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Programmatic Assessment of Carve-In and Carve-Out Arrangements for Medicaid Prescription Drugs

October 2007

Association of Community Affiliated Health Plans (ACAP)

The Lewin Group was engaged to provide a discussion of the programmatic issues involved in the use of a "carve-in" versus a "carve-out" approach for pharmacy benefits within capitated Medicaid managed care programs. To address this issue, Lewin interviewed a variety of key stakeholders including Medical Directors and Pharmacy Directors from managed care organizations  in both carve-in and carve-out states, as well as representatives who could provide insight into the state Medicaid agency, provider, and pharmacy perspectives.

Client Area: Associations
Expertise Area: Medicaid and CHIP


SCHIP in North Carolina: Evolution and Reauthorization Challenges and Opportunites

March 2007

North Carolina Health and Wellness Trust Fund; University of North Carolina at Chapel Hill

This report explores the history of the North Carolina Health Choice for Children program over the past decade. The report also summarizes the perspectives of several key stakeholders and experts about the about the issues that will be discussed at the federal and state levels during the SCHIP reauthorization process.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


Independent Assessment of New Mexico's Behavioral Health Program

March 2007

New Mexico Medical Review Association

This report conveys the findings of the Independent Assessment of the access, quality, and cost-effectiveness of health care services delivered under New Mexico’s Behavioral Health Collaborative. This report fulfills the requirement of the Centers for Medicare and Medicaid Services (CMS) that state Medicaid authorities arrange for an independent assessment of a state’s 1915(b) waiver programs. The Lewin Group has reviewed the access- and quality-related state contractual requirements, ValueOptions’ proposal to the State of New Mexico, Managed Care Audit, ValueOptions’ provider network, selected reports, provider satisfaction survey, national performance standards and MHSIP performance, ValueOptions’ Quality Management Program, and various financial reports. Based on the comprehensive review of submitted reports and data related to consumer and provider satisfaction, the program is off to a strong start in some respects and a challenging start in others. ValueOptions and the Interagency Behavioral Health Purchasing Collaborative have implemented a behavioral health system that is designed to not only provide access to quality health services, but also integrate other non-medical health member needs. The State of New Mexico has set extensive and specific requirements for performance, which ValueOptions has already met or appears to be making significant progress towards. New Mexico’s behavioral health system meets CMS guidelines and requirements in terms of access, quality, and cost-effectiveness.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP, Mental Health and Substance Abuse


Independent Assessment of New Mexico's Medicaid Managed Care - Salud!

February 2007

New Mexico Medical Review Association

This report conveys the findings of the Independent Assessment of the quality, access, and cost-effectiveness of health care services delivered under the New Mexico Medicaid Managed Care program, Salud! This report fulfills the requirement of the Centers for Medicare and Medicaid Services (CMS) that state Medicaid authorities arrange for an independent assessment of a state’s 1915(b) waiver programs. The Lewin Group has reviewed the quality- and access-related state contractual requirements, each Salud! health plan’s quality improvement program, member and provider survey activities, HEDIS® and CAHPS® performance, provider network, and member materials, and various financial reports. The State of New Mexico has created a favorable environment for quality, access, and cost-effectiveness to occur in each of the three MCOs. Thus, the program clearly meets CMS guidelines and requirements in terms of quality, access, and cost-effectiveness.

Client Area: Associations
Expertise Area: Medicaid and CHIP


Assessment of HUSKY, Connecticut's Medicaid Managed Care Program

January 2007

Connecticut Association of Health Plans

Lewin assessed the performance of Connecticut's HUSKY Program, a capitated Medicaid initiative operated through contracts with four health plans. The study was coordinated through the Connecticut Association of Health Plans. The study's purpose is to provide objective information about the HUSKY Program and to compare the policy alternatives of retaining HUSKY versus adopting a "managed fee-for-service" model of coverage. The study finds the HUSKY Program to be successful (above national Medicaid managed care norms) on several key fronts -- delivering large-scale cost savings to taxpayers, fostering access to physician and preventive care services (e.g., EPSDT), and achieving high rates of enrollee satisfaction. The study concludes with a broad set of policy recommendations to strengthen HUSKY going forward, including a sharp increase in underlying Medicaid physician/dentist fee schedules to address the core problem that many "front-line" practitioners are reluctant to serve the State's poverty population.

