Medicaid MCOs → MCO Coverage
Engaging MCOs to Attain Coverage
This page describes the dynamic and flexible role managed care organizations (MCOs) can play in promoting coverage for the National Diabetes Prevention Program (National DPP) lifestyle change program in Medicaid, and includes the following topics:
- Why Work with MCOs?
- Strategies for Engaging MCOs
- Coverage Options Utilizing MCOs
- Performance Improvement Projects
In states that use Medicaid managed care, collaborating with MCOs represents a tremendous opportunity for supporting coverage for the National DPP lifestyle change program in Medicaid, both before and after Medicaid coverage of the program has been established in the state.
Prioritizing engagement with MCOs early on may help states:
- Generate buy-in from MCOs and excitement about the value of the program
- Establish trusted relationships with MCOs
- Create MCO pilot opportunities to gather data in support of statewide Medicaid coverage for the program
- Begin establishing the necessary infrastructure for the National DPP lifestyle change program, making statewide implementation a more streamlined process once coverage has been obtained
- Address any challenges in billing, coding, and delivery of the program early on to help set the program up for success
In addition to understanding the value of working with MCOs, it may be beneficial for states to understand why MCOs would be interested in partnering to expand delivery of the National DPP lifestyle change program. This can help states better prepare for conversations around partnering with MCOs. Through work with MCOs, NACDD has obtained various viewpoints from MCOs on the sustainability of the program and the role of managed care. While these excerpts are not representative of all MCO perspectives on the National DPP lifestyle change program, they can serve as a starting point for understanding how to build lasting partnerships.
Why MCOs Are Interested in the National DPP Lifestyle Change Program
The National DPP lifestyle change program often aligns with MCOs’ goals. MCOs have expressed interest in improving health outcomes, educating members on their health risks, and looking at member needs holistically. MCOs are prioritizing partnerships that aid in preventing, rather than just treating, diseases. Not only does the program focus on preventing type 2 diabetes, participation in the program can also help members improve other health outcomes like high blood pressure, weight loss, sleep apnea, and more. More information on this topic is available on the Evidence page of the Coverage Toolkit. MCOs may also view offering the lifestyle change program as a method of building trust between the MCO and its members, which often increases an individual’s desire to participate in their treatment plan.
The National DPP lifestyle change program is also an ideal means for MCOs to meet their organizational health equity goals. MCOs recommend that states interested in partnering with them seek to understand the MCOs’ plans and goals, particularly the health equity plans that are submitted and approved by Medicaid. States should also have knowledge of prevalent health-related social needs (HRSN) in the areas an MCO serves. CDC-recognized organizations with the ability to link members to additional evidence-based programs aimed at addressing HRSN would likely incentivize MCOs to forge partnerships. States interested in learning more about MCO requirements to improve health equity, such as those included in the National Committee for Quality Assurance (NCQA) accreditation, can visit the Quality Metrics page of the Coverage Toolkit. More information about how the National DPP lifestyle change program can improve health equity and address HRSN is available on the Health Equity and the National DPP suite of pages on the Coverage Toolkit.
Partnerships and MCO Roles
MCOs have shared that flexibility and open communication were keys for developing successful partnerships between MCOs and CDC-recognized organizations or state health departments. This included:
- Building strong relationships and engaging in regular communication at the beginning of the partnership, which was especially important for organizations engaging in their first community-based organization/MCO partnership.
- Understanding the roles and organizational norms of each partner organization.
- Patience and understanding of potential timeline delays by MCOs, given their administrative processes and the need to get executive approval for some aspects of their work.
Process efficiencies can be gained when state partners are involved in the work early on. Since MCOs are interested in maintaining strong relationships with state partners, engaging in pilots that involve CDC-recognized organizations, MCOs, and state partners can serve as a strong foundation for the work. Cross-sector partnerships between all parties can help reduce silos, solve problems, and create pathways for future partnerships.
To support the long-term sustainability of partnerships engaged in the National DPP lifestyle change program, MCOs found it helpful to have staff dedicated to identification and recruitment of program participants at the MCO and partner organizations. By employing staff who can focus on program details, partners can ensure they are able to quickly address challenges or workflow barriers. Looking toward the future, this may also include adding support staff, such as community health workers (CHWs), to the MCO or CDC-recognized organization project teams to assist with identification, outreach, or engagement and retention efforts.
