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How does the sales cycle work for technology solution vendors in the Medicaid space?

Many of our clients are solution vendor professionals working in the health and human services space (including the full spectrum of solution verticals selling in this space). The article below is based on our experience working with sales teams who have best-in-class capture processes.

Reading time: 15-minutes

Intended audience: Information Technology or Solution Business Development or Governmental Affairs Team Members in HHS solution vendors companies

Key Topics: Overview of HHS/Medicaid sales cycle, Comparison to other verticals, Fee for Service vs. Managed Care, Main stages of procurement cycle, Timelines

 Overview of the Medicaid industry sales cycle

This article will cover the high level overview of the sales cycle for opportunities in the health and human services (HHS) space, including:

  1. How the Medicaid sales cycle differs from other healthcare verticals (comparing to commercial and Medicare)
  2. The two major paths of the Medicaid sales cycle: Fee For Service vs managed care
  3. The typical procurement cycle
    1. Detecting opportunities pre-RFP
    2. Duration of RFP periods
    3. Delays and cancellations

How the Medicaid sales cycle is different from other healthcare verticals 

One of the first things sales professionals notice about selling in the Medicaid space is that its different from selling into commercial or even Medicare Advantage environments. In the commercial space, traditional relational-selling techniques are the norm. The Medicare Advantage space can also be highly relational-selling, but brings with it the added regulatory component that makes it more similar to selling in the Medicaid space.

Selling into the Medicaid space is very different because of 2 major factors:

  1. Relational selling is trumped by regulatory and process acumen– While your network of contacts is important, most opportunities in this space are driven by formal procurement cycles. The sales team that is more versed in Medicaid and HHS procurement approaches will be more successful than the team with “stronger” contacts but without the Medicaid sales knowledge.
  2. Value propositions are complicated by a more diffuse decision-making process AND the healthcare complexity of the Medicaid population– While you may be able to engage only a few key decision makers in a commercial (or Medicare Advantage) sale, Medicaid/HHS sales will involve multiple business units inside a health plan (or government agency) and multiple levels of staff. Your sales efforts will touch the C-Suite, but will also include many other parts of the organization. This is because of the extensive regulatory environment, but also because the Medicaid member populations being served by your solutions are much more complex than those in commercial or Medicare Advantage plans.

The 2 major paths of the Medicaid sales cycle: Fee for Service vs Managed Care 

Depending on the scale of your solution, you may want to sell either to state agencies or Medicaid managed care plans. (There are some instances in which both capture paths might make sense). State agencies typically make very large purchases of technology solutions that will be used by all providers in the Medicaid program in their state (such as claims processing systems). Managed care plans typically purchase solutions that will be used for the operations of their plans and programs only.

Reasons to focus your sales efforts on Medicaid managed care

Many solution vendors find the unpredictability, complexity and length of the direct-to-states sales path too difficult, so they quickly pivot into the Medicaid managed care capture path. The styles used to sell to commercial targets are also similar to those used to sell to Medicaid managed care plans. Because of these reasons, solution vendors typically focus on Medicaid managed care at least in the beginning of their Medicaid sales efforts.

Reasons to focus your sales efforts on state agencies

There are two main reasons to focus on sales to state agencies:

  1. Your solution is so large that it is not something a single plan (or even multiple plans) can purchase, or
  2. Even if your solution is not too large for a single plan buyer, you may want to sell to agencies to get your solution to be preferred or required for all managed care plans

The Main Stages of the Typical Procurement Cycle

The Medicaid sales cycle can be broken down into 4 main stages as shown in this diagram:

Detecting opportunities pre-RFP

The single most important part to get right

It is important to detect procurement opportunities before an official request for procurement is announced for 3 main reasons:

  1. By the time the procurement is announced it may be primed for a specific vendor
  2. Early detection places you in an advantage for proposal preparation (bidders often have less than 30 days to prepare large proposal packages)
  3. If you detect an opportunity early enough, you can provide input into the overall strategy

The RFP Stage – Expect the unexpected

Duration of RFP periods

While RFP timelines vary for each procurement, a typical RFP in the Medicaid space will take about 3 to 6 months from the time the RFP is released.

