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Management Consultant – IV&V Medicaid Job at Public Knowledge in Colorado

 
 

Management Consultant

Applicants must be willing to travel and should be within an hour of a major airport.

Company Summary

Public Knowledge is a national management consulting firm that helps government agencies solve tough problems and thrive in complex environments. We do this by providing planning, procurement, and implementation services. Most of our work is in Health and Human Services. You can learn more about us at www.pubknow.com. GLI® Group has acquired Public Knowledge, which provides Public Knowledge with the financial backing and infrastructure of a larger company.

Position Summary

This management consultant would spearhead research efforts to gather information for large projects and programs and propose creative solutions. This person would collaborate with project managers and team members to support project administration, time management, and budgeting.

Duties & Responsibilities include, but not limited to:

Research

  • Gather information for a project by conducting interviews, surveys, facilitating groups, analyzing client documentation, conducting research of best practice and academic literature, and the application of other information gathering tools.

Project Support

  • Learn and apply the tools and techniques we have for projects.
  • Work with project managers to support the administration of projects (ensure staff adhere to standards, organizing the time of other team members, supporting project meetings, and assisting with project financial management).
  • Help your team meet project objectives, timelines, and deliverables within budget.

Analysis, Communication, and Consultation

  • Using your experience and research results, analyze and organize information identifying root causes of issues, opportunities for improvement, and generate ideas to improve the client situation.
  • Based on your analysis, research, and experience participate with your team in the development of recommendations for actions that will improve the client situation.
  • Communicate the results of our work (information, analysis, and recommendations) through the participation in the development and delivery of written reports, formal presentations, and oral discussions with your team, and as requested clients and stakeholders.

Firm Knowledge Sharing and Growth

  • Freely share your knowledge, skills, and abilities with your peers in the firm.
  • Perform firm administrative activities (maintain your resume, record your time accurately).
  • Grow your skills and experience by participating in projects and actively pursuing continuing professional education.
  • Develop an effective working relationship with clients and colleagues.

Required Education and Other Credentials:

  • Bachelor’s Degree required
  • Valid Driver’s License
  • PMP certification is strongly preferred

Required Experience and Skills:

  • At least three (3) years of project management experience, preferably in major IT systems-related work.
  • At least three (3) years of experience conducting IV&V work, preferably in health or major IT systems-related work.
  • Experience in systems development best practices and knowledge of the typical artifacts created as part of a system development project is required. Knowledge of Medicaid and or Integrated Eligibility is a requirement and familiarity with MITA. Knowledge of multi-project integration programs and multi-system data consolidation efforts is preferred.
  • Knowledge of the components of Software Development Life Cycle and best practices including all waterfall and agile frameworks as well as SaaS, COTS, and Custom design solutions
  • Deep knowledge of Medicaid and Health IT that spans the development and testing of systems through the operation of the programs the technology supports
  • Proven ability to report observations, conclusions, and making recommendations for improvement about project problems and issues; ability to focus and to be objective on the assessment of SDLC processes and products
  • Must have experience in bringing focus and organization to ambiguous situations
  • Must demonstrate creative and strong analytical and problem-solving skills
  • Demonstrates excellent interpersonal skills Must have flexibility and ability to adapt quickly to new situations
  • Must have ability to establish and cultivate strong work relationships
  • Must have clear, concise written and verbal communication
  • Must have demonstrated life-long learning skills
  • Desire to work in a collaborative, fast-paced, entrepreneurial environment
  • Ability and willingness to travel (reasonable travel will be required)
  • Proficient knowledge of Microsoft Word, Excel, and Outlook
  • Must have excellent oral and written communication skills, including the ability to communicate with officials at all levels in government and industry
  • Must have the ability to handle and organize multiple projects and deadlines
  • Must demonstrate a high degree of attention to quality, details, and correctness
  • Ability to work with colleagues in a virtual environment (via conference calls, web meetings, and using digital collaboration tools such as Zoom and cloud document repository)

Physical Requirements and Working Conditions:

  • Must have the ability to travel to client sites
  • Ability to work from a home-based office
  • Must have the ability to work at a computer for extensive periods of time
  • Must have the ability to speak on the telephone for extended periods of time
  • Must have the ability to read (paper or computer screen) for extended periods of time
  • Must have sufficient hand, arm, and finger dexterity to operate a computer keyboard and other Company equipment
  • Must have the ability to be self-driven, work independently and as part of a team

We offer excellent benefits that include:

  • Comprehensive Health and Dental Insurance
  • Retirement Plan
  • Disability Benefits
  • Flexible Work Hours
  • Generous Vacation Program

Applying

Think you’ve got what it takes? Apply online at on our website and include an introduction to yourself and your qualifications.

This job post should not be interpreted as all-inclusive; it is intended to identify major responsibilities and requirements of the job. The incumbent may be requested to perform other job-related task and responsibilities than those stated above.