About Medicaid Managed Care
“Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and MCOs that accept a set per-member-per-month (capitation) payment for these services.” See Medicaid.gov.
In a Medicaid fee-for-service (FFS) delivery system, a Medicaid beneficiary can receive care from any qualified provider willing to enroll under Medicaid. Managed care approaches allow the state to waive the individuals’ freedom to choose any Medicaid enrolled provider and require the Medicaid beneficiary to utilize an MCO’s network of providers or otherwise restrict the enrollees’ choice of which providers they can utilize. This waiver is typically accomplished through the Medicaid State Plan, a 1915(b) waiver, or a section 1115 demonstration waiver.
States use diverse strategies to outreach to MCOs. Depending on the goals of the outreach, a state may only engage MCOs with Medicaid contracts or it may engage all MCOs in the state. Successful engagement strategies can facilitate state and MCO collaboration on making the case for coverage, executing contracts between the MCO and CDC-recognized organizations or umbrella hub organizations (UHOs), launching MCO pilots, and building the infrastructure for statewide Medicaid coverage for the program. Provided below are strategies for states to consider when determining how or when they should connect with MCOs.
Leverage Existing Relationships
- Understand the existing relationships among the Medicaid agency, state health department, and MCOs. Existing relationships can be an opening for discussions on MCO engagement with the National DPP lifestyle change program and can lead to essential links to MCO leadership.
- Identify points of contact at each MCO. This could be individuals working in population health, community health, or utilization and care management departments. A description of common divisions or roles within MCOs is provided in the MCO Functional Units section below.
- State health departments have found it useful to work with the Medicaid agency, especially if only MCOs with a Medicaid contract are being contacted. The Medicaid agency provides a natural access point to establish contact with MCOs and can result in the ability to speak directly with MCO medical directors and/or MCO executive leadership, who often interface regularly with the Medicaid agency.
Leverage MCO Associations
- If contact with MCOs cannot be achieved through the Medicaid agency, initiate contact with a state association of MCOs, statewide committee, or any other organization that includes MCO representation.
- For example, one state reached out to the MCO committee within their statewide association of health plans to share information about the National DPP lifestyle change program.
Leverage National Landscape
Leverage the Existing National Landscape for Multistate MCOs
- In general, multistate plans are trending towards consolidation at the enterprise level, meaning that state-level decision-making is lessening. When approaching a multistate plan, identify the national-level trends that may impact conversations about coverage for the National DPP lifestyle change program.
- If a multistate MCO reaches a critical mass with required statewide coverage, meaning a substantial number of states in their network are requiring coverage, it may become appealing to include it as a value-add benefit in a non-required market.
- However, there are some limitations to using coverage in one state as leverage in another. If this critical mass is not met, multistate MCOs may not see the upside of covering the program in a non-requirement state.
- Plans with multiple lines of business, may consider providing similar services to all their beneficiaries. Health plans often use population health approaches to make those decisions.
Leverage Group Meetings
Leverage Group Meetings and One-on-One Calls
- Reach MCOs through one-on-one calls, group meetings (such as MCO medical director meetings), webinars, or a combination of these approaches.
- Some states have presented on the National DPP lifestyle change program to groups of MCOs, followed by one-on-one calls with each MCO to provide more personalized information on how the program could be implemented. Presentations to groups of MCOs have featured the program’s efficacy, a presentation from a CDC-recognized organization, and information on launching a pilot. Attending or sending representatives to these forums can help CDC-recognized organizations or UHOs become more deeply involved in decisions such as rate setting and other relevant conversations.
- States may also consider sending a survey to the health plans attending their presentations to assess the extent of existing diabetes-related efforts before proposing a pilot. This can help the state frame the National DPP lifestyle change program as a value-add for the MCOs. To learn more about MCO surveys, see the Step 1C: Survey MCOs section below.
- Conduct efficient follow-up that encourages ongoing conversation about a potential pilot or another engagement opportunity.
