MES Certification Navigator
MM

Member Management

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 (11)

RefOutcomeSources
MM1The system auto-assigns managed care enrollees to appropriate managed care organizations, per state and federal regulations.
CFR 42 438.54
MM2The 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.
CFR 42 438.10, 438.54
MM3The system disenrolls members at the request of the plan and in accordance with state procedures.
42 CFR 438.56(b)
MM4Disenrollments are effective in the system the first day of the second month following the request for disenrollment.
42 CFR 438.56(e)
MM5The system notifies enrollees of their disenrollment rights at least 60 days before the start of each enrollment period. This notification is in writing.
42 CFR 438.56(f)
MM6To 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).
42 CFR 438.208(b)
MM7The system allows beneficiaries or their representative to receive information through multiple channels including phone, Internet, in-person, and via auxiliary aids and services.
42 CFR 438.71
MM8The 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.
42 CFR 438.10(c)
MM9Potential 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.
42 CFR 438.10(e)
MM10The 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).
Section 1902(a)(83), 1902(mm), SMD # 18-007
MM11The 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).
42 CFR 438.68