Public Knowledge is an Equal Opportunity Employer

 
 

Clipped from: https://www.hispanicjobs.com/jobs/46942663-management-consultant-iv-v-medicaid-at-public-knowledge?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

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The Medicaid Subject Matter Expert(SME)

JobDescription
Summary:


The Medicaid Subject Matter Expert(SME) will provide support in the area of proactive data analysis used toidentify investigative targets in the Medicaid Program. The SME will performfraud, waste and abuse detection, deterrence and prevention activitiesinvolving Medicare and Medicaid providers, suppliers, and other entitiesreceiving reimbursement under one or both of the Medicare and Medicaidprograms. This includes providers,suppliers, and other entities performing under Medicare Advantage, the MedicarePrescription Drug Program (Part D), Medicaid Managed Care, and other programsadministered or operated by CMS or State Medicaid Agencies for Medicare claimsprocessed within the jurisdiction.

Duties/Responsibilities:

· Providesubject matter expertise and technical assistance on matters related toMedicaid policies and regulations.

· Identificationof proactive data studies in the Medicaid program, resulting in identificationof high ROI fraud schemes in the Medicaid program in IL, IN, IA, KS, KY, MI, MN,MO, NE, OH and WI

· Generateinvestigative leads related to trending fraud schemes

· Remaininformed of current Medicaid fraud and abuseissues/schemes through researching reports such as CMS MIG Reviews, OIG StateReports, National Association of Medicaid Directors (NAMD) Briefs and otherresources included in the Medicaid SME Research list

· Identifyand document state program vulnerabilities

· AttendMedi-Medi meetings with external customers

· Ensureconfidentiality of all PHI and sensitive information

· Travelas required for meetings or training

· Performother duties as assigned

Minimumrequired qualifications/skills:

· BA or BS degree

· Minimum of three (3) years of Medicaidexperience is required

· Experience in program integrity or medicalreview

· Excellent oral, written and verbal skills with experiencecompiling data and writing reports

· Ability to work independently with minimalsupervision in a fast-paced environment with strict deadlines

· High proficiency level with Microsoft Excel andWord

· Working knowledge of Microsoft PowerPoint

· Excellent research skills including internetresearch

· Ability to work independently with minimalsupervision

· Must have and maintain a valid drivers licenseissued by state of residence

Preferredqualifications/skills:

· Certified Fraud Examiners (CFE) designationand/or Accredited Healthcare Fraud Investigator (AHFI) designation

SupervisoryResponsibilities:

· None

Location:

· Work from Home

OfficeEquipment (if a WFH position):

· A locking cabinet and/or desk appropriate for storingdocuments and electronic media

· A cross-cut or micro-cut (preferred) shredder

· A broadband internet connectionwith minimum download speed of 15MB – 20MB. (Wireless Air Cards are not approved forwork from home use. Free/public wi-fi connections not approved.)

· Telework office connection can be hard-wired direct orWi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 +AES. (WPA and WPE are not approved.) Recommended home wireless standards: WirelessG Goes through walls, but Medium speed. (Use if router not visible); WirelessN – Great for Speed, but not effective through walls. (Use if router visible); WirelessAC – High speed, but not effective through walls or distance. (Use if routervisible)

· Separate phone line (can be a cell phone)

· Office equipment (such as laptop and printerwill be provided)

PhysicalRequirements:

· May require prolonged periods of sitting at adesk.

Other:

· Successful candidates will be required to consentto background checks, credit check and other contract related screenings

· Travel may be required, and all travel expenses, if applicable,are reimbursable via GSA standards

 
 

Clipped from: https://www.glassdoor.com/job-listing/medicaid-sme-ces-JV_KO0,12_KE13,16.htm?jl=3775145130&utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

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Senior Manager of Medicaid Analytics (Work At Home) – Apply Today Now – Bedford, TX, USA – Bedford

 
 

 
 