The major stages are:

  1. RFP is released, proposals are prepared– You should plan on about 30 days for the time allowed to respond to an RFP.
  2. The buyer (state or health plan) reviews submitted bids– Initial decisions take another 30 days or longer. If there are multiple bidders who make it past the initial vetting, this stage can take longer and evolve into an extensive best-and-final offer (BAFO) model.
  3. The winning bidder and the buyer establish the actual contract- Contract negotiations add another 30- 60 days. Buyers often select 2 vendors to enter preliminary negotiations with, and this stage can add additional time and revisions.

Besides the normal timelines observed, there are other ways more time can be added to the process. One of the most common ways this can happen is through the vendor Q and A process. When buyers collect questions from vendors, there are often items of scope that are clarified or changed. In some cases, the buyer will issue an addendum which can allow for more time to accommodate the change in proposals.

Delays and cancellations

It happens more often than any of us prefer

Delays can be caused by many factors, including:

  1. CMS approvals take longer than expected (for the federal share)
  2. The vendor review and approval process takes longer than expected
  3. BAFO / contract negotiations takes longer than expected

Cancellations can happen for a variety of reasons, including:

  1. Budget authority may be pulled by the state legislature
  2. Another program initiative takes priority

An incumbent offered the solution as part of an amendment to their existing scope

How You Can Optimize Your Sales Capture Approach to the Unique Medicaid Industry Sales Cycle

In addition to your own research into this vertical, there are a few key tactics that can help you overcome some of the common challenges in the space.

  1. Target your capture strategy to the appropriate Medicaid path-The tactics used in the 2 major paths are very different, and it is important to prioritize based on which path you feel is right for your near and long term goals. If your value proposition is refined enough, it should be clear which path is best. The maturity of your solution can also help guide this choice.   
  2. Engage a firm with deep expertise and extensive contacts in the space to accelerate your efforts and train sales staff. We provide this type of assistance to our technology solution vendor clients, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.
  3. Improve your ability to surface opportunities before they go out to bid- In Medicaid, you must know each state market in-depth to be able to identify opportunities earlier. If you have an in-house market intelligence team, they can track state budget bills and legislation. They can research MMIS contract cycles to gauge when large changes to technology spending will occur. On the managed care side, your team can stay on top of Medicaid waiver applications with CMS to predict when plans may need help with new scope. You can also research MCO contracts to understand key timelines. Your team can review EQRO reports and related PIPs to identify specific pain points for an MCO. We also provide state-level tracking for opportunity detection for clients, and are happy to discuss at any time.
  4. Consider adding a Medicaid-specific sales intelligence product to your toolkit. While there are multiple options for general sales intelligence in the healthcare space, if you are considering (or already executing) a sales strategy tied to Medicaid or HHS-vertical revenues, the more specific your research sources, the better. Our HHS GreenBook combines extensive RFP collection with copies of incumbent proposals, contracts and in depth state market profiles.

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What are the key differences between Medicaid and other payer spaces from a pharmaceutical manufacturer perspective?

Many of our clients are pharmaceutical industry professionals working to increase access for Medicaid members to drugs, devices and therapies. These clients include manufacturers, PBMs and other organization types. The article below is based on our experience working with professionals who have successfully navigated this space. Concepts have been simplified for clarity.

Reading time: 7 minutes

Intended Reader: Pharmaceutical manufacturer sales executives and marketing teams

Key Topics: The state by state nature of Medicaid programs, How PBMs are different in Medicaid, Variation across P&T committees

  The State-by-state Nature of Medicaid Programs

If you’ve seen one Medicaid program, you’ve seen one Medicaid program.

One of the first differences pharmaceutical professionals notice is the uniqueness of each state Medicaid program. While there are national dynamics in play with some of the larger rebate programs, each state has a large degree of control over its coverage and reimbursement policies.  

