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Implementing Pharmacist Contraceptive Prescribing: A Playbook for States and Stakeholders

January 25, 2021

More than 19 million individuals in the United States lack meaningful access to birth control within their communities; low-income women, women of color and individuals from other historically marginalized communities have been shown to have greater difficulty in accessing reproductive healthcare generally and contraception in particular. This report provides state policymakers and other stakeholders with legislative, regulatory, reimbursement and operational strategies to effectuate pharmacist prescribing and increase access to contraception.

Enhancing Access to Family Planning Services in Medicaid: A Toolkit for States

May 22, 2019

Important aspects of family planning coverage—including eligibility levels, benefits, and payment policies— vary by state. This toolkit provides an overview of the issues that most affect access to family planning services and supplies, and the policy options available to state Medicaid agencies to enhance access. To enable evaluation of the current family planning landscape and monitor progress toward improved access, this toolkit also provides an inventory of data analyses.

Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools

January 1, 2018

This report explores practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues. It is widely recognized that social factors, such as unstable housing and lack of healthy food, have a substantial impact on health outcomes and spending, particularly with respect to lower-income populations. For Medicaid, now dominated by managed care, this raises the question of how states can establish managed care rates to sustain investments in social supports.

In or Out: An Examination of Medicaid's Coverage Determination Policies

August 1, 2015

Medicaid, the joint federal and state program that provides health insurance for low-income individuals, is rapidly becoming the largest purchaser of health care services in the United States. Given Medicaid's size and scope, and the central role it plays in the health insurance market, information on how it determines which health care services and interventions to cover has significant implications, not only for Medicaid enrollees but also for the entire health care system, including developers of emerging technologies.This report reviews how Medicaid and other large public health insurance programs in the US and abroad determine coverage for specific health interventions (e.g., procedures, therapies, technologies, and devices) within a covered benefit category. It highlights themes from research on and interviews with select state Medicaid agencies regarding their coverage determination processes and standards, including approaches to covering behavior change interventions. Finally, it discusses policies and procedures for achieving greater rigor and transparency in this decisionmaking.The authors conclude that state agencies, including California's Medi-Cal, should consider incorporating the following core features into their coverage determination policies:A defined process by which third parties may initiate a coverage reviewA systematic evaluation of high-cost, high-utilization servicesA systematic approach to securing and evaluating evidence of the effectiveness and value of the new interventionA defined standard by which the state will evaluate whether to cover the intervention

Innovation Waivers: An Opportunity for States to Pursue Their Own Brand of Health Reform

April 15, 2015

States have long been the testing ground for new models of health care and coverage. Section 1332 of the Affordable Care Act, which takes effect in less than two years, throws open the door to innovation by authorizing states to rethink the law's coverage designs. Under State Innovation Waivers, states can modify the rules regarding covered benefits, subsidies, insurance marketplaces, and individual and employer mandates. States may propose broad alternatives or targeted fixes, but all waivers must demonstrate that coverage will remain as accessible, comprehensive, and affordable as before the waiver and that the changes will not add to the federal deficit. This issue brief describes how states may use State Innovation Waivers to reallocate subsidies, expand or streamline their marketplaces, replace or modify the mandates, and otherwise pursue their own brand of reform tailored to local market conditions and political preferences.

State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment

August 28, 2014

States across the country are embracing integrated care delivery models as part of their efforts to deliver high-quality, costeffective care to Medicaid beneficiaries with comorbid physical and behavioral health needs. The Medicaid expansion authorized by the Affordable Care Act brings greater import to these efforts, as millions of previously uninsured low-income adults, many at increased risk for behavioral health conditions, gain coverage. State efforts to ensure that Medicaid beneficiaries have access to integrated care, however, are hindered by a fragmented behavioral health system that is administered and regulated by multiple state agencies and levels of government, and by purchasing models that segregate behavioral health services from other Medicaid-covered services. Drawing on a review of the literature and interviews with consumers, providers, payers, and policymakers, this report explores strategies states are deploying to address or eliminate system-level barriers to integrated care for this medically complex and high-cost Medicaid population.

Arkansas: A Leading Laboratory for Health Care Payment and Delivery System Reform

August 19, 2014

As states' Medicaid programs continue to evolve from traditional fee-for-service to value-based health care delivery, there is growing recognition that systemwide multipayer approaches provide the market power needed to address the triple aim of improved patient care, improved health of populations, and reduced costs. Federal initiatives, such as the State Innovation Model grant program, make significant funds available for states seeking to transform their health care systems. In crafting their reform strategies, states can learn from early innovators. This issue brief focuses on one such state: Arkansas. Insights and lessons from the Arkansas Health Care Payment Improvement Initiative (AHCPII) suggest that progress is best gained through an inclusive, deliberative process facilitated by committed leadership, a shared agreement on root problems and opportunities for improvement, and a strategy grounded in the state's particular health care landscape.

Addressing Patients' Social Needs: An Emerging Business Case for Provider Investment

May 29, 2014

Despite growing evidence documenting the impact of social factors on health, providers have rarely addressed patients' social needs in clinical settings. But today, changes in the health care landscape are catapulting social determinants of health from an academic topic to an on-the-ground reality for providers, with public and private payers holding providers accountable for patients' health and health care costs and linking payments to outcomes. These new models are creating economic incentives for providers to incorporate social interventions into their approach to care. Investing in these interventions can enhance patient satisfaction and loyalty, as well as satisfaction and productivity among providers. A variety of tools for addressing patients' social needs are available to providers looking to leverage these opportunities. With the confluence of sound economics and good policy, investing in interventions that address patients' social as well as clinical needs is starting to make good business sense.

The Role of the Basic Health Program in the Coverage Continuum: Opportunities, Risks and Considerations for States

March 5, 2012

Outlines issues for offering subsidized coverage to those eligible for insurance exchange subsidies by using federal dollars that would otherwise go to those subsidies, including continuity of coverage, impact on exchanges, and financial feasibility.

Federally-Facilitated Exchanges and the Continuum of State Options

December 20, 2011

Examines the features in eligibility, enrollment, plan management, consumer assistance, and financial management of three health insurance exchange models: state-based, federally facilitated, and partnership exchanges. Considers implications for states.

HHS Proposed Rules on Exchange Implementation Requirements

August 12, 2011

Highlights provisions of the new regulations and commentary on state health insurance exchanges that clarify or amplify the 2010 healthcare reform or offer insight into federal guidance or consensus on their establishment, functions, and other issues.

Medicaid's Role in the Health Benefits Exchange: A Road Map for States

March 31, 2011

Examines issues for integrating Medicaid into the administration, operation, and coverage continuum of insurance exchanges. Discusses eligibility, enrollment, and outreach; contracting, standards, and requirements; benefits design; and infrastructure.