**Overview** **:****This role is an opportunity to build a Data & Analytics team supporting Cigna’s Medicaid business from the ground up. The Medicaid business needs the right leader to build a mature data platform and analytics capability to enable growth. The Medicaid Data & Analytics Lead will translate the Medicaid business’s strategic objectives into a roadmap of tools and capabilities that will use data to help make better business decisions and deliver more personalized business insights. The candidate will assemble a team of data experts and business analytics professionals to deliver a broad portfolio of projects, spanning foundational data capabilities, reporting, analytical tools, population health, and customer insights. They will engage in a collaborative, cross-functional group spanning senior leadership and a variety of functional areas (e.g. operations, clinical management, finance, medical economics, and network).****The right leader will possess a strong degree of creativity, innovation, business and financial acumen, leadership ability, and a core data/analytics skillset. They will also demonstrate a talent for translating between technical and non-technical audiences, as well as a desire to champion a data-driven culture with our business partners.****Responsibilities:****Create a detailed roadmap of new capabilities and timing needed to develop a mature Medicaid analytics function** **Develop a strong perspective on the Medicaid business’s strategic goals** **Build relationships with Medicaid senior leadership and key stakeholders** **Understand the current state of Medicaid data and reporting and the existing gaps for all stakeholders** **Create a project plan to document the proposed approach to closing gaps and meeting stakeholder needs****Build a small team from the ground up to execute on the roadmap** **Lead recruitment for a talented team of data, analytics, and reporting professionals** **Set high standards for talent acquisition to attract a high-caliber team with a balance of skill-sets** **Create a team culture of success, innovation, and ethics****Create a strong data foundation for analytics, in partnership with IT organization** **Develop data views, including internal and external sources, to support automated reporting and more sophisticated analytics** **Document and work to automate existing manual data and reporting processes****Identify and recommend operational, clinical, and network trends and opportunities** **Align with state value-based programs and reporting** **Prepare population health analytics by cohorts or acuity levels** **Identify of data anomalies in network and clinical trends for action** **Support Medicaid business with proactive business analytics that align with state contracts****Lead the development of a management scorecard and a suite of reports to allow business leaders to assess and diagnose key trends** **Build automated reporting on financial performance, medical cost trend, clinical management, and other areas** **Provide insights and commentary on drivers of results****Prioritize and execute on the creation of new analytical tools to provide deeper, more granular insights on customer behavior, provider performance, clinical program outcomes, and other business drivers.** **Consider a variety of analytical techniques to meet business need (e.g. financial models, matched-case control studies, machine learning, etc.)** **Provide ad hoc analysis and insight as needed****Operate in a highly ethical and compliant manner, with attention to the unique regulatory demands of the Medicaid business****Qualifications:****Bachelor’s degree or higher in a quantitative field (statistics, mathematics, computer science, finance, actuarial science, data science, business analytics, or equivalent training)****7+ years of work experience, including experience with health care data and statistical analysis****Prior Medicaid business expertise strongly preferred, particularly with prior work in clinical, network, and/or operations functions****Strong expertise working with complex databases, including advanced SQL skills****Strong business and financial acumen, including knowledge of health insurance financial drivers****Strong customer focus, communication, and management of business partner expectations****Ability to think creatively and put structure around complex problems****Ability to translate business needs into practical applications and solutions****Ability to clearly present findings to a diverse group of teams with varying levels of technical expertise****Prior managerial experience strongly preferred****Location is flexible, including WAH option****About Cigna**Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram._Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.__If you require reasonable accommodation in completing the online application process, please email: …@cigna.com for support. Do not email …@cigna.com for an update on your application or to provide your resume as you will not receive a response._

 
 

Clipped from: https://www.applytodaynow.site/job/senior-manager-of-medicaid-analytics-work-at-home/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

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Patient Support Representative jobs in HCA Medicaid Eligibility(RCPS) in United States. | Laimoon.com

Work From Home

SCHEDULE: Full-time

Do you have exceptional customer service and the ability to plan organize and exercise sound judgment? Do you have demonstrated communication, problem solving and case management skills and the ability to act/decide accordingly?

Now is the time to join our team of motivated and nurturing individuals conducting eligibility screenings, assessment of patient financial requirements, and counseling patients on insurance benefits and co-payments. The ideal Patient Support Representative serves as a liaison between the patient, hospital, and governmental agencies; and is actively involved in all areas of case management. You should also share a passion for our purpose, “To serve and enable those who care for and improve human life in their community.”

Does this sound like you? If so, APPLY TODAY. See what makes us a fabulous place to work!

Parallon is now seeking a Patient Support Representative

You can also Like us on
Facebook: https://www.facebook.com/ParallonRCSJobs.

WHAT WE CAN OFFER YOU:

  • We offer you an excellent total compensation package, including competitive salary, excellent benefit package and growth opportunities. We believe deeply in our team and your ability to do excellent work with us.
  • Your benefits package allows you to select the options that best meet the needs of you and your family. Benefits include 401k, paid time off, medical, dental, vision, flex spending, life, disability, tuition reimbursement, student loan repayment, employee discount program, and employee stock purchase program.

WHAT YOU WILL DO:

  • Screen and evaluate patients for existing insurance coverage, federal and state assistance programs, or hospital charity application.
  • Re-verifies benefits and obtains authorization and/or referral after treatment plan has been discussed, prior to initiation of treatment. Ensures appropriate signatures are obtained on all necessary forms.
  • Obtain legally relevant medical evidence, physician statements and all other documentation required for eligibility determination.
  • Complete and file applications. Initiate and maintain proper follow-up with the patient and government agency caseworkers to ensure timely processing and completion of all mandated applications and accompanying documentation.
  • Ensure all insurance, demographic and eligibility information is obtained and entered into the system accurately. Document progress notes to the patient’s file and the hospital computer system.
  • Participates in ongoing, comprehensive training programs as required.
  • Follows policies and procedures to contribute to the efficiency of the office. Covers and assists with other office functions as requested.
  • All other duties as assigned

ABOUT US

Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade we remain dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.

