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Medicaid Community Engagement, Work Requirement and Consumer Empowerment Programs: Key Implementation and Operations Issues and Considerations

This week, our In Focus section highlights HMA Medicaid Market Solutions’ (MMS) efforts to support state flexibility in designing and implementing Section 1115 Demonstration Waivers promoting member engagement and personal responsibility. Over the coming weeks, HMA MMS will present a series of articles providing in-depth analyses of the many facets of these new Medicaid models. This week, we examine important issues and considerations for implementing Medicaid consumer empowerment, community engagement, and work requirements.

Across the country, several states are actively pursuing the incorporation of community engagement, work requirements, and consumer empowerment strategies into their Medicaid programs. Requiring able-bodied low-income adults to work or engage in other meaningful community-oriented activity to access or maintain Medicaid coverage has already been approved in four states: Arkansas, Indiana, Kentucky and New Hampshire. Moreover, even though the long-term impact of the recent federal court ruling on Kentucky’s 1115 waiver is not clear, interest in Medicaid consumer empowerment, community engagement and work requirement initiatives is not diminishing. For instance, in June, Virginia lawmakers approved Medicaid expansion with the condition that the Commonwealth apply for federal permission to include work requirements (last month the Commonwealth issued a request for information related to this initiative).

Irrespective of the specific program designs being implemented in various states, based on HMA’s experience working with Indiana and Kentucky, we believe it is important to address operational and technological implications of such new programming to ensure the program’s successful implementation.

Issues and Considerations

  • Information system design, configuration and integration are important considerations when developing these programs. Because of their design, these programs include more data requirements than traditional Medicaid managed care or fee-for-service programs. As an example, these programs may require new or additional methods for verification of self-reported activities. Typical MMIS, MCO systems, and HIPAA compliant transaction types (e.g. 834/enrollment data) are not designed to maintain, and thus exchange, newly required data values. Additionally, non-typical interface designs may be required. Interfacing between program partners, such as MCO-to-State eligibility and enrollment (E&E) systems, may require a rethinking of system interfaces and, in some instances, system changes.  Finally, the development and implementation of new data use and data exchange agreements will be critical for successful program implementation. These agreements tend to be very resource-intensive, can involve attorneys from multiple parties, require adherence to multiple laws and regulations that are not necessarily “harmonized”, and may entail considerable consumer outreach and education for them to be accepted.
  • A major risk in planning and implementing Medicaid community engagement, work requirements, and consumer empowerment initiatives is the failure to obtain participation and input from all program partners and IT resources in initial project phases. This can lead to risks, implementation delays, and potential change orders. Therefore, states should include representation from all stakeholders, including other agencies and contracted partners, in project governance from project inception. An integrated project management organization (PMO), with representation from these stakeholders, is valuable in addressing program design and operational decisions. Publishing and distributing design and requirement decisions often, along with frequent status, can be helpful in keeping all stakeholders informed. It is also critical that business and technical requirements development include both business and IT resources.
  • Addressing compliance aspects of new community engagement initiatives requires early identification of the “best”, “leak-proof” mechanisms for managing program information, particularly data used to verify certain eligibility requirements. This should be based on cost, reach/coverage/availability, and ability to implement and maintain solutions. Again, it is valuable to engage representation from all stakeholders and a strong team of analysts that can conduct persuasive, defensible alternatives/cost-benefit assessments of the various feasible ways in which different aspects of the proposed program can be operationalized.
  • Addressing critical issues and considerations should enable states to align requests for IT/systems funding, including Advanced Planning Documents (APDs) with the implementation plan and budget for the entire initiative. Including the team that normally works on APDs in deliberations regarding program design as early as possible can ensure that the optimal mix of information systems and related functionality is built into the APD funding request.
  • Traditional “member portals” may not support required communication and exchange of information with Medicaid beneficiaries. Community engagement initiatives call for enhanced member engagement modalities and functionalities. New system functionalities and capabilities for consumer reporting of activities required to maintain eligibility will be required. The development and implementation of new consumer facing technologies and work flow capabilities will also be required.
  • Increased capacity for various business functions will be needed. Modeling staffing needs and associated technology supports based on the impact of program design on contact centers, grievances and appeals staff, vendor management, and the aforementioned compliance, monitoring and evaluation functions should be done as early in the design of the program as possible.  The modeling should account for 1115 waiver evaluation requirements that will increase data needs and analysis.

How HMA Can Help

HMA is uniquely positioned to help states exploring or already committed to implement consumer empowerment, community engagement and work requirements programs.  Our Medicaid Market Solutions (MMS) and Information Technology Advisory Services (ITAS) teams can collaborate with state officials on these types of projects by bringing together expertise and experience in program policy and design, program operations and evaluation, and information technology.

HMA has worked with the states of Indiana and Kentucky on the design, implementation and operation of Medicaid consumer empowerment, community engagement and work requirement programs.  Most recently, in Kentucky HMA’s role in the implementation of the 1115 waiver has encompassed:

  • Supporting the Commonwealth in the development of the 1115 waiver. This included facilitating State policy decision-making, waiver drafting and technical support through the CMS waiver negotiation process.
  • Reviewing requirements and associated system design, interface and business process flow documentation to ensure compliance with 1115 Waiver, Special Terms and Conditions and Kentucky HEALTH program policy.
  • Verifying and validating that Kentucky HEALTH program policies and requirements are accurately addressed throughout information system design, development and implementation activities.
  • Monitoring test planning and execution activities.

Additionally, HMA is currently supporting the evaluation plan design for Indiana’s Healthy Indiana Plan (HIP) and New Hampshire Granite Advantage (GA) Health Care Program; following CMS approval of these plans HMA will conduct monitoring activities and produce evaluation reports per said plans.

For more information on HMA’s capabilities and experience, please contact Senior Consultant Chip Cantrell at [email protected].