1. Preventive, Case-Managed Services Offered by Nevada Medicaid Page 1
Nevada Medicaid Contracted Managed Care Organizations and Their Preventive, Case-managed
Services
Thomas Weber
Policy Systems and Environmental Changes
Chronic Disease Prevention and Health Promotion Section
July 15, 2015

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“The ACA seeks to transition individuals from one-off emergency visits to continuous,
complete care, including preventive and chronic care. This requires well supported teams,
integrated with local community medical systems, so newly-covered patients can
experience coordinated care—not just more episodic, Band-Aid care. It pushes us to look
at the broader population, as that is where real reform lies.”
- Wells Shoemaker, MD, Medical Director of the California Association of Physician
Groups
Introduction
The Patient Protection and Affordable Care Act has now had most of its major provisions
phased in, resulting in a sizeable expansion of the United States healthcare system. The ACA is
designed to make primary care more accessible, but the increase of coverage will strain the
system currently in place, potentially overloading facilities and providers trying to deliver high
quality care at an affordable cost (Kaprielian & Dean, 2013). Providers are going to be seeing
more patients as American citizens are now required to obtain health insurance, with the
Congressional Budget Office (2012) estimating that each primary care physician will on average
receive 60 new patients. In addition to this individual mandate, which requires that eligible US
citizens obtain health insurance, Medicaid coverage has expanded in 23 states as a result of the
ACA. The Congressional Budget Office (2013) expects this will add an additional 10 million
more people to the population healthcare providers are already responsible for. As of April 2015,
Nevada alone has seen the addition of 221, 450 new Medicaid beneficiaries since the beginning
of expansion, resulting in a 66.6 % increase (Medicaid.gov, 2015). Nevada’s healthcare
providers will now be tasked with providing quality and cost efficient care to this new proportion
of the population that now has healthcare coverage. Finally, every day 11,000 new seniors across

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the country become eligible for Medicare, many of whom have chronic conditions that require
ongoing and intensive treatment, placing more pressure on providers to deliver quality and
affordable care (Kaprielian & Dean, 2013).
The ACA and Healthcare Reform
The Affordable Care Act provides a framework and environment that creates new
opportunities for improving the quality of life of the population. The new system in place can
also help address any issues that arise as the United States healthcare system is expanded and
reformed by allowing for the development of an effective workforce that can not only reduce
health disparities but facilitate access to care through new health delivery system models (Health
Resources in Action of Boston, 2013). As these new methods of healthcare delivery are
formulated, an emphasis on integrative, team based care is being promoted in order to help
alleviate the stress that many providers will likely be facing as new patients start coming in.
Team based care is the provision of comprehensive health services to individuals, families, and
communities by at least two health professionals working collaboratively with patients, family
caregivers, and community service providers on shared goals aimed at achieving health care that
is safe, effective, patient-centered, timely, and efficient (Hupke, 2013). Team-based care can
help physicians use their time more effectively, and is also the only way to address the needs of
an expanding patient population with a simultaneous shortage of primary care physicians; the
current infrastructure for primary care in the US is not sufficient to meet the population
management needs that come along with the new primary, preventive care patient model (Hupke,
2013). Furthermore, the Institute for Healthcare Improvement, under the Affordable Care Act,
has come up with three objectives to improve the healthcare system known as the IHI Triple

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Aim, which utilizes team based care among other measures. The remaining barriers to integrated,
team based care are not technical; they are political (Berwick, Nolan, & Whittington, 2011).
(Institute for Healthcare Improvement’s Triple Aim. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx)
Improving the United States as well as Nevada’s health care system requires
simultaneous pursuit of three aims: improving the experience of care, improving the health of
populations, and reducing per capita costs of health care (Berwick, Nolan, & Whittington, 2011).
These aims are not independent of each other, and there will need to be balance when attempting
to meet them. At times, the aims can be achieved simultaneously. For example, eliminating
overuse or misuse of therapies and diagnostic tests can lead to both reduced costs and improved
outcomes, achieving two aims at once. According to Berwick, Nolan, and Whittington (2011)
conditions necessary to meet the Triple Aim include:
1) The enrollment of an identified population, such as Medicaid beneficiaries.
2) A commitment to universality for population members, meaning that all members are
treated equally.
3) The existence of an “integrator” that accepts responsibility for all three aims for the
specified population. The integrator’s role should include at least five components:

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a) Representing, advocating, and partnering with individuals and families in order to
help these members of the population establish a plan for ongoing care.
b) The integrator would be responsible for building the capacity and infrastructure
that would allow primary care services to be expanded, completing such tasks as
establishing long-term relations between patients and their primary care team,
developing shared plans of care, and coordinating care.
c) Improving population health management by increasing preventive care efforts.
d) Assure that payment and resource allocation support the Triple Aim.
e) Produce or contract for individual care and population-based interventions that are
evidence-based and highly reliable.
Nevada Medicaid Contracted MCO’s and Their Preventive Services
Nevada has been operating a mandatory managed care program in Clark and Washoe
Counties since 1998. The program is called the Nevada Mandatory Health Maintenance
Program, and covers health care services for many of Nevada’s Medicaid recipients (CMS,
2011). Risk-based managed care organizations are the institutions through which Nevada
Medicaid beneficiaries in Washoe and Clark counties receive all or most of their care (Kaiser
Family Foundation, 2015). The MCO’s require that beneficiaries choose a primary care provider
PCP before they can see other physicians or specialists. Under this model, primary care providers
act as “gate-keepers.” Patients must go through them before getting a referral to another provider
(Shafrin, 2011).
Nevada contracts with two of the national, for-profit plans Amerigroup Community Care,
and Health Plan of Nevada (the latter is owned by United Healthcare) to provide the healthcare

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services to this population. The state selects plans through a competitive bidding process and sets
rates through an administrative process using what is known as actuarial analysis. This analysis
accounts for differences in costs due to a number of factors, including age, gender, geography,
eligibility category, and health status (CMS, 2011). In order to provide care for any high-need
beneficiaries not served by the Mandatory Health Maintenance Program such as those in rural
areas, Nevada received federal approval for a section 1115 demonstration called the Nevada
Comprehensive Care Waiver NCCW. Eligible individuals receive benefits in a fee-for-service
FFS environment with mandatory care management to support improved quality of care (CMS).
If beneficiaries do not select an MCO on their own, they are assigned to a plan through a default
enrollment process based on a state-defined algorithm. These algorithms may not adequately
take into account existing beneficiary-provider relationships or other factors that may optimize
beneficiary access to care (Paradise & Musumeci, 2015).
According to the MCO Health Plan of Nevada and Amerigroup Handbooks (2015), being
in a managed care organization is similar to being in an HMO and means:
1. Members choose a Primary Care Provider (PCP) or personal doctor, to see when
they need medical care.
2. Members may make appointments for regular checkups with their PCP or
personal doctor, enabling PCP’s to get to know their patients.
3. PCP’s act as gatekeepers, arranging necessary extra care through the network of
doctors, hospitals and other healthcare facilities.

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Are the Managed Care Organizations required to provide care coordination or team based care?
(Case Management. Retrieved from http://www.domice.org/default.asp?page_id=141)
The MCOs acting as health maintenance organizations were originally designed in a way
that made them close to being “integrators” while performing functions similar to case
management, aligning their objectives with those of the Triple Aim (Berwick, Nolan, &
Whittington, 2011). However, as time progressed, an HMO became defined by its organizational
structure rather than its aims and performance (Berwick, Nolan, & Whittington, 2011). HMOs
restrict care by requiring referrals to specialists; this is how they “manage” care. Because of this
from of care restriction, MCOs became vulnerable to competitive retaliation by indemnity
insurers and others, which began offering products called “HMO” or “managed care” that merely
managed money, not care (Berwick, Nolan, & Whittington, 2011). MCOs are competing for
doctors and acute care suppliers in an environment in which medical providers are in control of
demand and thus revenue; the restrictive nature of HMOs makes them unattractive business
alternative for many providers, decreasing the quality of care experienced by Medicaid
beneficiaries (Berwick, Nolan, & Whittington, 2011).