Qualifications

EXPERIENCE AND EDUCATION NEEDED:

  • High School Diploma or GED or related experience in lieu. College degree preferred.
  • Preferred three years of hospital/medical business office experience with insurance procedures and patient interaction
  • Understanding of patient confidentiality to protect the patient and the clinic/corporation.
  • Ability to collect, synthesize and research complex or diverse information.

We are an equal opportunity employer and we value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Notice Our Company’s recruiters are here to help unlock the next possibility within your career and we take your candidate experience very seriously. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Gmail or Yahoo Mail. If you feel suspicious of a job posting or job-related email, let us know by clicking here. For questions about your job application or this site please contact HCAhrAnswers at 1-844-422-5627 option 1.

 
 

Clipped from: https://jobs.laimoon.com/jobs/externalview/23866196?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

 
 

 
 

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Medicaid Fraud Subject Matter Expert – Catapult Consultants

Catapult Consultants is now hiring a Medicaid Fraud Subject Matter Expert. The expert will Develop Medicaid and Medicare-Medicaid (Medi-Medi) proactive data analysis for identification of fraud schemes and trends. Provide subject matter expertise and technical assistance on matters related to Medicaid policies and regulations.  Support the Data Analysis, Medical Review, Program Integrity and Request for Information teams by consulting with staff and participating in investigative and/or data analysis efforts. 

Key Responsibilities:

  • Identification of proactive data studies in the Medicaid program, resulting in identification of high ROI fraud schemes
  • Remain informed of current Medicaid fraud and abuse issues/schemes through researching reports such as CMS MIG Reviews, OIG State Reports, National Association of Medicaid Directors (NAMD) Briefs and other resources included in the Medicaid SME Research list
  • Identify and document state program vulnerabilities
  • Attend Medi-Medi meetings with external customers
  • Ensure confidentiality of all PHI and sensitive information
  • Travel as required for meetings or training
  • Perform other duties as assigned

Basic Qualifications:

  • High proficiency level with Microsoft Excel and Word
  • Working knowledge of Microsoft PowerPoint
  • Excellent verbal and written communication skills
  • Excellent research skills including internet research
  • Ability to work independently with minimal supervision
  • Ability to perform multiple priority tasks
  • Associate must have and maintain a valid driver’s license issued by his/her state of residence

Preferred Qualifications:

  • A minimum of three years of Medicaid experience is required, program integrity or medical review experience preferred
  • Preference given to those with experience in IL, IN, IA, KS, KY, MI, MN, MO, NE, OH, WI

Required Education:

  • BA or BS degree preferred
  • Preference given to candidates with Certified Fraud Examiner (CFE) and/or Accredited Healthcare Fraud Investigator (AHFI) designations

 
 

Clipped from: https://catapultconsultants.applytojob.com/apply/fB7AdD2m0T/Medicaid-Fraud-Subject-Matter-Expert?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Feds boost Florida’s Medicaid coffers by extending COVID-19 public health emergency

MM Curator summary

The public health emergency was extended to April, sending $130M more to FL alone.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

TALLAHASSEE — Florida lawmakers have gotten a well-timed budget break thanks to a decision by the federal government to extend the nation’s public-health emergency due to the COVID-19 pandemic.

U.S. Health and Human Services Secretary Alex Azar extended the public-health emergency last week.

Azar’s decision means the federal government will continue to allocate a 6.2 percentage-point increase in money for Medicaid, the joint federal-state health care program. Before the extension, the additional funding was slated to expire in March.

Justin Senior, chief executive officer of the Safety Net Hospital Alliance of Florida, estimated that each month the extension is in effect frees up about $130 million in state money that would otherwise be needed to fund Medicaid. Senior’s association represents 14 of the state’s public, teaching and children’s hospitals.

“That’s a huge boost to the budget, both this year and potentially next year, that can help lawmakers avoid cutting health care in the middle of a pandemic,” said Senior, a former secretary of the state Agency for Health Care Administration, which runs much of the Medicaid program.

The good budget news came as lawmakers return to Tallahassee this week for the first round of committee meetings before the March 2 start of the 2021 legislative session. With the pandemic reducing state tax revenues, finding a way to balance the budget will be a major issue during the session.

Recognizing the national economic problems caused by the pandemic, Congress initially agreed in March to boost the federal Medicaid match for all states by 6.2 percentage points.

The decision by Azar to extend the emergency means that Florida should continue to receive the increased federal funding through the June 30 end of the state’s 2020-2021 fiscal year.