The main variables for a given state market include:

  1. Fee-for-Service– How does the state handle drug coverage for members who are not in a managed care plan? Are some drugs covered under FFS but others are not?
  2. Managed Care– What responsibility and authority do health plans operating in the state have for pharmacy benefits? For plans that are part of national brands, how centralized are those decisions?
  3. Collaborative Care Models– In recent years, some states have implemented these models. In these models, benefit decisions are often made by a board. Examples include CCOs in CO and WA.

State laws and regulations– Each state will have a different set of regulations on how coverage decisions are made, benefit categories products will be assigned to, and how marketing and communications can be done for members about pharmaceutical benefits.

Use of Pharmacy Benefit Managers  in the HHS Space

The role of PBMs in Medicaid is different

While pharmacy benefit managers (PBMs) are not unique to the Medicaid payer space, recent trends have shown the importance of understanding the impact the state government context has on PBM activities.

There are 3 key considerations for manufacturers evaluating the role of PBMs in Medicaid:

  1. The PBMs goal of conserving public funds– Since Medicaid is funded with both federal and state tax dollars, spending on pharmacy has a high degree of visibility. This is most apparent during the annual budget process in a given state. There is generally more scrutiny on PBM activities in the Medicaid space because of the ongoing need to show cost savings with public funds.
  2. The expanded scope of PBMs in the Medicaid space– Compared to PBMs in other payer spaces, Medicaid PBMs often take on extensive program management scope, including clinical drug reviews for states to inform decision-making (i.e., states outsourcing some P&T-type functions to PBMs).  Medicaid PBMs also negotiate Medicaid supplemental rebates.
  3. Recent concerns around transparency – While states have increased reliance on PBM services in recent years, there has also been some scale-back in certain state markets. This retraction is largely over spread pricing issues. There is a renewed call for transparency in PBM operations, and a new political focus on contracts.

Variation in  Structure and Operation of P&T Committees 

There are some similarities across states, but P&T operations vary widely

Federal law requires each state to have a P&T committee if the state wants to operate a Preferred Drug List (PDL). Each state must include physicians and pharmacists on the committee- but beyond this general requirement, each state can set its own procedures and schedules for the activities and decisions of the committee.

While states must cover any drugs on the federal Medicaid rebate program, coverage for other drugs is up to each state (or health plan if the state has delegated this to managed care). There has been a trend towards adopting more uniform PDLs for specific drug classes (in 2018, 14 state Medicaid programs had a uniform PDL)[1]. Some states have also moved towards streamlining medical neccessity criteria with uniform clinical protocols.[2]

While these trends toward standardization have been observed, wide variation by states is the norm.

Some states require utilization controls (such as prior authorization) for all new drugs before a P&T committee develops specific rules. Some states have rapid evaluation processes, but others have extensive protocols that can include pilots, meta-analyses and extensive expert review. These processes range from three months to one year for consideration of new drugs or newer / improved coverage for an existing drug. Like all things government, there is a political nature to the coverage and pricing in many Medicaid pharmacy programs that needs to be taken into account when addressing market access issues in a given state. In many states, the level of influence that the independent pharmacists association exerts can be the difference between coverage, or limited coverage with extensive controls. The role of advocacy organizations whose populations are impacted by your product is also often significant.

How You Can Address the Challenges and Complexities of the State Medicaid Pharmaceutical Environment

Besides your own research into this topic, there are a few key tactics that can help you overcome some of the common challenges related to improving market access in Medicaid markets. We assist clients with each of these strategies, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.

  1. Train your account teams on the details of each state Medicaid program they call on. Knowing the fundamentals of each state program is critical. Most teams used to the commercial space are initially unaware of this need in Medicaid, and then quickly become overwhelmed by the learning curve.
  2. Ensure your sales decks and messaging are aligned with the unique values and priorities in the Medicaid payer space. Telling the right story to a Medicaid audience is completely different than the normal narrative for commercial and Medicare Advantage audiences. Your sales collateral needs to account for the unique needs and perspectives of Medicaid program decision makers.  
  3. Evaluate what your traditional government affairs approach can and cannot do to help in the Medicaid space. Many manufacturers have a government affairs presence in multiple states. However, traditional government affairs approaches are often insufficient because of the complexity of players, advocates, and the economics of Medicaid financing.
  4. Set realistic expectations of timelines in your sales planning– Increasing access for a drug in the Medicaid space can take years. While the volume of members in the Medicaid space can drive significant revenues, there is usually a significant time investment, sometimes multiple years, before favorable coverage policies are fully realized. If you do not set appropriate expectations internally, you will create disruption and confusion in your sales organization.

