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Medicaid Acronym of the Day – RBMC

Risk-based Managed Care – MCOs are health plans that contract with states to provide comprehensive Medicaid benefits to enrolled Medicaid beneficiaries for a pre-set per-member-per-month (PMPM) premium, or capitation payment.3  This arrangement is known as risk-based managed care because MCOs are at financial risk for the Medicaid services specified in their contracts. States develop and oversee their own Medicaid managed care programs, subject to federal requirements. MCOs must meet federal and state-specific requirements that address matters such as: protocols for enrollment, disenrollment, and member support; ensuring an adequate provider network and access to care; grievances and appeals, and collection and reporting of data. Although MCOs are at financial risk for comprehensive Medicaid benefits, many states “carve out” certain services from their MCO contracts, such as prescription drugs or behavioral health services. These carved-out benefits may be provided and financed under a separate contract with a prepaid health plan (see definition below) or on a FFS basis. Alternatively, some MCOs may subcontract with prepaid health plans to provide such benefits.

Further reading

https://en.wikipedia.org/wiki/Medicaid_managed_care

 

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Medicaid Acronym of the Day – PCCM

Primary Care Case Management – PCCM is a model of Medicaid managed care that is outlined in the Medicaid statute. In PCCM programs, state Medicaid agencies contract with primary care providers to provide, locate, coordinate, and monitor primary care services for Medicaid beneficiaries who select them or are assigned to them by the state.1 2 In effect, the primary care provider – usually a physician or a physician practice, but sometimes a nurse practitioner, physician assistant, or other provider – serves as a beneficiary’s “medical home” for primary and preventive care. Under their contracts with primary care providers, states pay them a small monthly  case management fee in addition to regular FFS payments; unlike in risk-based managed care (see definition below), providers do not assume any financial risk under this model. States set requirements for the participating primary care providers, such as minimum hours of operation at each location, specific credentials or training, and responsibility for referrals to specialists. State staff carry out, or contract out, administrative functions related to PCCM (e.g., network development and credentialing). “Enhanced” PCCM refers to PCCM programs that include additional services and responsibilities to strengthen care coordination.

Further reading

https://www.cga.ct.gov/2009/rpt/2009-R-0216.htm

 

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Medicaid Industry Who’s Who Series: Richard Topping

Richard Topping is on the Board of Directors for the upcoming Medicaid Health Plans of America (MHPA) Conference in Washington, DC on October 29th -31st. Use code MHPA17-MM200 for $200 off your registration HERE!

 

Medicaid Who’s Who: Richard Topping – CEO, Cardinal Innovations Healthcare

  1.  How many years have you been in the Medicaid industry?

A: Nine Years

 2.  What is your focus/passion? (Industry related or not)

A: Finding ways to provide all Americans with access to health, education and economic opportunities.

 3.  What is the top item on your “bucket list?”

A: To visit St. Petersburg, Russia.

 4.  What do you enjoy doing most with your personal time?

A: Cycling

5. Who is your favorite historical figure and why? 

A: Winston Churchill, because he persevered and succeeded against difficult odds.

6.  What is your favorite junk food?

A:  Pizza

 7.  Of what accomplishment are you most proud?

A: Leading Cardinal Innovations through Medicaid transformation and driving policy reform.

 8. For what one thing do you wish you could get a mulligan?

A: All of my golf games.

 9. What are the top 1-3 issues that you think will be important in Medicaid during the next 6 months? 

A: Federal Financing; State System Design; Industry Consolidation

 

Richard Topping is on the Board of Directors for the upcoming Medicaid Health Plans of America (MHPA) Conference in Washington, DC on October 29th -31st. Use code MHPA17-MM200 for $200 off your registration HERE!

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Medicaid Acronym of the Day – RVUs

Relative Value Units – One element in the formula used to calculate the Medicare allowance for a given service in a specific fee schedule area; each Medicare physician fee schedule service is assigned RVUs for physician work, for practice expenses and malpractice expenses.

Further reading

https://en.wikipedia.org/wiki/Relative_value_unit

 

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Medicaid Acronym of the Day – REC

Regional Extension Center – One of as many as 70 organizations defined by a specific geographic area, funded through the Health Information Technology for Economic and Clinical Health (HITECH) Act, and charged with helping physicians choose, implement and achieve meaningful use of electronic health records.

Further reading

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925411/

 

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Medicaid 2.0

Here’s a great chart (below- click to enlarge) from our friends at MHPA to help you understand all the different pieces of legislation as well as the waiver apps in play.

Many thanks to Alex Shekhdar of Medicaid Health Plans of America for sharing.

 

Check out MHPA here – http://www.medicaidplans.org/

And check out Alex on the News Roundtable show this Friday, along with Kris Vilamaa and Cathy Huff.

If you want to attended the 2017 MHPA conference (I’ll be there), here’s the link – http://www.medicaidconference.com/

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Medicaid Acronym of the Day – IPA

Independent Practice Association – An independent group of physicians who legally organize as an entity and agree to contract as a group to provide patient services; the practices maintain their own offices and continue to see their own patients.

Further reading

http://www.aafp.org/about/policies/all/independent-physicianassoc.html

 

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Medicaid Acronym of the Day – ICD-9-CM

International Classification of Diseases, 9th Revision, Clinical Modification – A standardized system currently used in the United States that classifies diseases, injuries and external causes by etiology and anatomic location and assigns each entry an identifier that may be up to five alpha-numeric characters in length.

Further reading

https://www.cdc.gov/nchs/icd/icd9cm.htm