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(Team based care. Retrieved from http://www.caretriad.com/tag/team-based-care/)
MCOs are required to ensure that they meet state standards. The federal rules do not
establish specific standards for provider network adequacy, outreach practices, or timeliness of
access for beneficiaries (Paradise & Musumeci, 2015). The Affordable Care Act does not
explicitly require health care organizations to provide team based care, but it does promote this
form of healthcare delivery by creating systems that encourage and support teams of physicians,
hospitals, and other health care providers to collaboratively manage and coordinate care for
Medicare beneficiaries (CMS, 2010). If these providers meet certain quality and efficiency
benchmarks, they may receive a share of any savings resulting from the reduction of duplicative
services and the improvement of productivity and cost efficiency (CMS, 2010). Under this form
of managed care, organizations that foot the bill for a patient’s medical services have also started
managing that patient’s care; purchasers and insurers no longer simply write checks, but they
become involved in decisions about how much care a patient receives, how much money
providers will receive, and how that money is paid (Bodenheimer, Grumbach, 2002).

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An example of team based care promoted by the Affordable Care Act is described in
section 3022 of the legislation as the Medicare Shared Savings Program for Accountable Care
Organizations (ACOs), in which Medicare fee-for-service beneficiaries are assigned to ACO’s
(govtrack.us, 2009). This is one of the ways in which the ACA strives to improve the quality of
care, develop and promote new models of care delivery, appropriately price services, modernize
our health system, and fight waste, fraud, and abuse (CMS, 2010). Currently, only Nevada
Medicare beneficiaries are enrolled in an Accountable Care Organization. The two Nevada
Medicaid contracted MCOs are not delivering care in this manner; they are still fee for service
FFS HMOs. As a result people enrolled in Nevada Medicaid contracted MCOs/HMOs are not
sufficiently experiencing coordinated, team based care, both of which have been shown to
improve quality of care while containing costs (Kaprielian, & Dean, 2013).
In regards to preventive services offered, Health Plan of Nevada:
 Has a health education team staffed with certified health education specialists,
registered dietitians, and certified diabetes educators that offer classes, one-on-
one consultations, and online videos in an effort to enable its members to learn
how to make healthy choices and live healthier lives. Topics range from tobacco
cessation to making smart nutritional choices while grocery shopping.
 The website offers many reading sources on how to not only be proactive in
maintaining a healthy lifestyle by offering recommendations on balancing food
choices and getting enough exercise, but also how to manage conditions such as
diabetes and high blood pressure once you have them.

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 Provides preventive guidelines to its members based on United States Preventive
Services Task Force USPTF recommendations. However, the website urges
members to talk to their doctors about preventive services, and does not offer
outreach services to remind them they are due for a service.
 24/7 Telephone Advice Nurse Service
 Early and Periodic Screening, Diagnosis and Treatment EPSDT program
promotes regularly scheduled well-child visits for Smart Choice/Northern Choice
and Nevada Check Up members under the age of 21.
 Health Plan of Nevada’s website says they provide member outreach for
preventive care. After speaking to an ombudsman, I received a call back from an
agent with more oversight on the health education and wellness programs. I was
told during this telephone conversation that there were no true outreach programs
at this time.
Preventive services offered to Amerigroup’s Nevada Medicaid members include:
 Regular wellness visits with Primary Care Provider for adults. There is a wellness
visit schedule adults can access via the website that tells them what exams they
are due for.
 The Healthy Kids program which is the wellness plan for children. Services
during wellness visit include blood lead screening, vision screening, hearing and
dental screening, and immunizations.
 Health education classes, and sponsored community events.
 Member newsletter mailed twice a year containing information on staying well,
taking care of illness, and other topics.