Client Area: Associations
Expertise Area: Medicaid and CHIP


Medicaid Upper Payment Limit Policies: Overcoming a Barrier to Managed Care Expansion

November 2006

Medicaid Health Plans of America

The potential benefits of managed care have led many States to consider expansions in capitated Medicaid programs to the extent that they are consistent with state health care policy goals and specific market and political conditions. However, current Medicaid hospital reimbursement calculations only include fee-for-service Medicaid utilization, which places significant barriers to expanded use of capitated Medicaid managed care contracting in some states. States considering expanding Medicaid managed care must balance any potential benefits against the risk of losing substantial Federal Upper Payment Limit (UPL) funds that play an increasingly important role in supporting the public health care sector, including public safety net hospitals. This report explores Medicaid UPL issues and recommends a policy solution to preserve existing federal funds flow to support public safety net and other providers while also removing barriers to the expansion of Medicaid managed care. The recommended policy change would remove an unintended barrier to managed care expansion, which would in turn allow policy makers to evaluate more clearly the costs and benefits of their Medicaid contracting strategies and make policy choices according to what works best for their state.

Client Area: Associations
Expertise Area: Medicaid and CHIP


Medicaid Capitation Expansion's Potential Cost Savings

April 2006

The Medicaid Health Plans of America and the Association of Community Affiliated Plans

National Medicaid expenditures have risen at an average of 8.2 percent annually since 1995, outpacing states' revenue growth and placing enormous pressure on states to implement effective cost containment programs. The Medicaid Health Plans of America and the Association of Community Affiliated Plans jointly engaged The Lewin Group to quantify the savings that can be realized through state Medicaid agencies entering into capitation contracting with Medicaid managed care organizations. The report found, among other key points, that up to $83 billion can be saved over ten years if the capitation model were immediately applied to all appropriately suited Medicaid funds.

Client Area: Associations
Expertise Area: Medicaid and CHIP


Long Term Forecast of Medicaid Enrollment and Spending, 2005 - 2025

February 2006

Alaska Department of Health and Social Services
Lewin contact: John Sheils

In April 2005 the Alaska Department of Health and Social Services (ADHSS) contracted with the Lewin Group and ECONorthwest to develop a long-term forecasting model of Medicaid spending for the State of Alaska. This document describes the steps undertaken in the development of the forecasting model and provides details on the projected growth in enrollment, utilization, and spending on Alaska’s Medicaid program through 2025.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


Money Follows the Person Study

February 2006

Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities
Lewin contact Lisa Chimento

The Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities commissioned The Lewin Group to review and analyze the challenges and opportunities the State may face when undertaking a Money Follows the Person or “rebalancing” initiative. In essence, the study seeks to evaluate the manner in which Medicaid recipients access Medicaid benefits—either in institutions or in the community—and whether there exist policies or procedures that favor institutional placement over home and community-based services. It also reviews State initiatives on rebalancing and models the potential financial impact of Delaware’s adoption of a Money Follows the Person program.

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability, Medicaid and CHIP


Rate Setting and Actuarial Soundness in Medicaid Managed Care

January 2006

Association for Community Affiliated Plans; Medicaid Health Plans of America
Lewin contact: Lisa Chimento

The Association for Community Affiliated Plans and the Medicaid Health Plans of America retained The Lewin Group to conduct a study of the ways that states have implemented rules from the Balanced Budget Act of 1997 regarding actuarial soundness, in order to identify both best practices and continuing areas of concern. Lewin developed a survey to gather information from states and health plans on current rate-setting practices. This report presents the results of the survey.

Client Area: Associations
Expertise Area: Medicaid and CHIP

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