Wednesday, April 27, 2016

The Medicaid Managed Care Regulation is here!

Since the last major updates to Medicaid Managed Care regulation in 2003, Medicaid and managed care have both evolved dramatically. After years of waiting, CMS released the long-awaited final Medicaid Managed Care 'Mega-Reg' Rule. For those of you who would like to review it immediately, it is available here. As you know, this draft regulation will govern the activities of states and plans participating in the Medicaid and CHIP programs going forward. The time to plan has ended! It is “Game Time”!

IIR's Medicaid Managed Care Congress will be your first opportunity to dissect the implications of the Mega Reg and its impact on your daily operations and overall bottom line from thought leaders in the space including ACAP, Mostly Medicaid, and more.


Medicaid Managed Care Congress (MMCC 2016)
Marriott Harbor Inn
Baltimore, MD
May 18-20

MMCC’s Mega Reg Pre-Conference symposium will address and break down the rule, and analyze and interpret its effect with like-minded individuals and organizations. Key topics will include:

• Require transparency and fairness between plans and states in rate-setting
• Encourage efficient, realistic use of limited resources;
• Hold fee-for-service programs to the same standard as managed care;
• Set standards for network adequacy which reflect local conditions as they exist;
• Provide for realistic implementation timeframes for both plans and states;
• Promote the movement to value-based payment strategies; and
• Provide for comprehensive, accurate and fair quality reporting and standards.

Click here to download the full MMCC 2016 brochure

Below is a preview of the sessions in the Mega-Reg symposium:


Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations Association for Community Affiliated Plans (ACAP)



Clay Farris, Senior Healthcare Executive
Mostly Medicaid


Deborah Kilstein, Vice President, Quality Management and Operational Support
Association for Community Affiliated Plans (ACAP)



Larry Heyeck, Deputy Director for Legal Services State of New Mexico


Amy Thomas, Assistant Director of Plan Support
Association for Community Affiliated Plans (ACAP)

Have a comment? Share your thoughts in the comments section or follow us on Twitter: @healthcarebiz and #MMCC16

Tuesday, April 19, 2016

Medicaid Managed Care Congress: Q/A with Carol Steckel (WellCare Health Plans)

Medicaid Managed Care Congress
With the Medicaid Managed Care Congress (MMCC 2016) right around the corner (May 18-20, 2016) we have reached out with the Q/A to one of the keynote speakers Carol Steckel, MPH Sr. Director,  Alliance Development, WellCare Health Plans, Inc.

What do you think will be the major implications of the Mega-Reg?

- Mega-Reg has the potential to strengthen the states’ ability to use managed care to promote innovative and cost effective methods of delivering quality care to Medicaid and CHIP beneficiaries.

What do you wish someone would have told you before joining Medicaid/healthcare industry?

- Navigating such a complex system can pose challenges and the system routinely and frequently changes. These challenges are offset by the knowledge that the work you are doing is improving the lives of the people we serve.  

What upcoming major trends are you excited about?

- There is great opportunity for states and managed care organizations to work together to empower people to take control of their health. I am most excited about the linkages we are developing between physical health, behavioral health, and social determinants of health.

What is the secret to success in your opinion?

- Working hard to be part of the communities where our members live helps us bring together the resources needed to serve the most vulnerable populations. Our members often face challenges in life beyond their health. By connecting them to needed social and community services, we seek to improve their ability to take control of their health by addressing their overall needs. We also strive to engage them in needed preventive health services to ensure they are getting the right care at the right time at the right place.

For MMCC, what do you hope to learn more about / who do you want to hear from?

- Providing care to vulnerable populations often involves going the extra mile to find and engage members where they live, whether that is in their homes, in a shelter or under a bridge – none of which is possible without collaboration across sectors at the local level. Learning more about the efforts of community organizations working to support the social safety net can help MCOs identify and address care gaps that may be barriers to health. 

Do you have any best practices of success stories you’d like to share? If so, please elaborate.