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Recommendations
Federal legislation enacted in 1997 requires all states to report their managed care
encounter data to CMS as part of their Medicaid Statistical Information System (MSIS)
submissions, with federal regulations requiring that MCOs collect encounter data, ensure that
they are accurate and complete, and make them available to the state (Paradise & Musumeci,
2015). Additionally, the ACA strengthened the requirement for Medicaid MCOs to provide
encounter data to states and permits federal Medicaid matching funds to be withheld from states
that fail to report accurate enrollee encounter data to CMS (Paradise & Musumeci, 2015). To aid
in this process, the Medicaid Electronic Health Care Record (EHR) Incentive Program provides
incentive payments to eligible professionals, eligible hospitals, and critical access hospitals
(CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of their certified EHR
technology (Medicaid Electronic Health Records, 2015). This program has been run in the state
of Nevada by its Medicaid program since 2012, with funding coming from the American
Recovery and Reinvestment Act (ARRA) HITECH law (DHCFP, 2015). The Nevada Medicaid
contracted MCO’s should register with CMS using the CMS EHR Incentive Registration link
provided, as the MCO’s are already enrolled in NV Medicaid as eligible providers, which is a
prerequisite to use the program.
Amerigroup and Health Plan of Nevada could be using the meaningful use program on
their data to determine if correct screening procedures are taking place. Encounter data gives
state governments an important monitoring tool to make sure that Medicaid beneficiaries are
getting the necessary care. These data can be used to track rates of use of high-value or high-
interest services, such as preventive screening, immunizations, or hospitalizations, including
readmissions, and to identify disparities in utilization of services across populations or

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geographic areas within communities (Paradise & Musumeci, 2015). If discrepancies are noted,
the information could then be provided to the appropriate state programs for outreach, in order to
get these populations screened. As of July 13, 2015 a total of 455 providers and 30 hospitals
have received over $41,796,479.12 in payments from the Nevada Medicaid EHR Incentive
Payment Program (DHCFP, 2015).
Regarding Healthcare Effectiveness Data and Information Sets (HEDIS), Health Plan of
Nevada provides a Quality Improvement Provider Resource Guide and toolkit. The toolkit is
designed to provide the health plan’s network Primary Care Providers (PCP) with information on
quality measures and what they mean to the health plan (Health Plan of Nevada, 2015). Based on
the screening information received by Women’s Health Connection, the MCO’s data is not being
used for proper screening. The MCOs as well as Medicaid store information about ICD 9 and
preventive service CPT codes in a Hewlett Packard data warehouse. The state is working on
producing a program that would allow appropriate programs to access this data, in order to
handle further outreach and screening if necessary.
A state plan amendment could be filed that sets up a system in which Medicaid
reimburses for provider reminder systems and provider education. The amendment could also
include protocol for Medicaid to begin reimbursing for outreach programs. Without the support
of Nevada Medicaid, many efforts, such as incentivizing providers to encourage preventive care,
will be more difficult to achieve. The state can still offer providers resources, such as educational
material on patient centered medical homes, to increase awareness of the need to deliver more
preventive services. Evidence suggests that offering support to primary care providers through,
for example, educational materials and trainings, encourages them to provide these services,
resulting in higher rates of clinician screening and counseling (CMS, 2014).

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Conclusion
I chose the topic of discussing preventive and outreach services offered by the state’s
Medicaid contracted MCO’s after learning about a discrepancy that was occurring regarding
Women’s Health Connection (WHC) and the screening services the program offers. Many of the
women who were utilizing WHC became eligible for Medicaid after its expansion under the
Affordable Care Act. Because of this new form of healthcare coverage, this population was now
receiving screening services from Medicaid MCO’s. After looking at the screening rates received
by Medicaid, the state’s WHC program officer noticed that the rates decreased greatly, meaning
that the women who are not using WHC because they are now on Medicaid are not getting
screened as often. This was alarming to me, as it appeared as those the ACA was doing the
opposite of what it was intended to do, causing certain populations to receive inferior health care.
A possible reason behind this problem is that even though many of the healthcare system
changes outlined in the Affordable Care Act are federally mandated, such as coverage of
preventive services with no cost sharing by insurance plans, it is still be up to the states to
implement many other changes- or not to. For example, states can opt out of payment reform and
Medicaid expansion, but those that do opt out will forgo all or part of federal funding. There are
no federal requirements that force states to meet the standards of the IHI Triple Aim. However if
Nevada did so the state would not only save money in the long run as a result of a healthier
population, but also be more productive as a whole. The utilization of Community Health
Workers CHWs acting as “integrators” to help bridge the gaps between clinical-community
linkages could help Nevada achieve the goals outlined in the triple aim. CHWs would make it
much easier to improve the health of the population on many levels.

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