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 of the National Diabetes Prevention Program (National DPP) lifestyle change program in Medicaid, and includes the following topics:
 

  1. Why Work with MCOs?
  2. Strategies for Engaging MCOs
  3. Coverage Options Utilizing MCOs
  4. Performance Improvement Projects

Why Work with MCOs?

In states that use Medicaid managed care, MCOs are a tremendous opportunity for supporting coverage of 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 coverage of the program in Medicaid
  • 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

 

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.

Managed care plans manage utilization of their members’ services and identify care management strategies to improve health outcomes and increase access to the appropriate levels of care. Importantly, MCOs are often incentivized to emphasize preventive care. The incentives may be derived from contract requirements, including financial incentives incorporated into the contracts with Medicaid, or simply to adhere to best practices or to help keep costs of health care low. Therefore, the provision of quality preventive care is often critical to MCO care management. MCOs determine their own provider networks and can use this flexibility to design preventive health care strategies that are best aligned with the needs of their enrolled populations and benefit design. These contract requirements and responsibilities can result in the adoption of proven strategies to prevent chronic conditions.

Click here for a map of which states use Medicaid managed care.

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Strategies for Engaging MCOs

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, launching MCO pilots, and building the infrastructure for statewide Medicaid coverage of the program.

Leverage Relationships

Leverage Existing Relationships

  • Inventory the existing relationships between the state Medicaid agency, state public health agency, and state 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 a point of contact at each MCO. This could be individuals working in population health, community health, or utilization and care management departments at the MCO.
    • States have found it useful to work with the state Medicaid agency, especially if only MCOs with a Medicaid contract are being contacted. The state 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, who often interface regularly with the state Medicaid agency.

Leverage Associations

Leverage MCO Associations

  • If contact with MCOs cannot be achieved through the state 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.

Group Meetings

Group Meetings and One-on-One Calls

  • Reach MCOs through one-on-one calls, group meetings, webinars, or a combination of these approaches.
    • Some states have presented 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 MCO could implement the program. Presentations to groups of MCOs have featured the programs efficacy, a presentation from a CDC-recognized organization, and information on launching a pilot.
    • 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.

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 patients’ 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.
    • 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.
    • Describe how the National DPP lifestyle change program aligns with the goals of both the state Medicaid agency and public health, as appropriate. This can help further establish a partnership between Medicaid, public health, and the MCOs.

Highlight Examples

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 Medicaid covered benefit, 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 Questions

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 of the National DPP lifestyle change program.
    • For example, other states have 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 here, and resources to support the Demonstration’s success can be found here.


 

Coverage Options Utilizing MCOs

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

Value-Added Services

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.

Kentucky

State Example

Aetna Better Health of KY offered the National DPP lifestyle change program as a value-added service to its Medicaid managed care enrollees in 2017.

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 include CDC Program 1815 or CDC Program 1817 funding.

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.

The Strategies for Engaging MCOs, found above, can be deployed 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:

  1. provide useful information on what services MCOs are already offering for diabetes prevention,
  2. identify what prediabetes data MCOs are tracking, and
  3. 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.

State Example

Virginia

Virginia sent a survey to MCOs to collect information on their current efforts related to diabetes prevention. VA’s survey included questions about the type of CDC-recognized organizations contracted with, delivery modalities, types of data being collected (e.g., A1C, age, BMI, race/ethnicity, physical activity, and self-identified gender), member and provider awareness mechanisms, and interest in opportunities for technical assistance. Virginia noted that the survey was intended to assess the level of interest and engagement in the National DPP space by MCOs.

State Example

Michigan

As a first step in identifying pilot sites, Michigan staff from the Diabetes and Other Chronic Diseases Section attended a meeting with the Association of Health Plans, where they presented the idea of a pilot. Before these meetings, the Michigan Department of Health and Human Services (MDHHS) sent out a survey to attending health plans to assess current efforts around diabetes prevention. Michigan noted that by understanding the extent of existing efforts before proposing the pilot project, they could more effectively frame the opportunity as a value-add for MCOs.

State Example

Kentucky

The Kentucky legislature passed a resolution in 2019 (Senate Joint Resolution 7) which directed the Department of Medicaid Services to study the potential impacts of implementing programs similar to the National DPP lifestyle change program for Medicaid beneficiaries. The Department of Medicaid Services then required the Medicaid contracted MCOs to submit reports on how they would implement diabetes prevention. For more information, see the Role of the State Legislature in Medicaid Coverage page.

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 pilot by contracting directly with CDC-recognized organizations that serve the pilot MCO’s members. The 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.

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.

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.

Michigan

State Example

Michigan:

The Michigan Department of Health and Human Services (MDHHS) began a pilot of the National DPP lifestyle change program with United Healthcare Community Plan (UHC) MCO in January 2020. The objective of the pilot is to produce effectiveness data for the state Medicaid agency and to test what is required to administer the National DPP lifestyle change program to Medicaid beneficiaries.

