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On January 9, 2024, CMS approved a just under $7 billion amendment to New York’s Medicaid 1115 Waiver, allowing the state to make investments in Medicaid initiatives that expand access to primary and behavioral health, address health-related social needs (HRSN) to reduce disparities and promote health equity, and strengthen the healthcare workforce. The term of […]

On September 5, 2023, CMS released a new, voluntary state total cost of care model called the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. CMS plans to collaborate with states to increase investment in primary care, improve overall population health, advance health equity, and curb the growth of health care costs. States […]

As in any relationship, strategic relationships require time and commitment to develop a partnership with mutual benefits. It all begins with an introduction which will test the chemistry and the objectives between the two parties. At times, even when all the strategies are aligned, the interactions may not be comfortable. It’s an indication that the […]

In the first part of this series on Utilization Management (UM), we discussed the basics and some of the newer rules and regulations on entities conducting (UM) required by CMS beginning January 2024.  In this section, we will dive deeper into the process of UM and start to examine some of the best practices used […]

Deadline Approaching on December 14th: On August 14, CMS published the Request For Application (RFA) for Making Care Primary (MCP), a progressive roadmap to value-based payment for primary care providers with little-to-no VBP experience. CMS has indicated that the program may be aligned with the upcoming Washington 1115 Medicaid Waiver amendment which will have […]

Deadline Approaching on December 14th: On August 14, CMS published the Request For Application (RFA) for Making Care Primary (MCP), a progressive roadmap to value-based payment for primary care providers with little-to-no VBP experience. Both CMS and the State of New York have said that the program will be aligned with the upcoming New […]

On October 3rd, 2023, CMS published an ACO REACH Newsletter providing PY23 HEDR submission procedure and timeframe updates. Health Equity advancement is a fundamental component of the ACO REACH model and a key differentiator from its predecessor, the Global and Professional Direct Contracting Model (GPDC). CMS established HEDR requirements for REACH ACOs as part of […]

Utilization Management (UM) is employed by payers and by providers in global risk with UM delegation to ensure that patients get the right care at the right time in the right place in a cost-effective manner while maintaining high quality patient care and services. Many UM programs have recently come under fire because of the […]

As of August 2022, preliminary federal estimates showed that Medicaid enrollment stood at more than 90.9 million people, or more than one in four Americans, following the impact of the Families First Coronavirus Response ACT, which enabled continuous enrollment for Medicaid beneficiaries through the COVID-19 pandemic. As of March 31, 2023, Congress has stopped continuous coverage […]

The Medicaid population is a mosaic of individuals, each with unique needs and challenges. For clinicians and caregivers navigating this complexity, the integration of longitudinal patient data, outcome data, and financial data offers a beacon of clarity. The following represent some potential real-world applications for this integrated approach:   Elderly and Dual-Eligible Beneficiaries: :: […]