Medicaid Managed Care Congress presenter's logo - WellCare Health Plans- WellCare uses a coordinated care approach designed to ensure all of our members receive the unique services and supports they need to achieve and maintain the best health outcomes possible. This is based on our belief that a healthy community is one where social safety net providers and community-based organizations are thriving and supporting the needs of its citizens. We identify care gaps, which occur when the social safety net is stretched too thin. We partner with community groups to address these needs, and close the care gaps. We also work with academic partners to evaluate the programs to quantify the results in terms of cost savings, increased access to health case, and other benefits to the public health system. This approach allows us to deliver on our mission of enhancing our members’ health and quality of life and strengthening the communities we serve. 

Carol Steckel will also be presenting at the MMCC 2016 with a case study "Community advocacy, health connections model" which will cover three important questions:

- How to link a member to a community and/or social service?
- How to support the community in developing needed services?
- How to measure the impact of the program on our members?

To learn more about Carol Steckel's case study or to see who else will be presenting at the Medicaid Managed Care Congress download the brochure here

Have a comment? Share your thoughts in the comments section or follow us on Twitter: @healthcarebiz and #MMCC16

Tuesday, April 5, 2016

How Providers Can Help Increase Transparency Into Policy Plans

While doctors and dentists are on this this earth to help us live long and healthy lives, that often does little to ease the anxiety that many feel when visiting their office. In fact, increased levels of stress almost always accompany a visit to either the doctor or dentist’s office, in addition to a corresponding elevated blood pressure reading. The process can be made easier and more settling, however, when these same doctors and dentists properly educate their patents about new processes and policies being incorporated into the insurance.

Much of the anxiety that occurs when needing to go the dentist or doctor revolves around cost. Many simply do not know how, or if, they will be able to pay for any medical procedures that become necessary. They cannot understand their insurance policy, and are unsure of where to even go for help. For this reason alone, a staggering number of Americans simply stay away from the Doctor or Dentist’s office altogether until it is often too late. There are, however, certain things that insurance providers can due to help increase transparency within their policy plans.

Transparency Made Easier Under the Affordable Care Act

Transparency Made Easier Under the Affordable Care ActOne of the final rules implemented as a provision within the Affordable Care Act was a requirement that all health plans now should provide consumers with a uniform summary of coverage. This applies to those people currently enrolled in a place, as well as new applicants. This is a step in the right direction, as it now ensures that individual dental insurance is transparent and easy to understand. Benefits and provisions of coverage should be more clearly spelled out of individuals, and this will make it easier for them to determine what is and is not covered, and to what extent.

In this regard, providers can help to ease the stress and anxiety that many consumers feel over health and dental insurance related issue. In the past, it was felt that many individuals faced too many choices when dealing with insurance policies, and that they were not adequately informed as to how coverage actually works. One survey even found that people would prefer to go to the gym or even work on their taxes than take the time to read through earlier versions of health insurance policies.

The Transparency of Coverage Disclosures

Most insurance policies must now disclose any information that would enable consumers to better understand how their particular plan will reimburse the claims that are made for covered services, and whether or not a service would actually be covered under the existing policy. In essence, the following information must be disclosed in a transparent and easy to understand manner:

• Polices and Practices Related to the Payment of Claims
• Financial Disclosure to be Made on a Periodic Basis
• Data Enrollment Must be Disclosed
• Data Account For Those Who Unenroll Must Be Disclosed As Well
• Information on the number of claims that are denied in the end
• Information about rating practices
• Data related to cost-sharing and payments, particular in terms of out-of-network coverage that is available
• Data of the rights afforded to enrollees and participants under the terms of the policy

All of the information mentioned above is to be written in clear English that is geared specifically to the consumer, and should be designed for people who have limited proficiency in the language. This effectively makes it easier for individuals to understand their policy and what they should expect from the insurance provider.

