Identify the Appropriate Contact

Medicaid state agency staff are knowledgeable about initiatives that provide opportunities for community input on proposed changes to Medicaid and might have ideas about how evidence-based programs or other services can be integrated into new initiatives or existing efforts and included as a covered service. This can apply to any initiative, whether it’s a Medicaid Health Home initiative, a State Innovation Model (SIM) demonstration, or long-term services and supports (LTSS) Waiver program.

To cultivate a personal relationship with someone at your State Medicaid Agency, start by working with your organization’s internal Medicaid liaison to make the appropriate contact. If you do not have an organizational representative that maintains contact with Medicaid, contact your State Health Department or Area Agency on Aging. Most of the time, they already have a contact with Medicaid that they work with frequently.

Generally, the division within Medicaid that will pay for evidence-based programming is the Acute Care Division. You should ask to speak with someone from that division. Other avenues to explore include connections with the person who manages the Medicaid Managed Care or LTSS Waiver program. Because the State Medicaid Agency operates under many rules and regulations, it can take time to develop the relationship and see progress. Also, consider leveraging existing relationships to help support your efforts.

Do Your Research

Making the initial contact with Medicaid may feel challenging, so it’s important to prepare in advance of your initial contact. Do your research before the initial call or meeting with your Medicaid contact to show that you have an understanding of regulatory requirements, agency priorities, and the needs of Medicaid beneficiaries.

• Acquaint yourself with the regulatory requirements and frequently used terminology of the Medicaid state agency. This will help you establish common ground and language, while helping you demonstrate the value of your service to Medicaid.
• Develop a clear understanding of how Medicaid is currently being administered in your state. If your state has implemented Medicaid Managed Care, it would be helpful to do a little more research.
  • Gather information about which health plans have contracts with the State Medicaid Agency to serve as managed care organization (MCO) vendors and what benefits are covered by the MCOs.
  • Learn how the contracted health plans are performing in the provision of quality care as measured by the Centers for Medicare & Medicaid Services (CMS) performance measurement data sets. This is important because many Medicaid MCO plans have to align quality outcomes with Medicare quality outcomes to receive payment incentives.

• Find out about the challenges that the Medicaid state agency is facing, so that you can make the case for the benefits of adopting CDSME.
• Know the percentage of Medicaid beneficiaries or dual eligibles in your state with chronic illnesses, the extent to which they have access to CDSME programs, and how much Medicaid is spending on health care costs, including acute care, readmissions, and LTSS for this population.

Find out What Medicaid Policies are Currently in Place to Support Evidence-Based Programs

The first place to start with establishing Medicaid payment for evidence-based programs is to identify what policies are already in place that would support these programs. For example, if your state already covers an evidence-based program, like chronic disease self-management education (CDSME), as an approved Medicaid benefit, then you will need to apply to become a Medicaid provider and obtain a Medicaid provider number. In a standard fee-for-service reimbursement model, you will have to establish a billing system to receive payment. Whether or not CDSME is covered, you should ask the Medicaid state agency to put you in contact with the Medicaid MCO health plans that can benefit from offering CDSME to their patient population. Having the introduction come from the State Medicaid Agency can increase your chances of success in building partnerships with MCOs to make CDSME programs available to their members and ultimately paying you for delivering the service. In some cases, the Medicaid state agency will put in place requirements that Medicaid MCO Health plans cover CDSME for the population they serve.

State Medicaid Agencies develop and enforce Medicaid policies to monitor regulations about what is covered under Medicaid across the state. Therefore, if your state does not offer evidence-based programs  or other services as a covered benefit, you should be responding to opportunities to make recommendations for Medicaid changes that include them. It is important to ensure that your responses include data that demonstrate the benefits of specific services and show how offering services statewide can improve the health of the state’s population health and lower health care expenditures. 

Learn about Medicaid Stakeholder Groups

Medicaid is required by the Centers for Medicare & Medicaid Services (CMS) to obtain community input from key stakeholders on proposed changes to Medicaid. State Area Agencies on Aging are often among the group of key stakeholders. Participating in these groups is an opportunity for you to spread the word about the importance of offering evidence-based programs or other services as a Medicaid covered benefit and networking with others who can advance the cause. To learn more about Medicaid stakeholder groups, check your State Medicaid Agency’s website or contact your State Health Department and Area Agency on Aging to inquire about opportunities to become involved.

Develop a State-Focused Value Proposition

Whether you will be interacting with your State Medicaid Agency by providing community input, participating in stakeholder groups, or having conversations with internal Medicaid representatives, it is important to make a strong case for providing evidence-based programs or other services as a benefit. Since Medicaid serves the entire state, your State Medicaid Agency will want to know how you can provide services throughout your state. You will need to develop a solid statewide infrastructure, possibly developing partnerships and forming a network of service providers to meet the need. 

Crafting a value proposition can help you get your message across. It is important to make the case in your value proposition that evidence-based can improve health outcomes while lowering costs across the entire state. For example, here are benefits of CDSME that could be highlighted in a value proposition. 

• CDSME is proven effective in improving the self-management skills of patients, which leads to improved clinical outcomes (e.g., better self-reported health and quality of life, improved symptom management, increased activity level, reduced depression, improved medication adherence).¹
• Better clinical outcomes achieved through CDSME can help Medicaid improve the state’s population health and lower health care expenditures statewide by reducing health care utilization, such as hospitalizations and emergency room visits.
• CDSME improves patients’ communication with their health care providers and equips them with the skills to work with their providers in setting and obtaining achievable goals that result in improved health.

Include a cost-benefit statement in your value proposition with data to highlight the value of evidence-based programs or other services to the state and the potential return on investment (ROI) by offering the program as a Medicaid covered service. The ROI creates a “win-win situation” for your organization, Medicaid, and most of all, the patient.

Sustainable partnerships lead to sustainable evidence-based programs. One of the foundations of sustainable partnerships is the ability to establish common ground, set expectations, and identify mutually beneficial goals. In early meetings with your State Medicaid Agency, use your value proposition to guide discussions about setting expectations and goals for the partnership. Also in these early meetings, begin to identify potential champions who can assist you in developing and strengthening the partnership.

Source

1. National Council on Aging. Chronic Disease Self-Management Program: Summary of National and State Translational Research Findings. Found on the Internet at https://assets-us-01.kc-usercontent.com/ffacfe7d-10b6-0083-2632-604077fd4eca/0a91b1c9-5d37-4a94-b566-ca210a759e5d/Health-Outcomes-Evaluation-Revised-6.24.16-1.pdf. Accessed August 4, 2016