Current Trends in the Medicaid RFP Procurement Landscape This is a Presentation Subtitle PRESENTED BY: Michael Lutz Avalere Health October 31, 2017
About Us Michael Lutz Vice President mlutz@avalere.com 1.202.355.6093 Avalere Health An Inovalon Company 1350 Connecticut Ave., NW, Suite 900 Washington, DC 20036 2
Most States Enroll Some Beneficiaries in Risk-Based, Capitated Managed Care Plans Medicaid Managed Care Presence / CA OR CA WA OR AK WA NV AK NV ID AZ ID UT AZ UT MT MT WY* * WY NM CO TX HI HI NM CO ME ND VTME ND MN NH* SD WI NY VT MA MN NHCT MI SD WI NY MA RI NE IA PA CT NJ MI IL IN OH NE IA PA DE WV MD OH KS MO IL IN VA DC KY WV KS MO VA NC TN OK KY AR* NC SC TN OK Uses Risk-Based, Capitated MMCOs (40 + DC) AR MS AL GASC TX LA Planned Transition to MMCOs (1) MS AL GA LA MMCO: Medicaid Managed Care Organization *AR and NH currently enroll Medicaid expansion beneficiaries into exchange coverage through premium assistance; though funded by Medicaid, these are technically not MMCOs. **WY does not use MMCOs for Medicaid, but the state s standalone CHIP program enrolls beneficiaries in MMCOs. Source: Avalere State Reform 360, August 2017. FL FL Does Not Use MMCOs (9) None (1) Most states with expanded Medicaid eligibility and MMCOs enroll newly-eligible beneficiaries in managed care 3
Very Active Current Procurement Environment May Impact Coverage for About 11M Recipients / State Recipients Alabama MLTSS 25,000 Arizona 1,600,000 District of Columbia 190,000 Florida 3,100,000 Illinois 2,000,000 Massachusetts ACO 30,000 Mississippi 500,000 New Mexico 700,000 North Carolina 1,500,000 Texas STAR+PLUS 615,000 Virginia 737,000 Total 10,997,000 Relative Size of Recipients Impacted Avalere Analysis based on data from state procurement releases 4
Huge Plan Revenue Potential $269B MA: $5.6 Medicaid managed care payments spent in 2016 $8.7 $3 DC: $1 $8 $4.3 $12.4 * $65.4B $17.8 $2.5 $5.5 * $14.5B In Billions Medicaid managed care spent in 2016 by states with active or recent procurements States with recent procurements NOTE: *AL and NC are just moving to managed care for coverage of their Medicaid population. Values for NC and AL represent the amount spent on Medicaid enrollees in 2016 Sources: Kaiser Family Foundation; Health Management Associates 5
More Competitive Environment Fewer Contracted MCOs and Increased Competition Drive Plans to Increase Legal Action / Number of Contracted MCOs Competition Bid Protests 6
New Specific Design Requirements Value-Based Purchasing Elements Physical and Behavioral Health Work Assistance Provider-Led Entities Special Populations Tie capitation payments to MCOs via new payment models to increase quality and control costs Integrate and coordinate physical and behavioral health, even if the benefits are carved out to separate programs or entities While no states require recipients to be working or jobseeking for eligibility, plans must provide skills training and resources to help recipients look for employment Some states require bidders to be provider-led entities or have a providerled partner on the contract Long-Term Increasingly develop managed care programs for special needs, i.e., LTSS and developmental disabilities New procurement requirements and expectations mean plans programs must be structured in nontraditional ways, and plans must articulate capabilities explicitly. 7
Plans Must Demonstrate a Commitment to Stakeholders States Seek Demonstrated Results and a Clear Focus on Community-Centeredness / Quality Results RFP questions regarding quality outcomes are important both in response size and weight of overall scoring Increasing VBP requirements requires increasing quality reporting Local Involvement/Presence No longer enough to have a few staff members in the area; states want to keep a large portion of the dollars in-state States seek engagement with provider-led entities as a way to keep the dollars in-state 8
Plans Must Articulate Program Design and Results Move from Demonstrating Operational Task Proficiency to Integrated Management / Past RFP Focus Areas New RFP Approaches Real-World Scenarios Describe Quality Outcomes Articulate Value-Based Approaches Integrate and Coordinate Across Programs 9
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