- Following pilot proposal meetings with MCOs, one state found it useful to send information on the number and locations of CDC-recognized organizations throughout the state to help the MCOs have collaborative conversations about launching a pilot.
- When possible, states should also consider including a standing update on the agenda of pre-existing state or MCO meetings to help keep representatives up to date on progress, upcoming projects, or new partners. States can also consider including MCO staff in CDC-recognized organization or UHO meetings and events to help build relationships with staff and members of the community.
MCO Functional Units
Each MCO is unique, with variation in their structure, communication patterns, and how they approach covering the National DPP lifestyle change program. When engaging MCOs, it is important for partners to reach out to MCO staff who can help form connections and advance National DPP lifestyle change program contracting efforts. This may include positions such as MCO medical directors or population health department leads. These MCO partners, in addition to UHO or CDC-recognized organization executive leadership, can assist in making the case for why coverage and reimbursement of the program is important for improving health outcomes among beneficiaries.
After forming initial connections, MCO staff involved in billing, legal, or quality improvement processes should also be included in conversations to ensure that viewpoints from each department involved in the National DPP lifestyle change program workflow are included. For example, adding the lifestyle change program to MCO workflows may involve changes or additions to existing internal platforms. Involving information technology or reimbursement specialists can help to identify and overcome potential challenges before they occur. More information on developing workflows is available on the Medicaid Screening & Identification page of the Coverage Toolkit.
The table below provides an overview of common positions and functional units at MCOs. It is important to note that MCOs are structured differently in each organization and state. Therefore, it may require additional research or discussion with partners to determine where these functional units are housed within your partner MCOs, the best unit to contact, and at what stage in the contracting and workflow development process it would be appropriate to reach out. As such, an MCO’s structure may not exactly follow the delineation of duties outlined below.
|MCO Functional Units|
|Unit||General Description of Responsibilities|
|Senior Leadership||Composed of the Chief Executive Officer (CEO), President, Chief Medical Officer (CMO), Chief Financial Officer (CFO), Chief Operation Officer (COO), and/or heads of various departments including but not limited to provider relations/network management, quality, compliance, and information systems and technology. The MCO may also have a Board of Directors. The CMO is a senior physician leading the team of clinical professionals, which may include physicians, pharmacists, social workers, etc.|
|Strategic Planning||Engaged in program related research and may be closely involved with the strategic planning, direction, coordination, and implementation of the MCO’s programs, policies, and procedures.|
|Quality Improvement||Oversees functions like National Committee of Quality Assurance (NCQA) accreditation, Healthcare Effectiveness Data and Information Set (HEDIS) reporting, External Quality Review Organization audits, performance improvement projects (PIPs), member complaints, and other special projects. This department develops and executes an annual work plan that likely includes efforts to identify methods for improving outcomes among populations of focus, in which the National DPP lifestyle change program could be included. More information on this topic is available on the Quality Metrics page of the Coverage Toolkit.|
|Case Management||Provides case management to members with complex conditions or high utilization of services. Case managers are often nurses or social workers who work directly with individual members to assist them in navigating complex health care systems. Case managers may be able to identify members eligible for the National DPP lifestyle change program.|
|Population Health||Oversees strategy development for improving clinical health outcomes of members through improved care coordination. These departments may house innovative interventions such as the use of CHWs to deliver certain preventative services (even though CHWs may not be directly reimbursable by the MCO’s state Medicaid program). Population health departments may oversee population health analytics to identify high-risk members and recommend them for case management services.|
|Member Outreach||Contacts members for needed preventive services like wellness visits, immunizations, screening mammograms, colonoscopies, etc. Members of the outreach teams are involved in most member communications and would likely be key staff in outreach to eligible members for participation in the National DPP lifestyle change program.|
|Community or External Outreach||Interfaces with members in the community, often stationed at satellite centers in communities where they are available to members for questions or concerns. They may also attend community health events where materials about the National DPP lifestyle change program can be distributed.|
