Waiver priorities have been identified by the Trump Administration and present countless opportunities for states and carriers, alike. As states move to expand Medicaid through Section 1115 waivers, Medicaid Managed Care Organizations (MCOs) must look toward MITA-aligned, HIPAA-compliant financial management solutions.
This year’s Workgroup for Electronic Data Interchange (WEDI) National Conference kicked off day 2 with interactive sessions led by Keynote Speaker Seema Verma, Centers for Medicare and Medicaid Services‘ (CMS) Administrator, and Dr. Jack Lewin, National Coalition on Health Care‘s Chairman.
On October 10, 2018, Senate came to a decision on whether to move forward with a Democratic resolution to overturn a recent final rule on short term insurance. One day earlier, Senator Tammy Baldwin (D-WI) ignited a measure to reverse a recently approved decision on short-term health plans with a discharge petition, forcing a vote on resolution. Despite receiving support, from 49 Democratic Senators and Senator Susan Collins (R-ME), the petition fell one vote short of being escalated to the Senate floor. As result, the measure of reversing new regulations that allow insurers to sell health plans outside the Affordable Care Act (ACA) has come to a halt.
Social determinants of health (SDoH) are conditions in the environments in which people are born, live, learn, work, play, and age that impacts a wide range of health, functioning, and quality of life trajectories. Individual and community behaviors can influence health costs and outcomes regardless of being outside the control of the health system. Understanding social determinants of health is imperative for strengthening health and minimizing longstanding disparities in healthcare. More specifically, focusing on the health care system concerns of health coverage, quality of care, and medical bills is where Artificial Intelligence (AI) can step in. Focusing on the use of AI to model and understand social determinants of health will accelerate us towards a value-based care model while improving and maintaining health instead of treating illness.
Enrollment in Medicaid and Managed Care Organization (MCO) plans in the United States has reached an all-time high of 74 million recipients. According to Health Affairs, “an estimated 71 percent of Medicaid recipients are receiving their care via private health plans, both investor-owned and nonprofit.” In 2016, research behind the shift showed that managed care plans can provide services that state Medicaid agencies cannot fulfill. For example, network contracting, information technology, and use of management systems to display low-value care can vastly improve the health of beneficiaries.
Within minutes of President Obama signing the Affordable Care Act into law in 2010, lawsuits were filed challenging its constitutionality. Over the next six years, dozens of cases were filed challenging the ACA or Obama administration regulations implementing it. Although most of these cases were dismissed, four made it to the Supreme Court, including one that dramatically changed the scope of the ACA’s coverage of the uninsured by making the Medicaid expansions optional with the states. Many challenges were brought by Republican attorneys general, who championed the battle against the signature legislative triumph of a Democratic administration.