Since the launch of the Marketplaces and Medicaid expansion, one out of every 20 Americans has been added to the Medicaid roll. More than 51 million Americans receive physical health benefits from a private Medicaid health plan (or 70% of all beneficiaries) and as of Q3 2015, 41 states had some form of private managed Medicaid. Along with the rapid expansion of Medicaid, comes the push for managed care plans to adopt value-based care approaches that tie provider reimbursement to quality measures and better outcomes. This presentation gives physicians crucial details about Medicaid and CHIP Managed Care Proposed Rule CMS 2390-P, and the five factors for value-based payment success in the era of Managed Medicaid.”

1. Managed Medicaid: CMS 2390 Impact
Donna Costanza
Vice President, Value-Based Care Strategic Solutions
Conifer Health Solutions

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Donna Costanza
Vice President Strategic Solutions,
Conifer Health Value-Based Care
 Leads delivery and strategic solutions for clients which are responsible for providing high quality and
effective delivery of Conifer Health services and technology to clients
 Directs client management, network development and physician alignment strategies
 Previously the Chief Operating Officer of Cap Management Systems, leading health plan operations
and financial management of over 30 risk-bearing provider organizations and hospitals
 Has more than 20 years experience with managed Medicaid, Medicare and commercial programs

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Significant Scale Advantage
Service Centers
Headquarters
14,500+ EMPLOYEES
20 SERVICES CENTERS
800+ CLIENTS IN
43 STATES
BILLION MEDICALLY MANAGED
SPEND FOR EMPLOYERS
19$ +
Facts based on data ending Q4 2015
5.7MILLION MANAGED LIVES
+
MILLION PATIENT
TOUCH-POINTS ANNUALLY25+
BILLION NET REVENUE
PROCESSED ANNUALLY
28$
+

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CMS 2390-P Overview
Major proposed rule to align Medicaid managed care with
Medicare Advantage and qualified health plans (QHPs)
 First significant revisions since 2002
 Multiple statutory provisions on beneficiary protections
and state and federal oversight for program accuracy and
actuarial soundness related to payments
 Expands federal role in rate setting at both the
managed care organization and at the provider level
 Mandates states to launch comprehensive
quality strategies
 Places special focus on long-term services
and supports (LTSS)

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What’s driving CMS 2390-P?
Explosion of Medicaid managed care populations
Medicaid now accounts for about 16 percent of total personal
health care spending in the United States and will soon exceed
$500 billion in annual expenditures. Payments for managed care
account for 25-30 percent of all Medicaid benefit spending.
71.8%
Medicaid enrollees in
some type of managed
care arrangement
63% of children
48% of adults
33% of people with disabilities
13.9% of seniors
13.2% percent of dual eligibles
Populations enrolled in risk-based
managed care

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Some variance by markets – but still impacting
nearly every care community

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Major provisions of CMS-2390-P
 Network adequacy – Sets minimum federal network adequacy standards (States may be
required to adopt enforcement strategies)
 Beneficiary support system
 State-directed provider payments – CMS would still prohibit states from directing plans to
make provider payments, but would allow them to:
 Place contracted provider payments under particular (value-based) payment methodologies to
promote quality, or
 Incent providers to participate in particular initiatives

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Major provisions, continued…
 Medical loss ratio – Minimum of 85%
 Actuarial soundness – Significant change. States must certify actual payment
rates to CMS.
 Information standards – Plans would have to provide enrollees with member
handbooks and formulary information
 Grievance and appeals – Aligns Medicaid and CHIP grievance and appeals
processes with those that exist for MA and commercial coverage
 Marketing – Rule would clarify that Medicaid plans that also offer QHPs may
market both at the same time to the same individuals without violating the
Medicaid marketing restriction on the sale of private insurance

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Major provisions, continued…
 Plan choice – Would require states to provide beneficiaries with at least 14 calendar
days and appropriate informational notices to make a decision on plan enrollment
 Institutions of mental disease – Would permit capitation payments to plans for
enrollees who have a short-term stay – 15 days or less – in an IMD
 Quality of care – States would mandatorily need to launch comprehensive quality
strategies for Medicaid and CHIP programs
 Program integrity – Would require states to screen and enroll all Medicaid providers
to address what CMS describes as a lack of consistency between managed care and
FFS provider screening and enrollment
 Prescription drug coverage – CMS proposes to require that states cover, through
FFS, any Section 1927 covered outpatient drugs or classes of drugs that are
excluded from the managed care contract

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Moving from Fee-for-Service to Fee-for-Value
Clinical
Integration
Upside ACO Full Capitation
Employer
ACO
Episodic &
Bundled
Payments
Commercial
ACO
MSSP
ACO
Managed
Medicare /
Medicaid
Clinically
Integrated
Network
Upside/Downside
ACO
Licensed product
NextGen
ACO
Increasing expertise needed to manage risk and engage providers

