Health Highlights

Engaging Consumers to Improve Integrated Care Models

Author: Stephanie Anthony, Director, Manatt Health

Integrated care is a growing trend in health reform, as states seek to improve care quality, health outcomes and patient satisfaction while containing healthcare costs. Executed well, it can solve the problems caused by the fragmented delivery of health and social services, helping to enhance efficiency and patient health while managing spending. By linking primary care, acute care, behavioral healthcare (mental health and substance abuse disorders), and long-term services support, integrated care introduces holistic models that emphasize the consumer's perspective and make it easier for consumers and their families to navigate the healthcare system.

The process of seamless care coordination is particularly beneficial for those with chronic or disabling conditions who are coping with complex healthcare needs that require multiple services and providers. It also brings significant benefits to dual eligibles—those eligible for both Medicare and Medicaid—who have to cope with the challenges of navigating two administrative, financing, service and provider systems.

The Affordable Care Act (ACA) is driving many new integrated care initiatives, including duals demonstrations (bringing Medicare and Medicaid services together for those who have dual eligibility), health homes for patients with chronic conditions, patient-centered medical homes and Medicaid ACOs (Accountable Care Organizations). At the same time, many states are moving the elderly and people with disabilities—whether they have dual eligibility or not—into managed care for the first time.

Understandably, many in these populations have deep concerns about the unfamiliar managed care models. They often worry about being able to continue accessing their current providers…working with new providers who don’t have experience with care models or cultural competency with people who have disabilities or require long-term support…and compromising the privacy of their medical information. To make the new models work, states need to be attuned to consumer concerns—and ensure they are creating programs that meet the needs of their target populations. The most effective way to optimize success is engaging consumers in the earliest stages of concept development and ensuring they participate actively in designing and implementing new integrated care programs.

Why Is Consumer Involvement Critical—and What Do Consumers Bring to the Table?

The primary reason to engage consumers in the early stages of developing integrated care models is to ensure programs address patient concerns—and most importantly, meet both their health and their functional needs. For example, consumer perspectives are critical to understanding fully how the elderly and people with disabilities use the healthcare system, as well as the barriers they face to obtaining optimal treatment and care. These real-world insights can help ensure the new models are designed to reduce or eliminate hurdles and improve access, care and outcomes.

When engaging consumers, their families and consumer advocates in developing integrated care initiatives, it’s important to remember the diversity of populations the new models must serve. They must work for people of different ages and with a wide range of different chronic conditions, disabilities, functional limitations and service needs. They must also take into consideration a wide array of environmental factors that can contribute to chronic and disabling conditions, such as housing options and conditions, employment status and availability of family or other support systems. Therefore, it’s important that states engage a broad group of stakeholders that are representative of the populations that will be served by the new care models or programs.

Consumer groups are also important to involve because of the significant political influence they can wield at both the state and national levels. These groups can have a tremendous impact on a program’s enrollment and, ultimately, its success or failure.

Creating Successful Models Requires a Delicate Balancing Act

To create effective integrated care models that include the frail elderly, as well as people with disabilities, policymakers, providers and payers often must undergo a “paradigm shift” in how they think about the populations they serve—particularly non-elderly people with disabilities. For this segment, the care model is often less about providing medical or clinical interventions and more about ensuring access to support services and systems that help people live and function independently in their communities.

Designing and executing any successful integrated care model at the state level requires states to perform a delicate balancing act between advancing policy initiatives and supporting meaningful consumer engagement. While policies are meant to improve quality and care, they often also are focused on achieving cost efficiencies. Consumer input into model development and implementation must be weighed against the need to manage limited public resources.

Consumers Can Participate in a Myriad of Substantive Areas

There are a number of mechanisms states can use to involve consumers in designing integrated care models. For example, they can run member focus groups, model design workgroups, public stakeholder forums or advisory boards to generate ideas, discuss approaches and gain firsthand knowledge of how they can best serve their target populations. Experience has shown that consumers can contribute valuable insights and suggestions across a range of substantive areas, including:

  • Designing overarching policy concepts and program designs in key areas, such as eligibility requirements and service offerings
  • Developing the model of care, including defining health and functional assessments, addressing continuity of care and provider access issues, building individual care plans, selecting the care team and establishing the roles of various providers
  • Defining the services that will be covered across all areas, such as clinical, non-clinical, facility-based and community-based
  • Identifying appropriate quality metrics and provider reporting requirements
  • Creating efficient administrative processes, such as for grievances, appeals and customer service
  • Setting the rate structure
  • Determining prior approval and medical necessity standards
  • Building and supporting public awareness, outreach and education efforts
  • Determining optimal provider and health plan training requirements

How Have Consumers Influenced Policy Design in the Real World?

