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Medicaid Concepts: Member Engagement

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by member engagement?

With so much focus in the Medicaid space on improving health outcomes for the sickest, most vulnerable populations, the need to have the member engaged in their own health is clear. “Member engagement” is a broad term that includes a range of ideas: treatment compliance, emergency room avoidance, self-directed care, decision-making, health assessments, and member onboarding.

All efforts centered on member engagement are based on the idea that people will make better healthcare decisions when they are more engaged. One of the biggest obstacles to increasing member engagement today is the overload of information. It is increasingly difficult to get the member’s attention in an information-rich world of social media, email and entertainment.

Member engagement should not be confused with care management. Care management describes a model focused on care coordination, treatment pathways and targeting members with complex needs. While care management also relies on member engagement, the two terms are not synonymous.

What role does Medicaid play?

Over the past several decades, Medicaid agencies have worked to improve member-engagement. Many of the earlier efforts evolved out of the disease management programs of the late 1980s and 1990s. Newer efforts focus on maximizing the effectiveness of communications to members, targeting specific members to close quality gaps and aligning incentive programs to encourage healthy behaviors.

While much of the member engagement effort focuses on newer technology solutions (think smartphones or telehealth), there are still important functions related member engagement that happen in a call center, or when a member fills out a member satisfaction survey. Medicaid agencies, health plans, and providers all have opportunities to increase member engagement in a wide range of settings and thereby improve health outcomes.

Explore further

https://carenethealthcare.com/medicaid-member-engagement-strategies/

https://medcitynews.com/2018/09/here-are-some-high-impact-engagement-strategies-for-medicaid/?rf=1

https://www.chcs.org/media/PRIDE-Culture-of-Engagement-FINAL.pdf

https://healthpayerintelligence.com/news/how-to-improve-medicaid-member-engagement-care-coordination

https://www.colorado.gov/pacific/hcpf/performance-measurement-and-member-engagement

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Medicaid Concepts: Modularity

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by Modularity?

States spend billions of dollars each year on claims payment and related technology systems. These payments have traditionally gone to a handful of vendors able to build such large scale solutions.

It has proven difficult to flexibly evolve Medicaid technology systems when most functions reside in one solution. Over the past 20 years, CMS (which pays for the majority of the costs of these systems) has attempted to create positive disruption with an emphasis on modularity. In lay person’s terms, this means using a set of smaller modules that can work together to accomplish objectives instead of one monolithic system.

An entire industry has grown up around the concept of modularity, including both technology and consulting vendors.

To understand modularity, there are two related key terms:

MMIS– Medicaid Management Information Systems is the term used to talk about the technology systems needed to pay provider claims, conduct certain federally required functions (like fraud detection) and interface with other systems such as eligibility and enrollment. This term is defined in section 1903 of the Social Security Act. At the most simple level, states must have payment systems approved by CMS since CMS is paying so much of the costs of healthcare services.

MITA – The Medicaid Information Technology Architecture (MITA) initiative is sponsored by CMS and is designed to improve systems used in Medicaid programs. It has various goals and standards, and states have to report on their use of related principles in their system design.

One of the common concerns is perceived lack of precision in the definitions provided by CMS. Many stakeholders have called for CMS to identify a list of acceptable modules.

“A module is a packaged, functional business process or set of processes implemented through software, data, and interoperable interfaces that are enabled through design principles in which functions of a complex system are partitioned into discrete, scalable, reusable components. An MMIS module is a discrete piece (component) of software that can be used to implement an MMIS business area as defined in the Medicaid Enterprise Certification Toolkit (MECT)” – CMS State Medicaid Director Letter, August 16, 2016

What role does Medicaid play?

While CMS pays most of the costs of these systems, states procure them. As states update their MMIS systems, they have an opportunity to do a modular procurement. So far, states have typically sought to procure modules for claims payment, eligibility, drug management and electronic visit verification. In addition to modules, states also procure Systems Integrator (SI) contracts. SI vendors provide the overarching system needed to integrate modules together.

Explore further

https://www.medicaid.gov/medicaid/data-systems/medicaid-management-information-system/index.html

https://www.medicaid.gov/medicaid/data-systems/medicaid-information-technology-architecture/index.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidInfoTechArch/Downloads/mitaoverview.pdf

https://mmcp.health.maryland.gov/Documents/MMAC/2019/05_May/2019%20MMAC%20Summit_MMIS%20Transformation.pdf

https://doit.maryland.gov/contracts/Documents/catsPlus_torfp_status/M00B0600019-MHT-MMT-RFP.pdf

https://www.cns-inc.com/wp-content/uploads/2018/06/CNSI-Modularity-White-Paper-FINAL_0.pdf

https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/contracting/pre-solicitation-announcement.pdf

https://www.medicaid.gov/medicaid/data-systems/downloads/rfi-modular.pdf

https://www.medicaid.gov/medicaid/data-systems/medicaid-enterprise-certification-toolkit/index.html

https://downloads.conduent.com/content/usa/en/white-paper/defining-mmis-modularity.pdf

https://www.optum.com/content/dam/optum3/optum/en/resources/PDFs/optum-modularity-approach-for-hhs-medicaid.pdf

https://www.medicaid.gov/federal-policy-guidance/downloads/smd16010.pdf

https://www2.deloitte.com/us/en/pages/public-sector/solutions/medicaid-management-information-system-modernization.html

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Medicaid Concept: Loneliness as a Social Determinant of Health

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by loneliness as a social determinant of health?