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3 tips for Medicaid Health Plans on inviting solution vendors to your next RFP

3-minute read

Many of our clients are health plan professionals working in the health and human services space (including Medicaid plans and Medicare Advantage plans). The article below is based on our experience working with health plan staff who have succeeded in improving vendor management and procurement activities.

Tip 1: Invite more than you need

Its always good to have options. You should try to have at least two very strong candidates make it past the initial evaluation period. And in order to do that, you probably need at least 4 bidders to submit a proposal. And in order to have that many proposals, you probably need to invite 5 or 6 bid. But do invite specific vendors you have initially vetted (versus a broad open call) when possible. This will mean more work on the front end of your procurement effort, but will lead to stronger proposals and more interested vendors.

Tip 2: Rely on references from your health plan peers

Your number one asset in this process are other health plans who have done business with the bidders. In the Medicaid space, most plan staff are less concerned about competition (except during MCO contract award cycles) and are more concerned about improving the delivery of services in the Medicaid program. Don’t be shy about asking your contacts in other plans their opinion on vendors. You may need to do so informally to reduce any concerns over sharing confidential information.

Tip 3: Hold a 1 on 1 pre-invitation discussion with each vendor

Remember your goal is high quality proposals. In order to provide those, vendors need to understand as much as they can about your goals for the project. In addition to the normal group Q&A call offered to vendors, consider offering 1 on 1 discussions to make sure vendors are aligned with your vision for the project. The number of vendors interested will dictate how much time you can invest in this step. Its also recommended to conduct this part of the process with another trusted external consultant if possible. This step will minimize confusion over goals and scope before proposals are submitted.

2 More Tips

Knowing what to do is only the first step. Knowing how to implement these tips with your current team and many other priorities is more complex.  Here are a few other pointers on improving your options for your next vendor procurement:

  1. Create a short list of invitees and gauge interest with them before executing your full procurement effort– List the three vendors that immediately come to mind, and have a half hour exploratory discussion with a small group from their team. This can help you rapidly identify any key changes or clarification needed to your requested project scope without the extensive resource cost of an RFI. We also help clients scan the competitive field for vendor shortlisting options, and are happy to discuss any time.
  2. Assign an existing team member to own the procurement effort from a project management perspective OR hire an external consultant to focus on the effort- If your project is not too large, or not too complex, you can assign a team member to drive key work items that are often overlooked like scheduling and action item management. We offer project management support in all our client engagements, and are happy to discuss any time.

Reach Out

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Medicaid Concept: Medicaid Drug Discount Programs

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 Medicaid Drug Discount Programs?

One of the main ways that Medicaid agencies can control spending on drug benefits is by entering into rebate agreements with drug manufacturers. These rebate agreements offer Medicaid programs a discount on drug pricing in exchange for allowing drug manufacturers access to the very large markets of Medicaid membership. States can participate in the national Medicaid Drug Rebate Program (MDRP) and receive the discounts.

The other major drug discount program in the Medicaid space is the 340B program. This program allows “covered entities” to purchase drugs at a discount, and then resell those drugs at normal prices (thus keeping the difference).

What role does Medicaid play?

The national MDRP is managed by federal HHS. When states choose to participate, they must allow all drugs that have been negotiated at the federal level. States can also enter into “supplemental agreements” with manufacturers, which in effect provide preferential placement on a state’s drug formulary.

While the 340B program was designed to allow smaller hospitals and other providers to purchase drugs more cheaply, it has evolved into a way to generate increased revenues. States have noticed this and have begun to “take back” management of the drug benefit from health plans in order for the state to obtain these revenues.