|Website Design and Development or Social Media Team||If the MCO has a website and/or social media presence, these departments help develop and design content and may assist in communicating about the National DPP lifestyle change program benefit.|
|Provider Relations/Network Management||Works with the health care providers who are contracted with the MCO and are responsible for monitoring and maintaining network adequacy. The provider relations team recruits new providers and orients providers to MCO policies, contracts, problem solving, and available programs. Provider relations can assist in educating providers about the National DPP lifestyle change program benefit. The provider relations department is also primarily responsible for executing new provider contracts with the MCO. Additional information on contract types is provided on the MCO Contracting of the Coverage Toolkit.|
|Information Technology (IT)||Responsible for managing clinical software applications, including electronic health records (EHR) and other processes that help administrative staff maintain member records and communication. IT responsibilities may include data storage, provider network communications, billing systems, and member privacy protections.|
|Claims Processing||Oversees processing of claims submitted to the MCO, which may be done by the MCO or a contracted vendor. When covering a new benefit or engaging in a pilot program, it is important to include representation from the claims processing team to ensure that the planned processing will be compatible with the electronic and manual protocols.|
|Member Services||Assists members in finding a practitioner or specialist, making requests, filing complaints or appeals, or any other need a member may have. Member services will need to be educated on all aspects of Medicaid coverage for the National DPP lifestyle change program to answer any questions members may have about their access to the program.|
|Credentialling||Credentials and approves licensed clinical professionals to join the network of providers who care for members in the MCO. This department is supported by a review committee that primarily consists of physicians but may also include other clinical professionals. Depending on how the program is set up in the state, they may be involved in credentialing of UHOs, CDC-recognized organizations, or Lifestyle Coaches, however this process may lead to program implementation and reimbursement delays.|
|Contracting||Oversees vendor contracting, execution of business associate agreements (BAAs), and other legal documents which outline the requirements expected of the contracted vendor regarding protected health information (PHI) as outlined in Health Insurance Portability and Accountability Act (HIPAA), HITECH Act, and other laws. A vendor contract is the recommended contract type for CDC-recognized organizations or UHOs initiating National DPP lifestyle change program contracts. Additional information on contract types is provided on the MCO Contracting of the Coverage Toolkit.|
Tips for Communicating with MCOs
After determining where, how, and with whom they should connect with, states can also consider the following tips for effective communication with MCOs.
Make the Case
Make the Case for the National DPP Lifestyle Change Program
- Present the value proposition of the National DPP lifestyle change program to MCOs. This may be done by leveraging an existing MCO meeting organized by the state Medicaid agency, or by connecting with each MCO individually. Some key points to communicate to MCOs are:
- The National DPP lifestyle change program is unique among weight loss programs because it is evidence based. The original clinical trial and subsequent translational studies can be used to substantiate this point.
- Reference the Case for Coverage materials on the Coverage Toolkit, especially the Case for Coverage Presentation Outline. Add state-specific data to supplement national statistics.
- Share the value on investment (VOI) for MCOs covering the National DPP lifestyle change program.
- Emphasize that members’ healthier lifestyle choices gained from the National DPP lifestyle change program may contribute to a host of corollary health benefits and improved member satisfaction, in addition to preventing type 2 diabetes.
- Describe the relationships between diabetes and COVID-19; underscore the need for continued diabetes prevention, as those with diabetes are especially vulnerable to severe illness from the virus (1, 2, 3).
- Describe the nationwide infrastructure for the National DPP lifestyle change program, including the Medicaid coverage landscape and reimbursement of the Medicare Diabetes Prevention Program (MDPP) by CMS.
- Describe how type 2 diabetes prevention could be considered a value-add for the MCO and their members. If a plan offers the National DPP lifestyle change program, members may feel a stronger allegiance to their plan, which they perceive as genuinely looking out for their best interests.
Educate on UHAs
Educate the MCO on UHAs
- As an alternative to contracting directly with multiple CDC-recognized organizations, MCOs can consider contracting with an umbrella hub arrangement (UHA). In a UHA, the lead organization, or UHO, contracts with the MCO on behalf of a network of CDC-recognized organizations. Fully executed contracts between the MCO and the UHO ensures that each organization participating in the UHA has access to this reimbursement pathway. More information is available on the UHA pages of the Coverage Toolkit.