While there will likely still be a great deal of anxiety associated with visits to the doctor or dentist, this will be lessened somewhat with the advent of these new policies. Knowing what is covered and how the benefits will be paid can go a long way towards not only lessening the financial burden on the individual, but also towards making the process much more streamlined and comfortable in the end.

About the author:

Greg Dastrup is a world traveler and professional writer with a passion for learning new languages. He’s spent most of his career consulting for businesses in North America. You can follow Greg here.

Friday, April 1, 2016

The Implications of the Mega-Reg on the Medicaid Managed Care Industry: 2016 & Beyond

Healthcare word cloud featuring Managed Care, Healthcare Policy, Insurance
2016 is a year of transformation for the healthcare ecosystem - over the past year we’ve seen the implementation of major ACA provisions, delivery system reforms, payment reforms, and states pursuing better value. There’s been a recent shift away from taking a budget-driven approach, and is now driven by the desire to improve quality and outcomes. The implications will be huge and will go beyond Medicaid. 

We’ve had a short Q/A with Jennifer Babcock, Vice President for Medicaid Policy and Director of Strategic Operations, Association for Community Affiliated Plans (ACAP), who will also be chairing and presenting at the Medicaid Managed Care Congress in May. 

What upcoming major trends are you excited about? 

Medicaid is undeniably undergoing a great deal of change right now, and there are many advancing trends keeping all Medicaid policy analysts on our toes. One of the most exciting, from my perspective, is efforts by Medicaid health plans to impact social determinants of health and to integrate within the health plan help for people to get jobs, housing, nutritional support, even support as they leave the criminal justice system. A substantial number of ACAP member plans are doing important work in these areas, as described in a fact sheet we produced in 2014. Efforts by health plans to impact social determinants underscore that 
our collective goal is to improve the health and well-being of people covered in Medicaid.

Secondly, I’m excited to learn about efforts by plans, states, and providers to look at improving quality of health at the population level. Again, these efforts offer a great opportunity to
improve the health of the entire nation, given how expansive a coverage program Medicaid is. 

What do you think will be the major implications of the Mega-Reg? 

If finalized the way we at ACAP hope, the Mega Reg will erase any lingering questions about the crucial role MCOs play in Medicaid, leading the way to greater emphasis on the partnership between states and plans. I hope, for example, that CMS will require transparency between states and plans in general, and in particular with regard to the rate-setting process to ensure that all rates are set and approved in a timely and comprehensible manner. Also, I would like to see CMS move toward payment and coverage models that use MCOs to promote population health. Lastly, I would like to see movement toward standardized quality measurement that allows us to learn what Medicaid pays for, not just in MMC, but FFS as well.

Do you have any best practices of success stories you’d like to share? 

My colleagues at ACAP worked with a subset of ACAP plans last year on a substance use disorder collaborative, which resulted in this toolkit, which is available publicly for other health plans to use. This toolkit provides best practices for plans working with individuals impacted with SUD, including opioid addiction. It’s an example of how effectively and quickly Medicaid MCOs can respond to a significant population health problem. We are very proud of these plans’ efforts. 

For MMCC, what do you hope to learn more about? 

I am looking forward to hearing from the real experts about quality in Medicaid managed care and Medicaid. I am anxious to gain insights about how best to coordinate and standardize the myriad quality measurement and reporting efforts so that we can get on with the business of using results to improve care for people, and to improve Medicaid overall, and CHIP as well. While it’s fascinating to see the efforts many states are making to report on the adult and pediatric core measures sets (the CMS 2015 Annual Report on the Quality of Care for Adults in Medicaid and 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP were released in February of this year), I feel strongly that we all can do more to ensure that quality of care for Medicaid and CHIP enrollees is measured, reported, and improved.

Learn about the implications of the new regulations and beyond by joining the Medicaid Managed Care Congress (MMCC) in Baltimore, MD (May 18-20, 2016.) For more information about MMCC 2016 visit the website here.

Have a comment? Share your thoughts in the comments section or
follow us on Twitter: @healthcarebiz and #MMCC16