Explore further

https://www.macpac.gov/wp-content/uploads/2018/05/340B-Drug-Pricing-Program-and-Medicaid-Drug-Rebate-Program-How-They-Interact.pdf

https://www.hrsa.gov/opa/index.html

https://www.americanactionforum.org/research/primer-the-medicaid-drug-rebate-program/

https://www.whistleblowerllc.com/medicaid-drug-rebate-program/

https://www.kff.org/medicaid/issue-brief/understanding-the-medicaid-prescription-drug-rebate-program/

https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html

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Medicaid Concepts: Transportation 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 transportation 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, lack of transportation is another area that is generally recognized as impacting healthcare. In places where public transportation is not available, the ability to get to health appointments can be especially limited.  If a Medicaid member cannot actually get to the doctor’s appointment, then few of the benefits of proper care can be realized. According to a report from the American Hospital Association, more than 3.6M Americans do not get the care they need because they did have a way to get to their visit.

from the AHA report

What role does Medicaid play?

Many Medicaid programs have operated optional non-emergency transportation (NET) programs for years. While these programs address the issue, there are long standing challenges with missed pickup appointments, overly complicated dispatch systems and legacy providers.

Several innovative Medicaid programs have emerged using rideshare vendors (like Uber and Lyft) to streamline the member experience and improve visit completion rates. Medicaid programs can partner with these vendors (or have their Medicaid managed care plans partner with them).

While these options can help meet gaps in urban environments, transportation challenges in rural areas for Medicaid members will likely require alternative solutions.

Explore further

https://nationalcenterformobilitymanagement.org/transportation-and-social-determinants-of-health-destinationss

https://www.aha.org/ahahret-guides/2017-11-15-social-determinants-health-series-transportation-and-role-hospitals

http://www.hpoe.org/resources/ahahret-guides/3078

http://www.hpoe.org/Reports-HPOE/2017/sdoh-transportation-role-of-hospitals.pdf

https://www.ruralhealthinfo.org/topics/transportation

https://populationhealth.humana.com/social-determinants-of-health/lack-of-transportation/

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Medicaid Concepts: Managed Long Term Services and Supports (MLTSS)

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 Managed Long Term Services and Supports (MLTSS)?

These are the services provided to Medicaid members in a managed care model. Because of the unique member needs, the focus on care coordination and management,  and intense cost structure of this model many states have decided to use stand-alone managed care programs just for LTSS. The LTSS stands for long term services and supports. Add an “M” in front of it for “managed.”

CMS has encouraged states to use MLTSS models with an array of funding efforts and aspirational goals. These include the Money Follows the Person (MFP) inititiative and the Balancing Incentive Program (where states are encouraged to increase the percentage of LTSS provided in the home or community vs. in a facility).  These efforts have paid off- 25 states operate an MLTSS program as of November 2020 (compared to only 8 states in 2004).

Medicaid programs spent $167B on LTSS in 2016.

  • map from MACPAC 2020
  • from CMS technical specifications for MLTSS measures 2017
  • from Mathematica report, 2018

What role does Medicaid play?

States design the features of their MLTSS programs and contract with managed care companies to deliver the services. They also set eligibility requirements for members, which can include both functional and financial criteria.

States also work with plans and actuaries to set rates for these services.

States also have to manage the quality reporting process for these services, using measures selected by CMS. These measures generally focus on ensuring needs assessments and care plan requirements are met.

Explore further

https://www.medicaid.gov/medicaid/managed-care/managed-long-term-services-and-supports/index.html

https://www.macpac.gov/subtopic/managed-long-term-services-and-supports

https://www.medicaid.gov/medicaid/downloads/final-eval-dsgn-mltss.pdf

https://www.medicaid.gov/medicaid/downloads/eval-dsgn-mltss.pdf

https://www.michigan.gov/mdhhs/0,5885,7-339-71547_4860_78446_78448-474121–,00.html

https://www.medicaid.gov/medicaid/downloads/mltss_assess_care_plan_tech_specs.pdf

https://www.nj.gov/humanservices/dmahs/home/mltss.html

https://www.macpac.gov/subtopic/eligibility-for-long-term-services-and-supports/

http://mltss.org/wp-content/uploads/2019/12/MLTSS-Profile-12-9-19.pdf

https://www.medicaidinnovation.org/_images/content/2019-IMI-MLTSS_in_Medicaid-Report.pdf

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Medicaid Concepts: Value-Based Payment Models

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 value-based payment?