- In addition to illustrating the evidence behind the National DPP lifestyle change program, UHOs should be prepared to educate MCOs on the value proposition of the UHA model. For MCOs, the primary value proposition is the option to access a network of CDC-recognized organizations through contracting with one organization. Because the contracting processes at MCOs can be slow, executing one contract, rather than an agreement with each CDC-recognized organization, can help expedite network development and streamline reimbursement processes for the MCO. Developing a network of diverse providers delivering the National DPP lifestyle change program may also allow the MCO to reach a larger and more diverse proportion of the members they serve. This may include cultural diversity or multiple offerings in terms of program timing and modalities.
Communicate How Partnerships Can Help MCOs Meet Their Goals
- Partners should work to understand the priorities of the MCOs with whom they are trying to contract. For example, priorities may include:
- Quality service and goals
- Improved health of patients
- Cost effectiveness
- Strong relationships with health care providers
- Patient satisfaction
- Improved social well-being of patients
- Accurate and timely documentation
- National DPP lifestyle change program partnership can help MCOs meet these goals. For example, the program can help MCOs meet quality and accreditation standards, like the NCQA accreditation. Information is available on the Quality Metrics page of the Coverage Toolkit, which describes how federal regulations require states to develop and maintain strategies aimed at assessing and improving the quality of managed care services offered.
- Because of the trust they have built in their communities, partnerships with CDC-recognized organizations or UHOs can also help MCOs access populations of focus and/or those who have traditionally been difficult to reach through other programs or outreach efforts. Examples of how partners are serving populations of focus are available on the Addressing Health-Related Social Needs Through the National DPP Lifestyle Change Program page of the Coverage Toolkit. Information on the National DPP lifestyle change program, new partnerships, and upcoming initiatives can be featured in MCO newsletters and communications to provide insight into organizational efforts to meet goals and improve the health of their communities.
Highlight State Examples
- Many states currently provide some level of Medicaid coverage for the National DPP lifestyle change program. Some of these states are providing Medicaid coverage exclusively through their managed care plans. In these states, the National DPP lifestyle change program is not a covered benefit for fee-for-service Medicaid beneficiaries, however managed care plans are offering the lifestyle change program to their members largely due to leadership within the MCO. For additional detail on states covering the program in Medicaid, see the Participating Payers page of the Coverage Toolkit.
Anticipate MCOs’ Questions
- Prepare for questions from the MCOs, particularly related to barriers to implementing or covering the program. The Barriers to Coverage FAQ document addresses many of the commonly asked questions about coverage for the National DPP lifestyle change program.
- Begin conversations by level-setting on common terminology and/or CDC recognition processes. Even in states with existing Medicaid coverage for the National DPP lifestyle change program, states have observed that MCOs may still be in need of information on program delivery, Lifestyle Coach training, and the Diabetes Prevention Recognition Program (DPRP) process. Helping MCO staff understand roles and responsibilities of UHOs, CDC-recognized organizations, and Lifestyle Coaches can help MCOs overcome concerns and understand program benefits.
- States have also shared that MCOs understand the evidence behind the National DPP lifestyle change program, but desire evidence showing the effectiveness of the program for the Medicaid population in general or specific to their state. Studies evaluating the effectiveness of the program for the Medicaid population can be found on the Evidence page of the Coverage Toolkit.
- The Medicaid Coverage for the National DPP Demonstration Project is another source of evidence confirming that the lifestyle change program can be delivered successfully to the Medicaid population. More information on the Demonstration can be found on the Medicaid Coverage for the National DPP Demonstration Project page of the Coverage Toolkit.
Be Pleasantly Persistent in Your Engagement with MCOs
- While the National DPP lifestyle change program may be a primary focus for many CDC-recognized organizations and UHOs, it is only one of many programs and services covered by MCOs. Because of this, state partners may need to develop processes to maintain persistence in their communications with MCOs to remain on their list of priorities. While this persistence may at times feel excessive, states have often found it necessary to complete tasks and advance progress.