The Massachusetts Duals Demonstration is one example of the critical role consumer participation plays in designing and implementing successful integrated care models. The Massachusetts stakeholder engagement model proved so effective that The Centers for Medicare and Medicaid Services (CMS) adopted many of its features as a template for developing similar initiatives in other states. Massachusetts’ consumer engagement efforts yielded several examples of important areas in which consumers shaped the design of the program:

  • 1. Consumers identified that Medicare and Medicaid communications were too long, confusing and duplicative. Their feedback led to the unification and simplification of member notices and other communications.
  • 2. Consumers recommended the inclusion of an independent “long-term services and support” coordinator as a key member of an individual’s care team, when indicated. They also helped define the role and set the qualifications candidates needed to meet.
  • 3. Consumers strongly encouraged dental and peer support coverage, as well as continuity of care provisions to ensure access to existing providers during the 90-day clinical/functional assessment phase.


For integrated care models to be truly consumer centric and, ultimately, successful, they need to be based on consumer input. To develop solutions that address the needs and issues of target populations, it’s essential to have a firsthand view of their challenges, their concerns and their current obstacles to access. By involving consumers in creating integrated care models, states can ensure these new initiatives are successful in attracting enrollees, as well as in achieving their key goals of raising quality, enhancing care and improving patient satisfaction and outcomes.

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Trends to Watch as Pennsylvania Becomes the Latest State Poised to Adopt Premium Assistance

Authors: Deborah Bachrach, Partner, Healthcare Industry, Manatt; Patricia Boozang, Managing Director, Manatt Health

Click here to Download Your Free Primer on Advance Premium Tax Credits (APTCs) and Cost-Sharing Reductions—and Our Complimentary Brief Detailing the Premium Assistance Option.

On September 16, Pennsylvania announced that it would be expanding its Medicaid program using a premium assistance model similar to the one in Arkansas. With Pennsylvania's announcement, 25 states have shared their intentions to expand their Medicaid programs. Many more continue to consider the fiscal and reform implications of expansion and work with the federal government to craft workable approaches. If enacted nationwide, the ACA Medicaid expansion would enroll 21.3 million individuals by 2022.

What Is Premium Assistance?

The Centers for Medicare and Medicaid Services (CMS) has finalized regulations permitting states to use Medicaid and Children's Health Insurance Program (CHIP) funding to purchase coverage for eligible beneficiaries in the individual market, including through Qualified Health Plans (QHPs) in Exchanges. There are several reasons a state might use "premium assistance" to buy Medicaid-eligible adults coverage through an Exchange. Premium assistance has the potential to:

  • Allow an individual to keep the same health plan and provider network, even if his or her income fluctuates above or below the Medicaid eligibility level.
  • Provide Medicaid beneficiaries with the same access to providers as privately-insured patients—and ensure those providers receive the same payment.
  • Facilitate multi-payer patient and delivery reform, driving quality and performance improvements across government and private insurance products.

Premium assistance is not new. Under Section 1906 of the Social Security Act, states have had the authority to use Medicaid premium assistance to “wrap around” employer coverage for Medicaid-eligible adults. Medicaid programs can cover some or all of the premium and cost-sharing obligations of an individual’s employer-based coverage, as well as any additional benefits available through the state’s Medicaid program. In 2006, premium assistance was extended to CHIP.

Although it’s been a long-standing option, states have not widely adopted premium assistance. The opportunity to use premium assistance for purchasing coverage through new Health Insurance Marketplaces, however, has generated new interest in the program.

Manatt worked with Arkansas, the first state to adopt premium assistance, in designing its program. We are now in the process of supporting the state in obtaining CMS approval and fully implementing its premium assistance model.

Trends—and States—to Watch

By signaling its attempt to adopt premium assistance, Pennsylvania becomes the latest state to propose an expansion model that is tailored to its needs and culture. (Arkansas, as well as Iowa with its proposed new Health and Wellness Program, has followed the route of designing plans customized to its state.) Other states to watch for expected innovative approaches to Medicaid reform include Ohio, Tennessee, Michigan and Virginia.

States expanding and reforming their Medicaid programs are relying on 1115 Medicaid waiver authority. Section 1115 of the Social Security Act gives the Secretary of Health and Human Services the right to approve experimental, pilot or demonstration programs that promote the objectives of Medicaid and CHIP. The purpose of the waiver is to give states the flexibility to design and evaluate new approaches for improving their programs.

