Ohio Medicaid is considering changes to its enrollment process. What would that mean?

Titus WuThe Columbus Dispatch

When the Ohio Department of Medicaid went through its years-long process to revamp the Medicaid system, virtually all aspects were examined – including how participants enroll into it.  

The department hasn't publicized changes to the enrollment process, which will affect the more than 3 million low-income or disabled Ohioans who rely on government health insurance. Open enrollment into one of the state's six or seven Medicaid-managed care plans occurs every November.

But the department's initial plans have received some criticism, a reason the department is still reviewing and finalizing details.  

"We've had different discussions with different individuals and organizations. We are looking at that, and whether to make some changes to that policy," said ODM Director Maureen Corcoran in an interview. "We're working at potentially doing it differently."

How Medicaid enrollment is currently done 

As it's done now, a Medicaid participant already enrolled in a plan gets automatically assigned back to the same plan.      

If a person is newly eligible, the applicant is first checked if he can be put on a family member's same plan, as the case is for newborns. If not, the department looks at the doctors that an applicant has used to see which plan most of the providers are associated with. Any remaining people are then put through a "quality-based assessment assignments process" based on plan performance in areas such as payment and quality measures.      

The member gets notified that he or she has been assigned to a plan, and within 90 days, the member can voluntarily choose to make a different selection instead.

Overall, it's a mostly hands-off process for the individual.

A more active enrollment?

When it was looking at ways to revamp the system, the department took the position of wanting participants to be more actively involved in choosing a plan.

"Our goal was to try to help everyone make a choice," said Corcoran. "We want to try to educate and provide information about available services, so that we could improve the overall health literacy of everyone on the program, rather than sort of default."

Automatic enrollment into one's original plan would be taken away. Almost all applicants would be required to actively select a plan, and if they didn't, then they would go through the quality-based assessment process, which would also get an updated algorithm. 

The underlying idea was that the more people know about their own plan, the better the health outcomes.

"There were people on the program who didn't even realize some of those simple things… about transportation being available to your doctor, or that your management people can help coordinate your care," the director said.

But some have worried such changes would pose barriers for the Medicaid population, who tend to be difficult to reach and in disadvantaged communities. Therefore, they're less likely to successfully navigate the additional red tape and actively enroll.  

"Medicaid members would be at risk of being assigned to new plans without their direct approval or knowledge," wrote Franklin County Commissioner Erica Crawley. "People could experience obstacles or disruptions in their health plans and coverage."  

According to the department, only around 20% of people in the past actively chose their plans during open enrollment. Most prior communication has been only through the mail, said Corcoran, and the hope is to get the percentage up with a more aggressive communication strategy.  

But the department acknowledged Crawley's arguments and is reevaluating.

Financial stakes involved 

Loren Anthes, who leads the Community Solutions’ Center for Medicaid Policy, agreed with Crawley's point on the importance of ensuring continuity of care. The Medicaid population is hard to reach, but that's on the managed care plans, which are paid billions to do their job, he argued.   

He noted enrollees would likely still have that 90-day process to choose a different plan from the one they're automatically enrolled into. Even for folks who simply don't want to choose, getting a new plan through the quality-based assessment process could be better than automatic re-enrollment. 

"If you didn't make a choice, wouldn't you want to have your coverage be driven by who's doing the best, rather than who covered me before?" said Anthes.

Underlying that question are the implications of the huge financial stakes involved. The Medicaid portion is typically the state government's biggest expenditure; the contracts for new managed care plans total near $20 billion.  

The plans and the companies handling them are paid by the state a certain amount of dollars per patient taken care of. Any substantial dip in the number of enrollees could mean substantial money loss.  

Just by the numbers, the managed care organization at biggest risk from the elimination of automatic re-enrollment is Dayton, Ohio-based CareSource, which serves 1,409,000 of the 2,849,000 Ohioans in managed care – nearly half the total, state data shows.    

CareSource declined to comment for this story, saying in an email "there would be no value in us speculating on what we might be reacting to" until enrollment changes are finalized.

While MCOs are ensured a certain number of participants to be kept financially viable, the new algorithm for the "quality-based assessment process" – used to automatically  assign plans to people who don't actively choose – could pose another risk.

Corcoran said the algorithm will see changes, such as incorporating data from the new managed care plans entering into the Medicaid system. She declined to comment on details of other alterations currently being discussed.

According to Anthes, documents during the procurement process suggested changes would tie more of the algorithm into performance and quality.  

"We're going to say as a state of Ohio, when you do better managing those things, you will get a greater market share," he said. "That is very threatening to people who don't perform particularly well."

Regardless of whether financial interests or concerns about access are driving the conversation, finalized details are coming soon, the department said. Ultimately, the people enrolled in Medicaid are the top priority for any changes, said Corcoran.

"The last thing we want to do is disenfranchise anybody," said spokesperson Lisa Lawless.