Develop Diligent Documentation Processes to Reduce Delays
- By developing processes for clear tracking and documentation of next steps, states can ensure that progress is made in developing relationships, executing contracts, and obtaining reimbursement. Clear documentation can also help to reduce delays that may be caused by staff turnover at the MCO, CDC-recognized organization, or UHO.
Please see the Elevator Pitch for MCO Coverage of the National DPP Lifestyle Change Program document for talking points that can be used to present how coverage of the program can benefit Medicaid managed care and the communities being served.
MCOs can be valuable partners in gathering data in support of Medicaid coverage for the National DPP lifestyle change program and laying the groundwork for successful implementation. This section describes how MCOs have become involved through the following mechanisms:
- Value-Added Services
- State-Supported MCO Pilot
- 1915(b) Waivers
Even before the National DPP lifestyle change program becomes a covered Medicaid benefit in the state, some MCOs may choose to cover the program for beneficiaries as a “value-added” service. When this occurs, it is an opportunity for states to collaborate with the MCO to learn about successes and difficulties in implementation, which may be leveraged for eventual statewide coverage.
Value-added services fall outside direct care costs and are paid for by the MCO. Value-added services are not covered by Medicaid, and MCOs receive no state or federal Medicaid matching funds for offering these services. See the Attaining Coverage through a Medicaid State Plan page for a description of federal Medicaid matching funds. However, value-added services are considered to be incurred claims and counted in the numerator of the medical loss ratio (MLR) calculation. More information on the MLR can be found here.
Some MCOs offer value-added services because the program will result in cost savings, improve health outcomes, or attract Medicaid enrollees to their plan. Examples of value-added services are numerous and vary across plans and states, but typically include health education classes, dental and vision programs, or incentive programs. MCOs may choose to offer the National DPP lifestyle change program as a value-added service if there is a high risk for type 2 diabetes within its member population or a high demand for the program.
State-Supported MCO Pilot
Another way a state can gather Medicaid- and state-specific data about the National DPP lifestyle change program is through a state-supported MCO pilot. A state can utilize public health or other grant funds to fully or partially fund a pilot of the National DPP lifestyle change program in Medicaid. For example, the state may financially support a single MCO or multiple MCOs in offering the program to a subset of its members. Examples of state public health funds used to support these types of MCO pilots can be found on the Additional Initiatives page.
A state-supported MCO pilot allows states to test implementation of the program, including effectiveness for certain populations, whether there are sufficient CDC-recognized organizations, effectiveness of recruitment and retention strategies, and fiscal impacts. It also has the advantage of potentially being implemented on a smaller scale, such as in a certain region or within a specific MCO membership.
States interested in implementing an MCO pilot can utilize the MCO/Value-Based Care (VBC) Project Planning Template, which was developed to assist with the planning phases of an MCO or VBC pilot. The template is meant to serve as a guide for organizing thoughts and tracking efforts related to MCO and VBC pilot planning and can be adapted to fit the needs of individual states or organizations.
The Strategies for Engaging MCOs described at the beginning of this page can also be used when considering an MCO pilot of the National DPP lifestyle change program. These strategies are represented in a timeline of activities below.
Step 1: Identify MCOs, Pilot Participants, and Sites
Step 1A: Conduct Initial Research
Step 1A: Conduct Initial Research on MCOs
States can begin identifying pilot sites by researching populations and geographic areas that MCOs are focused on reaching and then creating a list of CDC-recognized organizations in that area. For example, states may identify jurisdictions/counties with a high number of MCO members and increased diabetes burden. A list of CDC-recognized organizations could then be generated for these identified areas. Targeting populations with the greatest need may help ensure that the infrastructure that is developed during the pilot will work for these populations when coverage is attained.
States may also benefit from identifying organizations that are both CDC-recognized and already enrolled in Medicaid, such as FQHCs, local health departments, or health systems. These organizations likely have existing contractual agreements with MCOs and amending existing contracts typically is less time intensive than setting up a new contract between an MCO and a CDC-recognized organization. One way that states can find this information is by conducting a survey of MCOs. See Step 1C on surveying MCOs for more details.