 

Defining value-based care / payment remains one of the largest challenges in all of the healthcare space, and Medicaid is no different. While everyone agrees that the concept means something akin to “pay more for better outcomes,” providers and payers continue to struggle to arrive at agreement on definitions, how to adjust for population mix and what incentives actually work.

 
 

Some terms you may hear related to value-based payment include: shared savings, gain sharing, risk corridors, incentives, withholds and pay for performance.

 
 

A sub-industry of solution vendors leverages the focus on value-based payments to drive sales and growth. These range from care management companies and specialized provider groups that use HEDIS performance as core to their value proposition, all the way up to software companies that have emerged to help providers keep track of the complex set of requirements in their value based contracts.

 
 

On the Medicare side, CMS implemented several value based programs meant to change the way providers are paid (as part of ACA). The most recent ones were rolled out in 2019: Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).

 
 

 
 

 
 

What role does Medicaid play?

 
 

Medicaid programs have also invested significant effort in migrating from the legacy fee for service system to value-based payment models. Early efforts included health homes and patient-centered medical homes (PCMH).

 
 

More recent efforts have attempted to leverage managed care plans to hold providers accountable for quality. Most states use HEDIS-based incentive systems for managed care payments. Many states require health plans to place an increasing percentage of their provider payments in value-based contracts. In these arrangements, the Medicaid agency establishes benchmarks and contracts with an External Quality Review Organization (EQRO) to oversee the plan performance.

 
 

States also have implemented innovative solutions separate from their managed care arrangements. Tennessee has a mature episode-based payment program that rewards providers for better outcomes on comprehensive bundles.

 
 

A few states have attempted to use Medicaid Accountable Care Organizations (ACOs). Many states also participated in the CMS-funded State Innovation Models (SIM) program to pilot new ways to use value-based payment approaches.

 
 

 
 

Explore further

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs

https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd20004.pdf

https://medicaiddirectors.org/publications/medicaid-value-based-purchasing-what-is-it-why-does-it-matter/

https://www.chcs.org/resource/value-based-payments-in-medicaid-managed-care-an-overview-of-state-approaches/

https://www.medicaid.gov/resources-for-states/mac-learning-collaboratives/value-based-purchasing/index.html

https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/functional-areas/vbp-benchmarking-brief.pdf

https://www.ama-assn.org/system/files/2019-04/medicaid-value-based-care-models.pdf

https://hhs.texas.gov/about-hhs/process-improvement/improving-services-texans/medicaid-chip-quality-efficiency-improvement/value-based-care

https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/meetings/2018/nacnep-sept2018-CMS-Value-Based-Care.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

 
 

 
 

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Medicaid Concepts: Telehealth

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 telehealth?

Telehealth (in any payer space) can mean a wide variety of healthcare services that are technology-enabled, including:

  • Remote patient monitoring 
  • Messaging
  • Virtual provider visits

Until recent years, most telehealth services were delivered using a hub and spoke model, which essentially connected providers across locations for specialist consultations. In the traditional hub and spoke model, a patient still has to travel to a location for the telehealth visit. As smartphones and related applications have evolved, patients also want more ability to have services delivered virtually, and more options have emerged for members to stay at their home and receive telehealth services.

A large industry of solution vendors has emerged in recent years, and has been especially successful during the COVID pandemic. Significant investment dollars flow through to these vendors, and a corresponding increase in sales and marketing efforts has occurred.

What role does Medicaid play?

