consumers about the available
participating Medicaid HMOs in their area.
|AHS' Enrollment Broker Contracts
|2010 - Present
||Agency for Health Care Administration
Medicaid Reform Enrollment Broker Program
|2006 - 2013
||Department of Healthcare and Family Services
Illinois Client Enrollment Broker program development and administration
|1998 - Present
||Department of Job and Family Services
Managed Care Plan Enrollment Services program administration
|1996 - Present
||Department of Health and Family Services
Managed Care Outreach, Enrollment and Education Specialist program administration
|1996 - Present
||Department of Health and Human Resources
Health Benefit Manager program administration
These HMOs (through their associated primary care providers) function as the "gatekeepers"
for Medicaid consumers-assisting, guiding and overseeing the utilization of health
services. As many states prudently have recognized, however, an HMO's gatekeeping
function is undermined if the consumer is not well-educated about managed care,
the role of HMOs and PCPs, and helped to wisely choose the "best fit" HMO/PCP. Enrollment
brokers educate the potential and current managed care enrollees with respect to
these issues. Only if the Project staff delivers an accurate, understandable and
culturally sensitive presentation can the benefits of managed care be realized.
Fortuitously, this is what happens when Automated Health Systems, Inc. (AHS) is
the enrollment broker, as we are in Florida, Illinois, Ohio, West Virginia, and
Wisconsin. Additional information about these contracts is provided below.
1 Eli Ginzberg, Improving Health
Care for the Poor: Lessons for the 1980's, JAMA, February 9, 1994, pp. 466.
2 Ibid., p. 467.
Florida Medicaid Reform Choice Counseling and Medicaid Options Project
Florida Medicaid Reform began in Broward and Duval counties in July, 2006, and expanded
into Baker, Clay and Nassau counties in July, 2007. Under Medicaid Reform, health
care services are provided by Health Plans, several of which are “specialty plans”
that offer services tailored to specific medical group needs and provide services
currently not offered by Medicaid.
One of the enhancements offered to Medicaid Reform enrollees is the ability to participate
in the Enhanced Benefits Reward$ Program, which allows enrollees who engage in healthy
behaviors to earn credits in their personal Enhance Benefits Reward$ Program account.
These credits can be used to purchase items such as over-the-counter drugs, vitamins,
and other health-related products at any Medicaid-participating pharmacy.
In 2010 AHS was awarded the Medicaid Reform Choice Counseling contract, through
which AHS’ Call Center Choice Counseling Specialists provide unbiased information
and education regarding the Medicaid Reform Program, available Health Plan options,
rights and responsibilities, enrollment timeframes, etc. and process Health Plan
enrollments, changes, and disenrollments as appropriate. Our Field Choice Counseling
Specialists do the same; however, these staff may also engage with enrollees during
group or one-on-one sessions at community sites or special needs agencies or, in
some instances, at the enrollee’s home. Special Needs Coordinators are available
via the Call Center to provide more detailed support, research, and follow up for
enrollees with complex physical or behavioral health care and other social needs.
Additionally, AHS’ Enhanced Benefits Reward$ Choice Counseling Specialists also
help enrollees understand how to earn credits and respond to benefit/balance inquiries.
One year after taking over the Medicaid Reform Enrollment Broker contract in Florida, AHS expanded our enrollment broker operations statewide to include all 67 reform and non-reform counties. Through the Medicaid
Options (non-Reform) contract, AHS informs an additional three million enrollees
throughout the State about the various managed care options available to them and
provides choice counseling in order to help them make a "best fit" managed care
selection. More information on these projects is available at www.flmedicaidreform.com and
Illinois Client Enrollment Broker Project
AHS provides comprehensive, unbiased phone- and field-based outreach, education,
and enrollment services to enrollees residing in counties where risk-based managed
care and PCCM are jointly offered. We also provide comprehensive mailings, including
initial New Enrollment Welcome packets, enrollment reminder letters, and auto-assignment
confirmation letters. Our sophisticated website includes not only links to all of
our educational materials and a calendar with links to our outreach events, but
also includes a robust, secure online enrollment module.
In March 2011, AHS also assumed enrollment broker responsibilities for the Aged,
Blind and Disabled (ABD) population. To ensure high service delivery, AHS reached
out to Enrollment Facilitators (community partners responsible for assisting eligibles
with enrollment selection and enrollment), coordinated the completion of contracts
and Business Associate Agreements, and trained and provided follow-up assistance
to Enrollment Facilitators. As part of this expansion, all information technology
activities were smoothly coordinated with the State in advance of the expansion,
and all customer service staff were provided with training on providing unbiased
support and education to the ABD population.