Step 1B: Outreach
Step 1B: Outreach to MCOs
As part of the planning process, states can conduct outreach to MCOs to gauge interest and assess the fit for their participation in a pilot. A state’s Medicaid agency may be able to help facilitate in the MCO outreach process through existing channels. To learn more about outreaching to MCOs, please see the Strategies for Engaging MCOs section.
Step 1C: Survey MCOs
Step 1C: Survey MCOs
Surveying MCOs can:
- provide useful information on what services MCOs are already offering for diabetes prevention,
- identify what prediabetes data MCOs are tracking, and
- be an important first step in learning the value MCOs assign to the National DPP lifestyle change program.
MCOs that are actively identifying and tracking members with prediabetes may make good candidates for piloting the National DPP lifestyle change program.
Another way to survey MCOs is by conducting a readiness assessment. The purpose of a readiness assessment is to uncover whether MCOs have what they need to create a successful pilot. A readiness assessment can ask MCOs about existing prediabetes data, available staff for a pilot, outreach capacity, and data sharing agreements.
Step 2: Launch a Pilot
Step 2A: Funding
Step 2A: Identify Funding Sources
Identifying funding sources early on is an important part of a successful pilot. States have funded their pilots through a variety of mechanisms. Illinois identified an MCO that had corporate funding available to direct towards a National DPP pilot program and used 1817 and 1815 grant funding to support the participating CDC-recognized organizations. Michigan is also using 1815 funds for their state-supported MCO pilot by contracting directly with CDC-recognized organizations that serve the participating MCO’s members. At least one participating MCO in Michigan is providing in-kind support in the form of staffing, outreach, and administrative supports for the National DPP lifestyle change program for their members. To learn more about about Michigan’s state-supported MCO pilot, see Michigan’s State Story of Medicaid Coverage.
Step 2B: Budget
Step 2B: Establish a Budget
When developing the pilot budget, states may consider the reimbursement rate, the number of members to receive the services, the geographic catchment, and participant incentives or supports used to overcome barriers to participation. States may also consider developing the reimbursement methodology at the outset of the pilot so that payment is built with a value-based framework.
Step 2C: Objectives
Step 2C: Align on Pilot Objectives
A pilot may seek to accomplish several different goals. States can work with stakeholders to align on the objectives of the pilot and to set reasonable expectations for achieving their goals. It is critical to ensure that the state Medicaid agency is part of this process. Having ongoing support from the Medicaid agency can help facilitate the transition from a pilot to attaining statewide coverage. Some potential objectives that a state may want to focus on include:
- Demonstrate the effectiveness of the National DPP lifestyle change program for a specific population.
- Advance the CDC-recognized organizations’ ability to submit claims and identify potential technical assistance needs related to the billing and claims process.
- Evaluate the cost of delivering the National DPP lifestyle change program and determine the value on investment (VOI) horizon MCOs are seeking.
- Identify the MCOs’ objectives and Medicaid’s objectives for a pilot, such as improved member outcomes, including weight loss, physical activity, and A1C reductions.
- Identify and assess effective recruitment, enrollment, and retention strategies.
- Evaluate network adequacy to support the National DPP lifestyle change program within a state or region.
- Build new or strengthen existing relationships among National DPP and Medicaid stakeholders.
Step 2D: Test Billing
Step 2D: Test Claims and Billing Submissions Processes
States can implement a test claims submission process during their pilot with the objective of helping CDC-recognized organizations submit claims and identify potential barriers in the claims and billing process. This “mock claims” process can help states establish the necessary infrastructure for submitting claims on a trial basis and familiarize organizations with the process. To enable the mock claims submission process, states may set up codes so the billing process mimics state Medicaid agency operations. Illinois is using their pilot to test a mock claims process so that CDC-recognized organizations can track participants’ progress and milestones and share this information back with their MCOs.
Step 2E: Technical Assistance
Step 2E: Offer Technical Assistance
States may consider offering technical assistance to MCO pilot sites to increase the likelihood of program success. Technical assistance for various aspects of the program may include supporting member outreach and recruitment, facilitating marketing and referrals, facilitating the development of billing and claims processes, supporting evaluation and monitoring, convening MCOs, and creating quality improvement plans. Michigan, for example, requires evaluation data from their pilot sites that allows the state to identify needs and provide technical assistance to programs that are not meeting CDC’s Diabetes Prevention Recognition Program (DPRP) standards. For additional information about the technical assistance provided by Michigan to pilot participants, see Michigan’s State Story of Medicaid Coverage.
