Medicaid consulting services
Applying a trusted combination of knowledge, research, and analytics
The breadth and depth of knowledge available through the Milliman Medicaid Consulting Group lets us create customized solutions for our clients in an effective, efficient, and timely manner. Our actuaries and consultants offer client-focused solutions to Medicaid rate-setting and other key financial analysis while also providing regulatory guidance and ensuring compliance with all our projects.
Actuarial consulting
With more credentialed healthcare actuaries than any other firm in the United States, we have unparalleled expertise in actuarial consulting, covering a wide scope of Medicaid-related needs.
Services offered include the following.
Capitation and rate setting and certification
- Review and summarization of encounter data
- Analysis of MCO financial information
- Future medical cost projections
- Administrative cost benchmarking analysis
- Rate setting for various program types including, but not limited to, acute care, Long-Term Services and Supports (LTSS), specialty populations, PACE, dental, and NEMT
Budget forecasting
- Historical expenditures review
- Evaluation of current expenditure trends
- Detailed analysis to estimate future expenditures and develop budgets
- Real-time monitoring of expenses related to budget
Federal waiver development – 1115, 1915b, 1915c, 1332
- Review historical expenditures
- Presentation of potential waiver outcomes to stakeholders
- Development of cost effectiveness and budget neutrality calculations for CMS
Risk adjustment and risk mitigation mechanisms
- CDPS +Rx and other mechanisms
- Custom risk weights and model adjustments
- Functional-based risk adjustment for LTSS populations
- Risk corridors
- Stop-loss parameters
- Service and population carve-outs
- MLR financial evaluation
- Specialty arrangements to address COVID-19 and other health emergencies
Savings opportunity analyses
- Value-based payment design
- Options for identifying inefficient spending
- Collaborative evaluation of new initiatives with MCOs
MCO RFP evaluation and assistance
- Development of data books and cost proposal templates
- Analysis of submitted cost proposals
- Discussion with MCOs related to future savings opportunities
Finance consulting
The Milliman Medicaid Finance team’s expertise in design, implementation, and evaluation of healthcare delivery, payment, and rate-setting systems for all types of provider services simplifies the landscape for state agencies. Our finance consulting services complement Milliman’s actuarial and policy practices, offering clients a single source solution that addresses the complexities of the Medicaid program.
Medicaid program funding strategy
- Design and implementation of healthcare-related tax programs (provider assessments)
- Intergovernmental Transfers (IGTs) and Certified Public Expenditures (CPEs)
Hospital payment and rate-setting systems
- Design, implementation, evaluation, and modification
- APR DRGs, MS-DRGs, EAPGs, APCs
- Payment incentive models promoting goals such as cost effectiveness, access to care, and quality
- Payment simulation and fiscal impact modeling
- Inpatient and outpatient cost analysis
- Rate adequacy analyses
- Alternative Payment Models (APMs)
Supplemental payment program strategy
- Assisting Medicaid programs with permissible supplemental payment strategies in both fee-for-service (FFS) and managed care organization (MCO) environments
- 438.6(c) state directed payment arrangements (pre-prints)
- Disproportionate share hospital (DSH) payment methods and compliance
- Uncompensated Care Pool (UCP) programs
- Graduate Medical Education (GME)
- Upper Payment Limit (UPL) payment programs and demonstrations of compliance
Long-Term Services and Supports (LTSS) payment systems
- LTSS system design and rate setting
- Nursing home services, including acuity-based prospective rate setting and payment models
- Home and Community-Based Services (HCBS) for all populations including behavioral health, aged and disabled, and others
- Payment incentive models promoting goals such as access to care and person-centeredness
- Development and administration of cost, wage, and other data survey tools
- Development of independent, resource- based setting methodologies
Policy consulting
With a diverse team of consultants with real-world experience at state Medicaid agencies, MCOs, and healthcare providers, our policy team applies a practical operations approach to policy initiatives with a focus on feasibility and ease of adoption. Partnering closely with Milliman’s actuarial, finance, and clinical experts, we seamlessly deliver tailored solutions for Medicaid state agencies. Our policy consulting services include the following:
Waiver development, healthcare reform, program development, and enhancements
- 1115, 1915, 1332, emergency waivers, and state plan amendments
- Delivery system reform and value-based payment
- Managed Long-Term Services and Supports (MLTSS)
- Behavioral health transformation
- Dual demonstrations/financial alignment initiatives
- High cost drugs
- Premiums assistance programs and Medicare savings programs
- Quality strategy
- Social determinants of health
Program conceptualization, design, and implementation
- Facilitation of visioning and strategic planning
- Best practice review and gap analyses
- Comparative analysis, benefit design, and improvements
- Statutory/regulatory research and assessment of program impacts
- Program evaluation metrics and cost-saving initiatives
- Value-based purchasing strategies and implementation plans
Managed care and administrative services/vendor operational support
- Procurement, contract evaluations, and vendor oversight programs
- Provider collaboration models, stakeholder engagement strategies, and planning for new program rollouts
- Administrative cost modeling
- Single PBM carve out, transformation implications, and MCO integration
- Care management redesign
- Behavioral health integration
- Retrospective program analysis