Medicaid provides health coverage to poor, elderly and disabled people. Enrollment in the program is countercyclical, increasing in tough economic times when there is reduced state tax revenue to help pay for it. When the economy is thriving and money to fund the program is available, enrollment decreases.

Before the COVID-19 pandemic, enrollment in Florida’s Medicaid program had usually been below 3.9 million people. As of Nov. 30, 4.475 million Floridians were enrolled in the program, a nearly 19 percent increase from the 3.76 million who were enrolled in  March 2020, prior to the economic shutdown associated with the pandemic.

While enrollment in Medicaid programs is increasing nationwide, Florida, which did not expand Medicaid eligibility under the federal Affordable Care Act, has seen some of the largest increases, according to Tom Wallace, the state Agency for Health Care Administration’s assistant deputy secretary for Medicaid finance analytics.

The Medicaid program does not cover all low-income Floridians and has different eligibility criteria based on age, income and assets and medical conditions. But increases have been seen in nearly every eligibility category, from children to poor seniors, according to Amy Baker, coordinator of the Legislature’s Office of Economic & Demographic Research.

While the federal extension means additional funds for the state, it also means additional restrictions. During the pandemic, state Medicaid officials cannot alter the program to make enrollment more restrictive than what it was prior to January 2020.

Additionally, so long as the public health emergency continues, the state is largely precluded from disenrolling anyone who was enrolled in Medicaid on March 18 or who enrolled due to the pandemic, with some limited exceptions. For instance, states can disenroll people who have been incarcerated or people who were presumed to be eligible for Medicaid but were ultimately determined ineligible.

Clipped from: https://thecapitolist.com/feds-boost-floridas-medicaid-coffers-by-extending-covid-19-public-health-emergency/

 
 

 
 

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Ohio names one pharmacy benefit manager for Medicaid to save cash

MM Curator summary

Gainwell will become the new PBM in Ohio, beating out 5 other bidders including Express Scripts and Magellan.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Ohio’s grand quest to finally slay the dragon of overcharges by pharmacy benefit managers starts Monday with the rollout of a new $158 million contract by the state Medicaid agency.

The Buckeye State’s premise, a unique approach just approved by the federal government: It takes a PBM to beat a PBM.

Bearing the sword on behalf of the state is Gainwell Technologies, a single PBM newly hired to work on behalf of Ohio taxpayers. The company will replace the multibillion-dollar conglomerates such as CVS Caremark and Express Scripts that currently serve as middlemen in the prescription drug supply chain for 3 million poor or disabled Ohioans.

At last count, those privately run PBMs were making off with nearly a quarter billion dollars a year, charging up to six times the going industrial rate, a state consultant found.

Ohio Medicaid Director Maureen Corcoran said the switch to a single, state-controlled PBM alone will save roughly $150 million to $200 million per year. However, the new arrangement also would cost the state revenue, such as about $23 million from a tax on health insuring corporations that no longer could be collected. And additional staff must be hired to handle duties the agency is taking over from managed-care organizations.

The bottom line will be revealed when Gov. Mike DeWine unveils his budget on Feb. 1, she said.

How PBMs make money often has been called a “black box” because even outside experts cannot figure it out. The new setup is designed to “break open the black box and be better accountable for tax dollars,” Corcoran said.

Medicaid, funded jointly by the state and federal governments, covers about $3.5 billion worth of prescription drugs a year in Ohio. (It is separate from Medicare, a federal program that pays for health care of those 65 and older.) 

“We will have a very-good-quality, experienced manager of these medications that will save the state money and will allow transparency about the care and the expenditures for this program that did not exist in the past,” Corcoran said.

Big changes for children, recipients on the way

Hiring Gainwell as Medicaid’s single PBM is one part of a huge restructuring of the state’s biggest agency that won’t be completed for another year. Still to come is the hiring of a pharmacy operational support vendor, designed to monitor the performance of Gainwell.

Also on the agenda is the OhioRise plan to cover specialized behavioral services for children with complex health needs. Those crushing expenses often aren’t covered by parents’ insurance, causing many to make the heart-breaking decision to voluntarily give up custody to the government so their children can be treated outside of Ohio. Thousands of other children are forced to live in group settings to get the care they need.

Starting in 2022, a federal waiver will allow the state to set up a specialized managed care organization with expertise in providing services for the most complex “multi-system” youth. Corcoran said the goal is to serve 50,000 children by the end of next year.

“We don’t have to take away custody; we can keep them in their family,” she said.

And likely the biggest state contract in history is set to be awarded later this month to winners of an 11-way competition to handle Medicaid’s managed care operations starting next year. The current contract, shared by six outfits, totals about $20 billion.

When what Corcoran calls a “new generation of Medicaid” is finally put in place, both Medicaid recipients and health-care providers will notice the difference.

One simple change will occur when a person on Medicaid changes managed-care plans. Now, they must make sure that their preferred Pharmacy A is on the new plan, or whether they must change to Pharmacy B. But with the state using a new centralized credentialing setup to decide which pharmacies and which drugs are covered, there will be no difference when making the switch.