Step 2F: Evaluate
Step 2F: Monitor and Evaluate the Pilot
Evaluating an MCO pilot can result in critical data to support the case for statewide coverage of the National DPP lifestyle change program in Medicaid and to encourage engagement from other MCOs. Evaluation is most effective when the state Medicaid agency is involved early in the process. States may evaluate their pilot by gathering outcomes data and preparing evaluation reports on the successes and challenges of the pilot. Some states may even require evaluation data from pilot sites to assess whether participating providers are meeting DPRP standards.
Gathering data from participants can help support the MCO’s recruitment and enrollment efforts by shedding light on the participants and their needs. States and CDC-recognized organizations can work with MCOs to determine which types of data the MCO is already gathering, how to use this data to support the pilot, and if any additional data needs to be gathered to help monitor the pilot.
After a pilot ends, states may find it useful to collect feedback from MCOs and CDC-recognized organizations involved in the pilot to identify successes, challenges, and areas of opportunity. This input can be used to guide the design of the benefit and implementation approaches when statewide Medicaid coverage of the program is attained. States may also want to invite the MCOs and CDC-recognized organizations that were involved in the pilot to participate in the benefit design.
To learn more about evaluation methods and examples of states that have evaluated the National DPP lifestyle change program, please see the evaluation section of the Data, Reporting, and Evaluation page.
A state that has codified the decision to cover the National DPP lifestyle change program in Medicaid through legislation or administrative rules will add the program to its benefit delivery system and start claiming federal Medicaid matching funds for the program when it is approved by CMS. In most cases, states will receive CMS approval by including a new benefit in the Medicaid State Plan. However, if the policies or processes the state intends to implement for the National DPP lifestyle change program cannot be fully accomplished through the Medicaid State Plan, the state may choose to use a 1915(b) waiver or a section 1115 demonstration waiver. Typically, states review the existing coverage mechanisms in the state, and cover the National DPP lifestyle change program using the most efficient existing mechanism.
Section 1915(b) waivers are used broadly to allow the use of Medicaid managed care. While it does not appear that any states are currently using 1915(b) waivers to cover the National DPP lifestyle change program, similar programs are incorporated within these waivers. 1915(b) waivers could be a viable coverage mechanism for the National DPP lifestyle change program in a state that uses 1915(b) waivers to implement its managed care delivery system. Programs included in the 1915(b) waiver qualify for federal Medicaid matching funds.
Ensuring Covered Services are Included in Medicaid Managed Care Regulations
Once the National DPP lifestyle change program becomes a Medicaid benefit , states should ensure the program is also included in any relevant MCO regulations that outline required covered services in managed care. For example, Maryland has a Code of Maryland Regulations that outlines all required Maryland HealthChoice (Maryland’s managed care program) benefits. When the National DPP lifestyle change program was added as a covered benefit in Maryland Medicaid via a section 1115 demonstration waiver, these regulations were amended to include the program. Other states may not specify this level of program detail through regulation, but may require that MCOs cover “all state plan services” or give their Medicaid agencies the discretion to determine what services to include in the MCO contracts and which ones to carve out.
States should seek to understand their unique regulatory environment to determine what steps, if any, are necessary to ensure coverage of the National DPP lifestyle change program in managed care once it becomes an approved Medicaid benefit.
After Medicaid coverage of the National DPP lifestyle change program is achieved, MCOs can be important partners in increasing utilization of the benefit. One way to achieve this is through Medicaid managed care Performance Improvement Projects (PIPs). PIPs are quality improvement projects developed and conducted by MCOs. PIPs typically focus on improving the delivery or outcomes of services already covered by Medicaid. Because PIPs can focus on either clinical or nonclinical areas like diabetes prevention, they are a potential vehicle for improving outcomes of the National DPP lifestyle change program, such as outreach and retention.
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