From the start, 1115 waivers have served as “laboratories” for states and CMS to create innovative ways for enhancing Medicaid coverage and delivery. They are turning to the waiver once again as they fashion and negotiate Medicaid programs under the ACA (Affordable Care Act).

Waiver flexibility in designing and running Medicaid is critical to states. Within the waiver framework, CMS can work to accommodate each state’s specific culture and priorities, helping it craft an expansion program geared to its unique needs and markets.

Once unique approaches to expansion are in place, states will be responsible for monitoring and evaluating their results. They will test a series of hypotheses designed to prove their models have achieved the goal of positively impacting access, cost and outcomes. All eyes will be on the performance and evaluation results coming out of Arkansas, Iowa and other unique models of Medicaid expansion and reform in the coming months and years.

Manatt Develops Free Primer on APTCs and Cost-Sharing Reductions

To provide an in-depth understanding of Advance Premium Tax Credits (APTCs) and cost-sharing reductions (CSRs), Manatt has developed a free presentation on both of these critical programs. The presentation is used to train Exchange staff, eligibility workers, navigators, certified application counselors and other assistors on APTCs and CSRs. By using a highly visual approach, it makes it simple to navigate the complexities of the APTC and CSR initiatives.

The presentation begins with some “level-setting” information, such as a glossary of key terms and a refresher on the role that APTCs and CSRs play in the ACA’s continuum of coverage. It then presents a “deep dive” into how APTCs and CSRs work, including:

  • Eligibility criteria for APTCs, including financial and non-financial criteria
  • The two ways in which APTCs can be received—in advance or at tax time
  • Options for using APTCs to purchase an array of plans
  • A detailed discussion of the method for calculating APTCs, including how age, family size, geography and smoking status impact size
  • A detailed review of the income measure (Modified Adjusted Gross Income) used to evaluate eligibility for and calculate the size of APTCs and CSRs
  • Eligibility criteria for CSRs
  • Information on how CSRs are used to reduce out-of-pocket spending on deductibles, co-insurance and co-payments, including the role of actuarial value in this process

Click here to download a free copy of the presentation or our complimentary brief, Purchasing Coverage for Medicare Beneficiaries in the Exchange: A Review of the Premium Assistance Option.

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Now You Can Have State-by-State Health Reform Updates Delivered to Your Inbox Free Every Week

The KidsWell Weekly Update—powered by Manatt Health—delivers state-by-state and federal health reform news and announcements to your inbox every week. It brings together all relevant reform updates from across the country into a single, easy-to-use resource—and puts them at your fingertips FREE. Now, you only need one tool to stay current on the latest developments, activities and legislation around health reform.

The newsletter also provides a direct link to the KidsWell web site—a one-stop platform populated by Manatt's expert team of health reform trackers. The Manatt tracking team continually monitors the volumes of both implementation and opposition activity to keep information on the site fresh, compelling and accurate. Tracking activity is rolled up into weekly reports; high-level state summaries; and user-friendly, interactive maps that allow point-and-click access to information and easy comparisons across states. You have a central, intuitive reference tool with the newest health reform facts, figures and insights, including:

  • State and federal implementation status, with updates on everything from public and private coverage to demographic data and eligibility levels to the political landscape.
  • National snapshots, featuring downloadable charts and maps comparing activity across all 50 states, with regularly updated views of Medicaid expansion, Exchange model types, Exchange-related legislative developments, ACA implementation funding, Medicaid coverage levels, Exchange activities and much more.
  • Health reform highlights, with the most recent health reform news from around the nation, updated every week

Both the newsletter and the web site are critical tools for guiding your organization through the legal, regulatory and political challenges of healthcare reform implementation. With access to the latest ACA-related developments, decisions and guidance, they ensure you remain current, informed and prepared to succeed in today's changing healthcare market.

Click here to access the KidsWell health reform tracking web site.

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You Have Another Chance to Benefit from What to Expect from Exchanges: A New, Free Webinar from Manatt and Bloomberg BNA (CLE Available)

View It Now On Demand—and Find out How One-Stop Shopping Will Shape Healthcare's Future. (Enter Code LGNEXT2 to Sign up Free.)