On the other end of the drug-supply chain, doctors and pharmacists — which currently must fill out as many as seven similar forms to make sure they can get Medicaid reimbursement, a process that can take months — will need to complete only one standardized state form.

Big PBM, lobbyist’s favorite lose out

The competition for the single PBM contract started out with six companies. But three — including Express Scripts, the second-biggest in the country — were eliminated along the way.

One of the final three considered was MagellanRx Management, which was represented by longtime lobbyist Neil Clark when then-House Speaker Larry Householder inserted the single PBM plan into the state budget in mid-2019. Both Clark and Householder are now under federal indictment for a what authorities say was a $60 million scheme culminating about the same time to build the Perry County Republican’s political power and pass a $1 billion bailout of Ohio’s two nuclear power plants via House Bill 6.

Corcoran noted that Householder’s original budget language was revised before the bill was passed, and that Gov. DeWine vetoed several specific mandates about the procurement process.

Deputy Medicaid Director Steven Voigt said the competition “was very fair, diligent, with plenty of safeguards. Every bidder had the same chance.”

Gainwell wound up with the highest score from the panel that evaluated the proposals, and the company also offered the lowest price.

Gainwell or its predecessor has received 16 Centers for Medicare and Medicaid Services certifications since 2010 — more than all other vendors within the same period, the Ohio Medicaid department said. It provides pharmacy services for 29 state Medicaid programs, and implemented 21 Medicaid system modules in eight states.

“They are not like CVS or Express Scripts or whatever; they are more of an entity that has specialized in IT, clinical support, not like traditional PBMs focus on drug market,” Corcoran said.

“They have all of the skills and tools and requirements that are needed. The combination of their pharmacy, various types of pharmacy experiences across 29 (states), means they have demonstrated boots on the ground experience in every element of this PBM design that we have selected.”

Gainwell would be paid $158.2 million if it remains for the entire 7.5 years of the state contract. The pact, which must be approved by the bipartisan state Controlling board, includes financial penalties and an “out” for the state if the new single PBM does not measure up to state standards, Corcoran said.

Gainwell, which says it has more than 7,500 employees, was created on Oct. 1 by the $5 billion sale of DXC Technology’s U.S. state and local health and human services business to Veritas Capital, a leading investor in Gainwell.

“As a construct of the words ‘gain’ and ‘well,’ the name reflects the company’s mission to empower its clients through technology in order to deliver health and human services programs that enable successful health outcomes for beneficiaries nationwide,” Veritas said in a Sept. 16 press release.

Clipped from: https://www.dispatch.com/story/news/healthcare/2021/01/11/pharmacy-benefit-managers-ohio-medicaid-saving-pbm/6556793002/

 
 

 
 

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Congress Delays Medicaid DSH Cuts, Makes Targeted Medicaid Policy Changes | Manatt, Phelps & Phillips, LLP – JDSupra

 
 

MM Curator summary

The latest COVID relief bill also delays DSH reductions another 4 years (they have been continuously delayed for more than 10 years now).

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

In late December, following several weeks of dynamic negotiations, Congress passed the Consolidated Appropriations Act, 2021 (the Act).1 The massive legislative package includes appropriations through September 30, 2021, $900 billion in supplemental appropriations to address COVID-19, a ban on surprise billing, extensions of expiring health programs and an amalgam of odds-and-ends health policy provisions.

The Act contains several key Medicaid provisions, including a delay in Medicaid Disproportionate Share Hospital (DSH) allotment reductions, new Medicaid supplemental payment reporting requirements for states and codification of non-emergency medical transportation (NEMT) rules, described below.

But despite the vastness of the legislation, key Medicaid priorities were not included. States and other stakeholders have been lobbying Congress to increase the Medicaid enhanced matching rate that applies to medical expenditures for the duration of the public health emergency (PHE) and extend it beyond the duration of the PHE. This COVID-19 relief provision and other Medicaid proposals, such as a proposal to extend Medicaid coverage of postpartum women eligible for Medicaid on the basis of their pregnancy, will be high priorities for Democrats as they work with the incoming Biden administration to secure a fifth round of COVID-19 stimulus funding early this year.

DSH and Supplemental Payment Reporting Requirements

Delay in Medicaid DSH Allotment Reductions. The Act eliminates reductions in Medicaid DSH allotments—that is, the cap on federal match for state Medicaid DSH expenditures—in fiscal year (FY) 2021. It also delays the remaining four years of cuts until FY 2024, as shown in Figure 1 below.

