Member Management
How this system supports the Medicaid Program
The Member Management module includes the function of determining eligibility for Medicaid, along with enrollment of members in their benefit delivery entities and the ongoing management of that member for the duration of their enrollment in Medicaid. Activities associated with Member communications and responding to Member requests are included as well.
CMS-Required Outcomes
Each CMS-Required outcome is based on statutory or regulatory requirements. CMS-Required Outcomes and Metrics are used to demonstrate that a system is compliant with the applicable federal regulations which pertain to that specific system or module. CMS-Required outcomes form the baseline for system/module functionality, which must continue to receive enhanced federal funding for operations.
| Reference # | CMS Required Outcomes | Default Metrics | Regulatory Sources |
|---|---|---|---|
| MM1 | The system auto-assigns managed care enrollees to appropriate managed care organizations, per state and federal regulations. | - Percentage of system auto assignment for MCO enrollees ongoing basis. | CFR 42 438.54 |
| MM2 | The system sends notice, or facilitates, to the enrolled member with an initial assignment, a reasonable period to change the selection, and appropriate information needed to make an informed choice. If no selection is made, the system either confirms the original assignment, or assigns the member to FFS. |
- Notice to the enrollee must be provided by the later of 30 calendar days prior to the effective date of the termination, or 15 calendar days after receipt or issuance of the termination notice.
- For States that choose to restrict disenrollment for periods of 90 days or more, States must send the notice no less than 60 calendar days before the start of each enrollment period. | CFR 42 438.10, 438.54 |
| MM3 | The system disenrolls members at the request of the plan and in accordance with state procedures. |
- Disenrollment requested by the enrollee. Without cause, at the following times:
- During the 90 days following the date of the beneficiary's initial enrollment into the MCO, PIHP, PAHP, PCCM, or PCCM entity, or during the 90 days following the date the State sends the beneficiary notice of that enrollment, whichever is later. - At least once every 12 months thereafter. | 42 CFR 438.56(b) (c), and (d) |
| MM4 | Disenrollments are effective in the system the first day of the second month following the request for disenrollment. | - Disenrollments are effective the first day of the second month following the request for disenrollment. | 42 CFR 438.56(e) |
| MM5 | The system notifies enrollees of their disenrollment rights at least 60 days before the start of each enrollment period. This notification is in writing. | - The system notifies enrollees, in writing, of their disenrollment rights at least 60 days before the start of each enrollment period. | 42 CFR 438.56(f) |
| MM6 | To prevent duplication of activities, enrollee's needs are captured by the system so that MCOs, PIHPs, and PAHPs can see and share the information (in accordance with privacy controls). | - The MCO, PIHP or PAHP makes a best effort to conduct an initial screening of each enrollee's needs, within 90 days of the effective date of enrollment for all new enrollees, including subsequent attempts if the initial attempt to contact the enrollee is unsuccessful. | 42 CFR 438.208(b) |
| MM7 | The system allows beneficiaries or their representative to receive information through multiple channels including phone, Internet, in-person, and via auxiliary aids and services. | - Percentage of beneficiaries or their representative received outreach communication by the following channels: phone, internet, in-person, and via auxiliary aids and services | 42 CFR 438.71 |
| MM8 | The state provides content required by 42 CFR 438.10, including but not limited to definitions for managed care and enrollee handbook, through a website maintained by the state. | - An electronic provider directory must be updated no later than 30 calendar days after the MCO, PIHP, PAHP, or PCCM entity receives updated provider information. | 42 CFR 438.10(c) |
| MM9 | Potential enrollees are provided information about the state's managed care program when the individual become eligible or is required to enroll in a managed care program. The information includes, but is not limited to the right to disenroll, basic features of managed care, service area coverage, covered benefits, and provider directory and formulary information. | - Notice to the enrollee must be provided by the later of 30 calendar days prior to the effective date of the termination, or 15 calendar days after receipt or issuance of the termination notice. | 42 CFR 438.10(e) |
| MM10 |
The system maintains an up-to-date (updated at least annually) fee-for-service (FFS) or primary care case-management (PCCM) provider directory containing the following:
• Physician/provider • Specialty • Address and telephone number • Whether the physician/provider is accepting new Medicaid patients (for PCCM providers), and The physician/provider's cultural capabilities and a list of languages supported (for PCCM providers). | - The system maintains an up-to-date (updated at least annually) fee-for-service (FFS) or primary care case-management (PCCM) provider directory. | Section 1902(a)(83), 1902(mm), SMD # 18-007 |
| MM11 | The system captures enough information such that the state can evaluate whether members have access to adequate networks. (Adequacy is based on the state's plan and federal regulations). | - Calculate accessibility of members to providers’ network based on state and federal regulations. | 42 CFR 438.68 |
State-Specific Outcomes - CMS Approved
States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.
When drafting state-specific outcomes statements, keep these tips in mind.
Examples for Member Management
We are actively gathering and evaluating outcomes statements crafted by states for this business area.
Please send examples from your state that you’d like to share to MESCertificationRepo@cms.hhs.gov. Our team will collect and share the best examples.
| State | Medicaid Program Goal | Outcome Statement | Metric(s) |
|---|---|---|---|