MDHHS is using 1815 funds for the pilot, which are not sent directly to the MCO. Instead, Michigan contracts with the National DPP lifestyle change program providers themselves, who receive reimbursement for the service. The 1815 funds consist of $30,000 to support 30 beneficiaries at up to $1,000 per participant. The MCO is providing in-kind support in the form of staffing and outreach, as well as program resources for members.

As part of the 1815 requirement, each CDC-recognized organization funded through Michigan’s value-based model is required to submit per participant program costs. MDHHS also collects evaluation data, including targets for enrollment, attendance, and weight loss. MDHHS set up a timeline for evaluation throughout the contract year and established a process for working with programs that are not meeting standards. This process creates a realistic model for pay-for-performance that builds capacity for CDC-recognized organizations to optimize their reimbursement amounts.

The public health emergency related to COVID-19 greatly impacted the implementation of this pilot, as the CDC-recognized organization site is a large health system. MDHHS has brought many stakeholders together to discuss these barriers and offer solutions to enrolling more participants. These strategies are currently under consideration.

MDHHS is also pursuing an MCO pilot in partnership with one of their CDC-recognized organizations, the National Kidney Foundation Michigan (NKFM), and six MCOs. In early 2021, the status of the MCOs’ involvement in the pilot ranges from contracting to ongoing outreach and enrollment. For one MCO, NKFM is facilitating enrollment by following up directly with interested members, which Michigan believes contributes to increased enrollment.

Illinois

State Example

Illinois:

Illinois began a unique MCO mock claims pilot in October 2020, which was funded by Meridian Health Plan of Illinois (“Meridian”) (an MCO) in partnership with the Illinois Public Health Institute (IPHI). The objectives of this pilot are to identify effective recruitment strategies and test claims and data sharing processes. The goal is to learn how stakeholders work together to provide the National DPP lifestyle change program and to use a mock claims process to prepare for when Medicaid coverage of the National DPP lifestyle change program is achieved. No actual money is being exchanged as part of the mocks claims process.

The CDC-recognized organizations participating in the MCO mock claims pilot are federally qualified health centers (FQHCs). The FQHCs receive funding from a combination of CDC Program 1815 and CDC Program 1817 funds to participate in the pilot, in addition to funding from IPHI to run the classes.

1915(b) Waivers

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.

1915(b) waivers allow states to use the cost savings generated from managed care delivery systems to provide additional services to Medicaid beneficiaries such as maternity care programs, Nurse-Family Partnership programs, and other non-Medicaid services. The additional services are subject to CMS approval and must be for medical or health-related care or other services as described in federal regulation.

1915(b) waivers provide states with the authority to wave core elements of federal Medicaid regulations. Under a 1915(b) waiver, the state is allowed to:

  • Limit the number of qualified providers Medicaid beneficiaries may obtain services from
  • Target specific geographic locations
  • Provide services to the waiver population that may not be comparable to other services provided to Medicaid populations. In this scenario, services may vary by amount, duration, and scope and populations excluded from the waiver program must be identified.

As with 1115 waivers, 1915(b) waivers must be “cost effective” and the state must meet certain requirements around cost projections, rates, and monitoring. For more information on these specific requirements, visit the Managed Care Authorities page on Medicaid.gov.

Whether delivery of the National DPP lifestyle change program can meet these criteria is dependent on the state, the savings it has achieved through its managed care program, and what other programs it currently offers through a 1915(b) waiver.

Section 1915(b) waivers must comply with federal Medicaid requirements and are approved initially for two years and renewed for up to two-year periods (five years if the waiver includes the dual eligible population).

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Medicaid Managed Care Performance Improvement Projects

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.

Currently states and MCOs have some latitude in the number and topics of PIPs that are implemented, although they must be developed within established CMS protocol. This protocol specifies how a PIP is to be conducted and evaluated including “methods for selecting the topic, defining the study question, selecting indicators and study population, sampling methodology, data collection, implementation of the improvement strategy, analysis of data and interpretation of results, and planning for sustaining improvement.” (Source: Medicaid Performance Improvement Projects: A Means of System Transformation; available here).

PIPs are validated by an external quality review organization (EQRO). Costs associated with developing and implementing PIPs are included as part of the capitated MCO rate paid by the state, which is then eligible to claim federal Medicaid match for appropriate services. Costs related to these projects fall in the numerator for the Medical Loss Ratio (MLR) equation.

One issue to note is that 42 CFR § 438.330 outlines that CMS is permitted, in consultation with states and stakeholders, to specify standardized performance measures and topics for PIPs for inclusion in state contracts with MCOs. While states may request exemption from national PIPs, the goal is to make these projects more standardized moving forward.

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Oregon

State Example

Oregon’s Medicaid program, known as the Oregon Health Plan (OHA) contractually requires each of its coordinated care organizations (CCOs) to address four quality improvement focus areas from a list of quality improvement focus areas provided in Oregon’s 1115 waiver. Three of these four projects may serve as a CCO’s Performance Improvement Projects. In the 1115 waiver, the National DPP lifestyle change program is specifically enumerated as an example intervention in the “Addressing population health issues” focus area.


 

References:

Content last updated: July 21, 2021