Figure 1. Change in Medicaid DSH Allotment Reductions

  

FY 2021

FY 2022

FY 2023

FY 2024

FY 2025

FY 2026

FY 2027

Previous Reduction Amounts

$4 billion2

$8
billion

$8
billion

$8
billion

$8
billion

–

–

Modified Reduction Amounts

–

–

–

$8
billion

$8
billion

$8
billion

$8
billion

 
 

Changes to Calculation of Hospital-Specific DSH Limit. The Act also modifies the maximum amount of Medicaid DSH payments an individual hospital may receive, by redefining what costs are included when calculating hospital-specific DSH limits. States’ DSH payments to individual hospitals may not exceed a hospital’s uncompensated care costs for uninsured patients and Medicaid-enrolled patients. The second component—uncompensated care costs for Medicaid-enrolled patients—is the difference between the costs of services provided and payments received from Medicaid, and is referred to as the Medicaid shortfall.

Department of Health and Human Services (HHS) guidance and rulemaking regarding how hospitals calculate Medicaid shortfall for DSH purposes have been contentious and led to a litany of lawsuits. The issue at hand is how to account for Medicaid enrollees who have another source of coverage, such as Medicare or commercial insurance, when calculating Medicaid shortfall. Although HHS policy has been that states must account for all third-party payments when calculating hospital-specific DSH limits, some hospitals have argued that only Medicaid payments should count against the hospital-specific DSH limit.

Congress adopts an entirely different method for calculating Medicaid shortfall, as recommended by the Medicaid and CHIP Payment and Access Commission (MACPAC). Rather than focus on whether payments for individuals with third-party coverage should count in the hospital-specific DSH limit calculation, the Act simply omits from the calculation all costs for Medicaid-eligible patients with third-party sources of coverage where the third-party source of coverage is the primary payer. As a result, hospitals that treat high volumes of patients with Medicaid and third-party coverage (such as children’s hospitals that treat neonates, who commonly are covered by commercial insurance and Medicaid, or hospitals serving large numbers of dual eligibles) may report less Medicaid shortfall. And because many states use hospitals’ uncompensated care amounts to distribute DSH payments among hospitals, this change is likely to impact the distribution of Medicaid DSH payments among hospitals in certain states.

Supplemental Payment Reporting Requirements. The Act imposes new requirements on states to report any supplemental payments made through their Medicaid programs. By October 1, 2021, HHS must establish a system for states to submit reports on supplemental payment data as a requirement for a State Plan Amendment that would provide for a supplemental payment. In their reports, states will be required to explain, among other elements, (1) how supplemental payments are in keeping with the Social Security Act’s mandate that Medicaid payments be consistent with “efficiency, economy, quality of care, and access,” as well as with the purpose of the supplemental payment; (2) the criteria used to determine which providers qualify for a supplemental payment; (3) the methodology used to distribute the supplemental payments; and (4) the amount of supplemental payments made to each provider.3

Supplemental payments will continue to be a hot-button issue for many federal policymakers and increased transparency through required reporting may fuel future policy changes.

Other Medicaid Provisions

The Act includes several other Medicaid policies including:

  • Codification of NEMT Requirements. The Act requires states to provide NEMT to Medicaid beneficiaries who lack access to regular transportation (including those enrolled in benchmark and benchmark equivalent coverage). Previously, the requirement existed only in regulation, and the Trump administration had threatened to eliminate it. In making NEMT a mandatory benefit through statute, Congress also establishes some guardrails around the new benefit, namely by including NEMT provider requirements and by directing that the Medicaid state plan provide for methods and procedures to prevent unnecessary utilization and to ensure that payments are consistent with efficiency, economy, and quality of care and sufficient to promote access. The Act directs the Government Accountability Office to study NEMT services, with a particular focus on preventing and detecting fraud and abuse. The legislation also requires CMS to report Transformed Medicaid Statistical Information System data to Congress along with recommendations regarding coverage of NEMT to medically necessary services; to convene a series of stakeholder meetings to discuss best practices for improving Medicaid program integrity related to NEMT; and to review and update, as necessary, CMS guidance to states about designing and administering NEMT coverage. Finally, the legislation authorizes states that utilize NEMT brokerage programs, as permitted under Section 1902(a)(70), to consult stakeholders in establishing their programs.
  • Eligibility Restoration for Citizens of Freely Associated States. The Act eliminates the five-year bar on Medicaid eligibility for citizens of the freely associated states (i.e., Micronesia, Marshall Islands, and Palau) who are legally residing in the United States. The legislation restores access to Medicaid for this population after a drafting error in the 1996 Personal Responsibility and Work Opportunity Reconciliation Act excluded them from coverage.
  • Medicaid Extenders. The Act includes funding through FY 2023 for the Money Follows the Person Rebalancing Demonstration, which helps states rebalance utilization and spending toward home- and community-based services (HCBS) rather than institutional care; spousal impoverishment protections, which allow states to disregard individuals’ spousal income and assets when determining eligibility for Medicaid HCBS; and the community mental health services demonstration program, which provides eight states with enhanced funding to improve behavioral health services through Certified Community Behavioral Health Clinics.

