THE CHALLENGE: The state has six health plans running on different systems. The current data vendor was not able to collect all the required data, process the information, and upload it to the state’s data warehouse in time for rate-setting activities. We developed master data requests and liaised with multiple contractors to identify the data elements that satisfied the required efficiency analyses. Mercer worked directly with the state's MCOs to ensure that data submission was consistent and accurate.
Actions taken and results
THE CHALLENGE: The state was tasked with restructuring the Medicaid program to achieve improvement in outcomes, sustain cost and build a more efficient administrative structure. Key features included moving behavioral health services from fee-for-service into managed care and incorporating the ability to manage specialty behavioral health services. MCOs would now be responsible for managing integrated physical health, behavioral health and home and community based services.
actions taken and results
THE CHALLENGE: The state wanted to expand coverage and capacity for an array of ASAM levels of care and support adoption of medication-assisted treatment. The state wanted to support providers and managed care organizations in this transition by helping them fully understand service definitions, provider qualifications and billing expectations. The state also recognized the need to gather current SUD program and staffing information from providers in order to assist in provider reimbursement and capitation rate development.
Actions Taken and Results
THE CHALLENGE: Faced with rising medical trends and a shrinking state budget, the state engaged Mercer to identify and quantify inappropriate use of medications within their capitated MCO pharmacy programs. Both the state and the MCOs needed confidence in the credibility of a pharmacy-specific rate-adjustment process that identified program inefficiencies. The development of an actuarially sound algorithm and analytical tool that would produce defendable results required the integration of clinical, pharmaceutical, and actuarial expertise.
actions taken and resultsMercer can help bring an entirely new managed care program to reality or assist states in expanding or improving existing programs.
States should build synergies to support quality processes that integrate the HCBS quality framework into broader Medicaid managed care quality requirements.
Many states are seeking new and innovative ways to deliver, pay for and manage long-term services and support programs – but there is no one-size fits all solution.
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CMS takes a clear stance on how MCOs should treat vendor costs in MLR reporting, including PBM spread. After seeing the first few MLR reports required under the...
The recent focus and research on social determinants of health show that individuals with low incomes are more likely to be impacted by SDOH. Medicaid programs are..
As kids, most of us were probably warned not to give in to peer pressure. Clearly this reflects an appreciation for how we can be negatively influenced by...
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