While most of the social determinants of health conversation focuses on various forms of food, clothing and shelter issues, loneliness and isolation have also been shown to play a significant role in health outcomes. Recent studies suggest that loneliness can have as big an impact on health as smoking or obesity. Cigna has conducted extensive surveys with generational breakouts that show millennials and generation z are loneliest of all, and its affecting their health. NIH has also studied loneliness and social isolation in older Americans.

Loneliness acts as a fertilizer for other diseases. The biology of loneliness can accelerate the buildup of plaque in arteries, help cancer cells grow and spread, and promote inflammation in the brain leading to Alzheimer’s disease. Loneliness promotes several different types of wear and tear on the body.” – Steve Cole, UCLA

What role does Medicaid play?

Some states have launched programs to target loneliness specifically (Ohio‘s friendly caller program is one example). Medicare Advantage plans have also launched similar efforts during the COVID pandemic.

Explore further

https://www.cdc.gov/aging/publications/features/lonely-older-adults.html

https://jamanetwork.com/channels/health-forum/fullarticle/2774708

https://www.webmd.com/balance/news/20180504/loneliness-rivals-obesity-smoking-as-health-risk

https://pubmed.ncbi.nlm.nih.gov/25790413/

https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks

https://hms.harvard.edu/magazine/imaging/treatment-loneliness

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Medicaid Concepts: Jail Health

This is part of our Medicaid Concepts series, in which we try to provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by jail health?

In general this discussion includes both healthcare services while incarcerated and during the transition period once the individual leaves prison and returns to society. While incarcerated, there are a range of services and contractors who provide physical and mental health services to prisoners. When offenders exit prison, there are programs operated by health plans and states to assist in the transition.

What role does Medicaid play in this area?

Medicaid can cover services for inmates and returning offenders. Before the Affordable Care Act in 2014 (ACA) many states did not choose to provide services to inmates under Medicaid because they usually did not meet eligibility criteria (non-disabled adults without dependent children). ACA provided new funding via the “expansion” group category that made it easier for prisoners to be eligible while inside.

 

Many states follow CMS guidance on suspending (vs terminating) inmate coverage once they enter prison. This allows the state to more easily resume coverage once the offender returns (which is a critical time period of transition, with much higher changes of mortality and other negative outcomes). This also allows for Medicaid to cover off-site healthcare services such as inpatient stays, even when the inmate goes back to prison after the stay.

States that do cover eligible prisoners usually exclude them from managed care capitation arrangements (instead covering them under their fee for service program).

States and health plans continue to try and improve the healthcare services provided to incarcerated and returning members. For returning members, Medicaid programs and plans focus on provider coordination, job services and closing gaps related to social determinants of health.

Explore further

https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2016/08/how-and-when-medicaid-covers-people-under-correctional-supervision

https://www.commonwealthfund.org/publications/issue-briefs/2019/jan/state-strategies-health-care-justice-involved-role-medicaid

https://www.naco.org/resources/medicaid-coverage-and-county-jails

https://www.macpac.gov/wp-content/uploads/2018/07/Medicaid-and-the-Criminal-Justice-System.pdf

https://www.disabilitybenefitscenter.org/faq/health-insurance-in-prison

https://www.healthcare.gov/incarcerated-people/

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Medicaid Concepts: Waivers

What is a Medicaid waiver?

A Medicaid waiver program is a special program that allows a state to vary from the standard Medicaid rules so that it can offer more targeted services to specific populations. Waiver programs are thus an alternative to the services in the State Medicaid Plan. While a state must provide the entire service array to anyone who meets the criteria of its Medicaid program, by using a waiver it can provide them only to certain groups (such as those with Traumatic Brain Injury, or those members who can get services inside their home and avoid a nursing home. Waivers must be approved by CMS, and have a capped funding amount.

What are the types of waivers available?

Each of the waiver types are commonly referred to by the part of the Social Security Act that governs them. See below for information on the most commonly used waivers:

  • Section 1115 waivers- also known as demonstration waivers. These allow a state to test out a new financing model, cover a new population or a new service delivery model.
  • Section 1915b waivers- also known as managed care waivers. These waivers allow a state to contract with health plans to deliver services to members.
  • Section 1915c waivers- also known as home and community-based services (HCBS) waivers. These waivers allow states to offer services in the community to members that otherwise would need facility-level care.

Explore further

The CMS list of state waivers

https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html

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Medicaid Concepts: Waiting Lists

What are waiting lists?

Waiting lists are used to ration services for severely disabled Medicaid members who need them. These waiting lists have long been a controversial mechanism to allocate services funded under a Medicaid waiver program.

How is it used in Medicaid?

Since states get a specific amount of funding approved for waivers, and there are more individuals who need services than can be funded under the waiver, waiting lists are used to control utilization. There are hundreds of thousands of people who have been determined to need the services, but can not get them.

It is important to note that traditional (non-waiver) Medicaid services are funded in an-capped model, and states do not use waiting lists for those services. Waiver services typically are more targeted for specific, more severe needs.

Waiting lists fluctuate over time, and from state to state. Medicaid expansion in 2014 caused a resurgent focus on waiting lists, because states were now spending billions more on generally healthy individuals (the expansion group), while thousands of severely disabled members still wait for the services they need.

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Medicaid Concepts: Medical Loss Ratio

What is the Medicaid Loss Ratio?

Medical Loss Ratio is the proportion of premium revenues spent on clinical services and quality improvement. It is commonly referred to as MLR.

How is it used in Medicaid?

In recent years as with many things, CMS has brought new regulations for Medicaid Managed care related to MLR. These new regulations require states to monitor the MLR for MCOs and establish criteria from this data for setting future MLR. The minimum MLR has also been set by CMS at 85% and establishes that noncompliant MCOs can have rates lowered in the future.

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