Exchanges will become the public face of the Affordable Care Act (ACA) when they open for business in 2014. The ultimate vision is to create an Amazon-like experience, leading to a health insurance system that is easier to navigate and more responsive to consumers' needs. On our path to that goal, both public and private Exchanges are experimenting with a variety of approaches and models—and all of the healthcare stakeholders are re-thinking how they'll operate in a changing environment.

Last week, more than 900 of your colleagues participated in a new webinar from Manatt and Bloomberg BNA guiding them you through the emerging Exchange marketplaces. If you couldn't attend the original presentation, we don't want you to miss out on the valuable insights shared. View the webinar free now On Demand to:

  • Gain a full understanding of the Exchange marketplace, its regulations and requirements—as well as the responsibilities of relevant players.
  • Explore the models states are implementing and the range of different versions, from single payer to privatization.
  • Discover the roles the Exchanges will play in the healthcare system across key functions, from providing access to affordability programs to managing funds to monitoring QHP (Qualified Health Plan) performance.
  • Learn the latest information on certification and enforcement issues.
  • Delve into the details of premium stability programs, including risk adjustment, reinsurance and risk corridors.
  • Examine how Exchanges will interact with other key players, including Medicaid and state insurance departments—as well as how public Exchanges may relate, both competitively and cooperatively, with private Exchanges in the market.

Don’t miss this chance to get a close-up look at the regulatory requirements defining Exchanges and how they are playing out in the real world. Our expert presenters include:

  • Joel Ario, Managing Director, Manatt Health
  • Melinda Dutton, Partner, Healthcare Industry, Manatt
  • Scott Falk, Executive Editor, Bloomberg BNA
  • Lisa Rockelli, Managing Editor, Bloomberg BNA

And remember to enter the code LGNEXT2 to register FREE.

Webinar attendees also had the chance to download Manatt’s recent articles on the ACA, including our three-part series on employer obligations and opportunities and our pieces exploring public vs. private Exchanges and examining effects on market access strategies. To access your free copies, just click here.

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Don't Miss the Second Webinar in BNA Bloomberg's New Health Reform Series, Presented by Manatt: Medicaid Expansion: The Foundation of the ACA Coverage Continuum

Click here to Register and Discover How the ACA Is Transforming Medicaid—and the Impact on the Healthcare Landscape. (Enter Code LGAUEBR3 for a 20% Discount off of BNA's Registration Fee—and Earn CLE Credit.)

Make sure you don't miss the second program in BNA's new health reform series, presented by Manatt. Scheduled for October 31 from 2:00–3:30 p.m. ET, the session will focus on Medicaid expansion, one of the most critical aspects of health reform and the foundation of the ACA coverage continuum

Why is this topic so important? The Affordable Care Act (ACA) provides authority and enhanced federal funding for states to expand their Medicaid programs beginning in January 2014 to all adults under 65 with incomes below 133% of the Federal Poverty Level. To date, 25 states have announced their intentions to expand Medicaid. Many more continue to consider the fiscal and reform implications of the expansion, and work with the federal government to craft workable approaches. If enacted nationwide, the ACA Medicaid expansion would enroll 21.3 million individuals by 2022. Apart from the expansion, the ACA makes dramatic changes to Medicaid benefits and eligibility categories, as well as eligibility and enrollment requirements and processes.

Clearly, Medicaid is one of the pillars of universal coverage under the ACA. By bringing millions more Americans into the healthcare system, it will play a significant role in shaping the strategies and plans for all healthcare stakeholders, from states to providers to payers to life sciences companies. Our all-new webinar takes an in-depth look at the facts, implications and impact around Medicaid program changes under the ACA—and how the healthcare players can adapt to a dramatically different environment—including:

  • The ACA’s changes to Medicaid—and the options and considerations of dealing with ACA-compliant programs
  • Expansion considerations for states, from fiscal implications to the coverage “black hole”
  • An overview of where state decisions stand today
  • The rules around enhanced federal funding for states expanding Medicaid
  • Alternative Benefit Programs and implications for Medicaid benefit packages and service delivery
  • The rules and effects of streamlining eligibility
  • The integration of Medicaid and Exchanges across key functions—and options for coordinating eligibility
  • The ACA mandate around disproportionate share hospital payments (DSH), designed to compensate hospitals for care to indigent patients
  • Other coverage alternatives for low-income consumers

Join us for this compelling look at the ways the ACA is transforming Medicaid…the impact on the healthcare landscape…and the changes, challenges and opportunities of ACA-compliant Medicaid programs. Our expert presenters include:

Remember to enter the code LGAUEBR3 for a 20% discount off of BNA’s registration fee.

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