Medicaid programs have historically paid more for telehealth than other payers (or had more generous coverage). This is changing as other large payers (such as Medicare) have relaxed previous restrictions on telehealth coverage during the COVID pandemic. Each Medicaid program sets its own rules related to telehealth, and there are often state laws governing payments for telehealth. These laws usually focus on whether telehealth must be covered, and whether it must be paid for at rates similar to in person visits.

Some of the challenges Medicaid agencies face related to telehealth are:

  • Determining which services can be delivered virtually and still meet HEDIS quality standards (which are  used in pay for performance models)
  • Determining which services can be delivered virtually and still meet HEDIS quality standards (which are  used in pay for performance models)
  • Determining which services can be delivered virtually and still meet HEDIS quality standards (which are  used in pay for performance models)
  • Determining which services can be delivered virtually and still meet HEDIS quality standards (which are  used in pay for performance models)

Explore further

https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html

https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/medicare-and-medicaid-policies/

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth

https://www.hhs.gov/coronavirus/telehealth/index.html

https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit-supplement1.pdf

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://telehealth.hhs.gov/providers/billing-and-reimbursement/

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

https://www.dhs.wisconsin.gov/telehealth/index.htm

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Medicaid Concepts: Third Party Liability and Coordination of Benefits

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 Third Party Liability (TPL) and Coordination of Benefits (COB)?


Some Medicaid members can have multiple sources of health insurance coverage besides their Medicaid coverage. (One GAO report estimates that 14% of Medicaid members had additional third party coverage in 2012). When this occurs, Medicaid is supposed to be the “payer of last resort.” In practical terms, this means that all other forms of insurance coverage should pay their share of the costs of a member’s care before Medicaid begins to pay.

There are various other types of payers that are required to pay before Medicaid does, including:

  • Employer sponsored health insurance
  • Pharmacy benefit managers
  • Medicare
  • Court-ordered health coverage
  • Settlements from a liability insurer
  • Workers’ compensation
  • Long-term care insurance

What role does Medicaid play?

In order to ensure compliance with the legal requirement for Medicaid to pay last, states are required to “take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan.” This means states must operate business functions dedicated to ensuring the total coverage picture for each Medicaid member is known and incorporated into payment systems.

The state activities to ensure this are collectively referred to as “coordination of benefits” (COB). At a high level COB involves data-matching and identifying other responsible payers. In states that have Medicaid Managed Care, Medicaid plans often are paid to execute COB activities on behalf of the state.

Explore further

https://www.medicaid.gov/medicaid/eligibility/coordination-of-benefits-third-party-liability/index.html

https://medicaid.georgia.gov/programs/third-party-liability

https://www.in.gov/medicaid/files/third%20party%20liability.pdf

https://www.macpac.gov/subtopic/third-party-liability/

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Utah’s Medicaid fraud bill on hold after strong criticism | KUTV

MM Curator summary

 
 

Utah is one of several states looking to reduce fraud in food stamps and related benefits programs, and Democrats oppose the effort.

 
 

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.

 
 

Spending hundreds of dollars to chase pennies: That’s what critics worry a new Medicaid fraud bill would lead to and all on the taxpayer’s dime.

It’s a measure one opponent goes as far as to call potentially catastrophic for Utah.
 

Lawmakers in support of the bill said Tuesday they want a process to investigate people who improperly receive state benefits.
 

This is something those in opposition argue is a very minor problem in Utah. Alliance for a Better Utah, a nonprofit, watchdog organization, said instead of pouring millions of dollars into searching for a needle in a haystack, we should address the real issue–the high rate of uninsured kids in the state.

The legislation would make an already lengthy Medicaid waiver application process even more involved, which neither the Trump nor Biden administrations have ever supported.
 

Dave Gessel, a representative with the Utah Hospitals Association, said they were not consulted and strongly oppose this bill.

Opponents said this would do little more than make it extra difficult for people in need to get help. The bill is on hold for now and not expected to go anywhere this legislative session.

 
 

Clipped from: https://kutv.com/news/local/utahs-medicaid-fraud-bill-on-hold-after-strong-criticism