More information about the Illinois Client Enrollment Broker Project is available
Ohio Enrollment Broker Services
In May of 1998, AHS was awarded a contract with the Ohio Department of Human Services
(now the Department of Job and Family Services) to administer an Enrollment Services
Project for the State’s Medicaid managed care expansion. Although the implementation
time frames were tight, AHS met the deadlines and began providing services on July
We currently interact with eight Health Plans, both voluntary and mandatory depending
on the county. Weekly selection, change, and assignment information is sent to each
plan for PCP assignment and selection verification. AHS is also responsible for
Health Plan assignment, a process involving on-line updates to the State’s Client
Eligibility System (CRIS-E) that occurs daily, and we assist enrollees with voluntary
PCP selection. Through a phone-accessed Managed Care Enrollment Center (MCEC), AHS
assists enrollees in enrolling in a Health Plan and selecting a PCP.
Additionally, AHS understands the needs of long-term care consumers enrolled in
various Medicaid programs, which often reflect more complex health needs as well
as a desire and need for more in-depth counseling, and we are working with the State
to implement an enrollment strategy for consumers participating in various long-term
care programs and facilities. For example, simply knowing that a Health Plan provides
all the services a consumer requires is not enough; how best to coordinate those
services is also a critical part of the selection process. Appropriate medical homes,
available care teams as well as the integration of the behavioral and physical health
services must all be taken into consideration. AHS has effectively trained and equipped
staff to assist these consumers in navigating these often confusing waters, all
with sensitivity and compassion in an unbiased manner. When AHS was successfully re-awarded this contract in 2012, the contract was modified to include operation of the Ohio Medicaid Consumer Hotline.
More information about AHS’ Enrollment Broker Services in Ohio is available
Wisconsin Enrollment Broker Services
In 1996, the Wisconsin Department of Health and Family Services (DHFS, now the Department
of Health Services) contracted with AHS to become the Enrollment Broker Contractor
and assist the state with Medicaid managed care expansion. At that time, enrollment
into Medicaid and BadgerCare HMOs (Health Maintenance Organizations) became mandatory
for consumers in zip code areas where there were two or more HMOs available from
which to choose. Additionally, we began to provide outreach, education and enrollment
for the SSI Managed Care Program in 2005.
Both our Call Center Customer Service Representatives and our field Outreach Specialists
use our tested education materials when working with potential and/or current Enrollees
to help determine their needs and assist them in identifying the MCO and/or PCP
with the best combination of location, cultural and linguistic characteristics,
and background or specialty to meet their needs. We understand that individuals
must be empowered to make their own healthcare decisions, and we strive to ensure
that Enrollees, not only select the best-fit health plan, but also understand how
to access the services available to them.
To further broaden our reach, we network with local and grassroots agencies in the
community to help us “spread the word” to our shared constituents. The provision
of technical assistance to these agencies is part of an outreach effort that maximizes
the talents of a wide array of public and private health, human, social, educational,
faith, governmental and civic entities as community partners. We have an excellent
reputation of working with community-based organizations to strengthen our outreach
and education efforts and enhance the community perception of the program.
Access the Wisconsin Department of Health Services' website at dhfs.wisconsin.gov.
The Wisconsin Enrollment Broker Project's home office is in Milwaukee. Call Center
Staff are available to assist clients via telephone on weekdays between 7:00am and
6:00pm. We have bilingual Spanish and Hmong staff as well as access to services
for clients who speak other languages and for clients who are deaf or hearing impaired.
The Enrollment Broker Call Center can be reached by calling toll free: 1-800-291-2002.
West Virginia Health Benefits Manager and Enrollment Services Project
AHS has been the Health Benefits Manager and Enrollment Services contractor for
the State of West Virginia since 1996. Prior to 1996, West Virginia Medicaid consumers
all participated in Fee-for-Service. AHS actively helped design and implement the
combination of a risk-based Health Plan component (Mountain HealthTrust, MHT) and
a PCCM effort (Physician Assured Access System, PAAS). AHS worked extensively to
network with community and provider groups and promote a successful managed care
experience for West Virginia’s Medicaid enrollees.
In 2007, the State implemented Mountain Health Choices (MHC), a Medicaid Redesign
initiative intended to dramatically increase the role of the enrollee in health
maintenance and disease prevention, and AHS actively participated in this implementation.
Upon redetermination, AHS enrolls each enrollee in a “basic level” plan and sends
an enrollment packet asking him/her to make a choice of Health Plan/PCP. The packet
includes a Member Agreement with a letter of explanation. Enrollees then have 90
days in which to meet with their PCPs, agree upon a health goal, return the Agreement
to AHS, and subsequently are enrolled in an “enhanced level” plan.
Those enrollees who take advantage of this opportunity to improve their health status
and make progress in reaching their goals accumulate Healthy Rewards (services not
usually covered by Medicaid) and maintain Enhanced coverage. At the end of a successful
year, the consumer has points in his/her Healthy Rewards Account that can be used
for benefits such as a health club membership.
More information about the West Virginia Health Benefit Manager Project is available