1 P.L. 116-260.

2 Beginning in December 2020.

3 The Act indicates in what appears to be a drafting error that each state’s report must provide an assurance that the total payments made to an inpatient hospital provider (but excluding DSH payments) do not exceed the upper payment limit (UPL). However, there is no hospital-specific cap on supplemental payments subject to the UPL; rather, the UPL is assessed at an aggregate level for defined classes of providers (which is established in statute). Congress and/or the Centers for Medicare & Medicaid Services (CMS) may seek to clarify this provision.

 
 

Clipped from: https://www.jdsupra.com/legalnews/congress-delays-medicaid-dsh-cuts-makes-8125523/

 
 

 
 

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California proposes expanding Medicaid coverage of continuous glucose monitors

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California wants to add $12M in the next fiscal year’s budget to pay for CGM for adults with Type 1 diabetes.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Dive Brief:

  • California Gov. Gavin Newsom proposed providing $12 million to expand coverage of continuous glucose monitors (CGMs).
  • The 2021-22 budget proposal is intended to increase access to CGMs among adults with Type 1 diabetes who are covered by California’s Medicaid program Medi-Cal. Abbott, Dexcom, Medtronic and Senseonics compete for the U.S. CGM market.
  • Trade group AdvaMed welcomed the proposal, arguing it will reduce overall healthcare costs, and called on other states to take similar steps to ensure access to CGMs.

Dive Insight:

Sales of CGMs such as Abbott’s FreeStyle Libre and the Dexcom G6 have grown quickly in recent years as Type 1 and Type 2 diabetics have identified the devices as ways to improve the management of their conditions. However, Medicaid coverage of CGMs is patchy with some states providing no coverage and others limiting access to the pediatric population.

California was one of the states with a Medicaid program that only provided CGMs to children who met certain criteria. Lawmakers sought to expand access in 2019, only for Newsom to veto the bill. Newsom said expanded access should be considered through the annual budget process.  

State lawmakers reminded the Democratic governor of his comments about the budget process late last year, adding that the COVID-19 pandemic has emphasized the need for improved access to CGMs. The lawmakers framed CGMs as a way to control spending on adult diabetes patients. 

The pressure has paid off. Newsom wants to include $12 million in funding to enable adults with Type 1 diabetes to access CGMs in California. The funding, which is set to kick in at the start of next year, is the start of an ongoing commitment to CGMs. Newsom’s office sees CGM funding as a way to boost health equity. Overall Medi-Cal funding is set to increase more than 10% in 2021-22.

The budget proposal comes shortly after an American Diabetes Association survey found 20% of people have foregone or delayed getting a CGM or other device due to financial constraints during the COVID-19 pandemic. Among people with a CGM or insulin pump, 15% have delayed sourcing consumable supplies for the devices, typically due to financial constraints.

AdvaMed praised the funding proposal, stating Newsom “is exactly right to push for expansion of Medi-Cal’s coverage of CGMs.” The trade group said providing the Medi-Cal population with CGMs is both the right thing to do and “a smart way” to reduce healthcare costs.

The California legislature will determine whether the budget request is enacted, and the proposal will take effect Jan. 1, 2022, if approved. 

 
 

Clipped from: https://www.medtechdive.com/news/california-proposes-expanding-medicaid-coverage-to-CGMs/593127/

 
 

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Bill to end Medicaid managed care advances in Illinois House

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Illinois lawmakers are ready to be done with MCOs.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

SPRINGFIELD – A House committee on Monday advanced a bill that would end the system of hiring private insurance companies to manage the state’s Medicaid program at the end of their current contracts and replace it with a standard fee-for-service payment system.

The bill also calls for a three-year moratorium on any hospital closures or downsizing.

However, it is expected that further amendments to the bill are being drafted, and it was unclear Monday whether a final version could be approved by both chambers of the General Assembly before the special lame duck session ends, either Tuesday or early Wednesday.

That proposal is part of a health care reform package being pushed by the Illinois Legislative Black Caucus, an agenda aimed at addressing racial and ethnic disparities in the state’s health care system.

Medicaid covers more than 3 million people in Illinois, according to the latest tally by the Department of Healthcare and Family Services, and the majority of them are enrolled in a managed care program. Nearly half of those enrollees, more than 1.4 million, are children in low-income families. Another 1.1 million are working-age adults, including more than 640,000 who became eligible with the federal expansion of Medicaid under the Affordable Care Act.

The idea behind managed care was to reduce costs and improve health outcomes by coordinating each person’s health care – making sure they get regular checkups and follow-up visits and coordinating services between primary care providers and specialists.

 
 

Clipped from: https://qctimes.com/news/state-and-regional/govt-and-politics/bill-to-end-medicaid-managed-care-advances-in-illinois-house/article_fe7c7e6e-4088-57b3-8da9-fe873e093502.html