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Conifer Health Services
Services Union Employer Bundled Services ACO/IPA MSSP RBO
Consulting
Marketing •
Payor and Provider Contracting • • • •
Provider Network Development • • • •
Provider Network Relations •
Data Storage
Data Warehouse • • • • • •
Document Intake • • • •
Eligibility Enrollment • • • • • •
Member Performance
Member Adherence • • • •
Member Engagement • • • •
Participant Portal • • • •
Population Health Member Risk Stratification • • • • • •
Provider Performance Provider Portal • • •
Reporting
Financial Analytics • • • •
Operating Performance •
Quality Performance • • • •
Regulatory Performance • • •
Self-Serve Analytics • • • •
Transactions
Claims Processing • •
Concurrent Review • •
Credentialing •
Grievance and Appeals •
Member Enrollment Cards •
Provider / Member Call Center • •
Referral Determination • •

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Success with Managed Medicaid
Five Areas for Consideration
• Contracting with Payers
• Utilization Management and Care Coordination
• Network Design and Adequacy
• Risk Experience
• Reporting and Compliance

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Successful IPAs, Health Systems, and
Risk Bearing Organizations:
Operate, control, monitor, track, and trend financial levers which deliver high quality
performance to its providers and members
 Payor Revenue
 Member Revenue and Expense
 Provider Expense
 Benchmark Analysis

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Revenue Levers
Revenue
 Payor Performance
 Attributed Populations (aid code, risk adjustment factor, age, sex).
 Incentive Programs (complex case, preventive measures, hierarchical condition codes).
 Shared Savings Programs (re-admissions, level of care, contracted services).

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Insights When Entering Risk Arrangements
Revenue Modeling
 Percent of Premiums
 Acuity Level/Risk Adjusted Factors
 Aid Code
 Age/Sex Adjustment
 Per Member Per Month
Expense Modeling
 Fee Schedules Design
 Division of Financial Responsibility Analysis
 Benefit Structure Consideration

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Division of Financial Responsibility (DOFR)
Group Hospital Blue Shield
Services
Patient Counseling •
Podiatry •
Pre- and Post-Transplant Services •
Radiation Therapy •
Acute Detox •
Psychiatric / Substance Abuse •
Urgent Care Services - Within Group Service Area •
Urgent Care Service - Outside Group Service Area •
Health Care
Professional
(inpatient)
Diagnosis, Treatment and Therapy •
Emergency Services - Within Service Area •
Emergency Services - Outside Service Area •
Pathology / Radiology / Anesthesia •
Transplant (all inclusive case rates) •
Transplant (physician fees excluded from case rate payment) •
Urgent Care Services - Within Group Service Area •
Urgent Care Services - Outside Group Service Area •
Visits / Consultations / Surgery •
Facility Services
(inpatient)
Emergency Services - Within Service Area •
Emergency Services - Outside Service Area •
Facility and Supplies •
Acute Detox •
Psychiatric / Substance Abuse •
Take Home Drugs •
Transplant (includes kidney) •
Urgent Care Services – Within Group Service Area •

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Expense Levers
Expense
 Provider Performance
 Physician Performance (HEDIS, HCC, PQRS)
 Utilization Performance (Referral, Visits)
 Provider Utilization (ER usage, admissions, LOS)
 Patient Performance
 Quality Performance(Preventive Measures)
 Complex Care Programs
 Patient Utilization (ER usage, adherence)

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$1.8m
 Group was losing $1M per year
 Placed on Corrective Action by
the Department of Managed
Healthcare; threat of enrollment
freeze and risk de-delegation.
Network maintenance
 Narrow network and renegotiated
provider contracts
Medical management
 Improved high-cost
pharmaceutical utilization
Financial risk design
 Renegotiated health plan
contracts
Increased profitability by
shifting from annual loss of
$1M to annual profit of $0.8M
90 PCPs receiving capitated payments for 30,000
managed Medicaid patients
The Client
The Challenge How We Helped The Results
Case Example: Managed Medicaid
PP_ManagedMedicaid_080415

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$2k
 Health plan desired to reduce ER
facility expense and offered grant to
physicians for reducing
 Physician group desired to create
an incentive plan to help ER
utilization and ensure capture of
grant dollars Reduction in
ER utilization
California IPA with 54,000 lives
200 primary care physicians serving the dual
eligible population in a highly competitive market
The Client
The Challenge How We Helped The Results
Case Example: Medicaid
PP_ManagedMedicaid_080415
Financial risk design
 Created incentive structure to reduce
ER utilization
Medical Management
 After-hours access to PCP offices and
contracted with urgent care centers
 Enrolled top ER users in case
management program
Member engagement
 Educated patients about correct use of
ER vs urgent care through direct mail
Paid per
physician
through incentive
programs
10%

20. Questions & Answers