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State Medicaid Behavioral Health Carve-Outs: The OPEN MINDS 2017 Annual Update

Carve-outs are Medicaid managed care financing models where some portion of Medicaid benefits— dental services, pharmacy services, behavioral health services, etc.— are separately managed and/or financed. In Medicaid behavioral health financing arrangements, there are five main models that states use to finance behavioral health benefits. Each of these models...

2015 Medicare-Medicaid Dual Eligible Spending

Dual eligibles, sometimes referred to as Medicare-Medicaid enrollees, are consumers that due to disability, age, and/or income are eligible to enroll in both Medicare and Medicaid. There are two main types of dual eligibles: full-benefit and partial-benefit. Like the name suggests, full-benefit dual eligibles are consumers who receive the...

The OPEN MINDS 2016 Medicare-Medicaid Dual Eligible Delivery System Report

Dual eligibles, sometimes referred to as Medicare-Medicaid enrollees, are consumers that due to disability, age, and/or income are eligible to enroll in both Medicare and Medicaid. There are two main types of dual eligibles: full benefit and partial benefit. Like the name suggests, full-benefit dual eligibles are consumers who...

The 2016 OPEN MINDS Medicaid ACO Trend Update

Accountable care organizations (ACOs) were originally developed as a Medicare construct as part of the Patient Protection and Affordable Care Act (PPACA) to improve care coordination and lower the cost of care. State Medicaid programs have taken the Medicare ACO model and adapted it for their own purposes pushing...

State-By-State Analysis Of Medicaid MCO Requirements For Provider Alternative Payment Reimbursement

Alternative payment methodologies (APMs) is an umbrella term used to describe payment models that focus on quality, cost of care, or both rather than utilizing pay-for-volume or fee-for-service payment models. APM are used across all payers—Medicare, Medicaid, and commercial—in different ways and at different levels. This report looks at...

Key Features Of Medicaid Behavioral Health Episodes Of Care

Generically, the term episode of care (EOC) means a bundled reimbursement for all health care services delivered in response to a particular health issue or for a package of treatment services that can be defined by diagnosis, time, or locale. For example, episodes of care are often used for...

The Future Of The Non-Traditional Medicaid Expansion Model: A State-By-State Guide

A 2012 Supreme Court decision ruled that states were not required to expand Medicaid to all adults under 138% of the federal poverty level. While some states went ahead and expanded Medicaid up to all adults via the traditional Medicaid program, other states choose not to provide coverage to these...

The 2016 OPEN MINDS Medicaid Managed Care Market Share Report

Managed care is the dominant Medicaid contracting model with 68.8% of the 75 million Medicaid enrollees receiving services through an at-risk managed care organization (MCO). In states with managed care, the Medicaid program generally contracts with a mixture of local and national private organizations to provide managed care services....

U.S. Medicaid Health Home Market: The 2016 OPEN MINDS Update

Medicaid health homes are a population-based integrated care service delivery model for individuals with chronic conditions and serious mental illness (SMI). They are not a physical space, which is a common misconception about the term. The model, as outlined by the Centers for Medicare and Medicaid Services (CMS), provides...

The U.S. Mental Health Market: $195.6 Billion In Spending In 2015

In 2015 mental health spending was $195.6 billion. U.S. per capita spending for mental health services in 2015 was approximately $608.49 per person. When mental health spending is broken down by payer, private insurance was the largest payer of mental health services at 28% or $54.6 billion in 2015,...

The Addiction Treatment Market: $36 Billion In Spending In 2015

In 2015 addiction treatment spending was $36 billion. U.S. per capita spending for addiction treatment services in 2015 was approximately $112.08 per person. The addictions treatment services market includes health services for addiction and substance abuse. Addictions treatment services are provided by a wide array of professionals, including certified counselors,...

The Effects Of Medicaid Expansion On The Uninsured Rate & Medicaid Costs

One of the major components of the Patient Protection and Affordable Care Act (PPACA) was the expansion of Medicaid to cover adults with income up to 133% of the federal poverty level (138% with the 5% income disregard). However, in 2012 the U.S. Supreme Court ruled that while Congress...

The 2016 OPEN MINDS Medicare ACO Update: A Three-Year Trends Report

The singular premise behind the accountable care organization (ACO) model is to lower the cost of care for a population while improving (or at least maintaining) quality of care. More specifically, ACOs are groups of providers, such as physicians and hospital systems that form an agreement to coordinate care...

Medicare Specialty Plans For Consumers With Chronic Conditions: The 2016 OPEN MINDS C-SNP & I-SNP Report

Created as part of Medicare Modernization Act of 2003, Medicare Advantage special needs plans (SNPs) have been in operation since 2006. SNPs are a specific type of Medicare Advantage plan that serve Medicare beneficiaries with complex conditions and needs. Plans must offer the full-continuum of Medicare benefits including Part...

Medicare Specialty Plans For Dual Eligibles: The 2016 OPEN MINDS D-SNP Report

Created as part of Medicare Modernization Act of 2003, Medicare Advantage special needs plans (SNPs) have been in operation since 2006. SNPs are a specific type of Medicare Advantage plan that serve Medicare beneficiaries with complex conditions and needs. There are three types of SNPs that serve different subsets...

The Changing Medicaid Carve-Out Market: The 2016 OPEN MINDS Update On Vertical Carve-Outs

In the past five years, payers have pushed for “integration” of care coordination – particularly for the super-utilizer group of high cost consumers with multiple chronic conditions and complex social support needs. This push for integrated care coordination has had a pronounced effect on the concept of the “behavioral...

Medicare Specialty Vertical Carve-Out Plans: The 2016 OPEN MINDS Medicare SNP Market Share Report

Created as part of Medicare Modernization Act of 2003, Medicare Advantage special needs plans (SNPs) have been in operation since 2006. SNPs are a specific type of Medicare Advantage plan that serve Medicare beneficiaries with complex conditions and needs. Plans must offer the full-continuum of Medicare benefits including Part...

The 2016 OPEN MINDS Medicaid Managed Care Market Share Report

Managed care is the dominant Medicaid contracting model with 68.8% of the 75 million Medicaid enrollees receiving services through an at-risk managed care organization (MCO). In states with managed care, the Medicaid program generally contracts with a mixture of local and national private organizations to provide managed care services....

The 2016 OPEN MINDS Medicaid Managed Care Update: A State-By-State Analysis

In understanding the impact of Medicaid and Medicaid managed care in any state, there are three key elements: the financing mechanism, the services provided, and the populations that are included. Generally, there are three financing mechanisms for the delivery of Medicaid benefits: fee-for-service (FFS), primary care case management (PCCM),...

What Is CARA & What Are The Strategic Implications? An OPEN MINDS Market Intelligence Report

On July 14, 2016 the U.S. Senate passed the Comprehensive Addiction and Recovery Act of 2016 (CARA) and the Act was sent to the President’s desk to be signed into the law. CARA is being hailed as the most comprehensive reform of addiction in decades and the first to...

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