December 9, 2010

3130 Fairview Park Drive, Suite 800 | Falls Church, VA 22042 | phone: (703) 269-5500 | fax: (703) 269-5501 | www.lewin.com

December 9, 2010

West Virginia Department of Health and Human Resources Office of Purchasing ATTN: Donna Smith One Davis Square, Suite 100 Charleston, WV 25301

Re: RFP MED 11010

Dear Ms. Smith:

The Lewin Group is pleased to submit our technical proposal to provide administrative and operational services for the West Virginia Bureau for Medical Services’ Medicaid managed care program. Lewin offers an exceptionally qualified team that has worked closely with the Bureau for Medical Services since 1995. We welcome the opportunity afforded by this RFP to offer our technical and analytic expertise in continued support of the West Virginia Bureau for Medical Services.

The Lewin Group will provide expertise in Medicaid managed care operations, capitation rate development, and program evaluation and improvement strategies, alongside our in-depth understanding of the current federal regulatory environment. Our project team reflects these capabilities, providing high-level policy and program experience, operational expertise, broad national exposure, and West Virginia knowledge.

The Lewin Group accepts all RFP terms, and certifies that our bid price was arrived at without any conflicts of interest.

I am authorized to bind The Lewin Group to the terms set forth in the enclosed proposal to the West Virginia Department of Health and Human Resources. My contact information is:

Lisa Chimento, Chief Executive Officer The Lewin Group 3130 Fairview Park Drive, Suite 800 Falls Church, VA 22042 Phone: (703) 269-5556 Email: [email protected]

Thank you for your consideration of our proposal. We look forward to the opportunity to address any questions you have.

Sincerely,

Lisa Chimento Chief Executive Officer RFP #MED11010 Managed Care Administration

Table of Contents

EXECUTIVE SUMMARY (4.1.4) ...... 1

VENDOR’S ORGANIZATION (4.1.5)...... 4 Business name and address: ...... 4 Subcontractor detail:...... 4 Financial information: ...... 4 Additional RFP Requirements: ...... 7

LOCATION (4.1.6) ...... 8

VENDOR CAPACITY, QUALIFICATIONS AND RELEVANT EXPERIENCE (4.1.7) ...... 9 The Lewin Group Organizational Structure ...... 9 Experience and Capabilities ...... 10

PROJECT APPROACH AND SOLUTION (4.1.8) ...... 30 Statement of Understanding...... 30 Scope of Work: Yearly Operations Plan (3.2.1) ...... 33 Scope of Work: Program Management and Improvement (3.2.2)...... 55 Scope of Work: Program Evaluation and Improvements (3.2.3)...... 76 Scope of Work: Federal Regulatory Compliance (3.2.4) ...... 87 Scope of Work: Additional Services (3.2.5)...... 95

VENDOR STAFFING (4.1.9)...... 110 Key Project Personnel...... 110 Project Staff Organization ...... 111

SUBCONTRACTING (4.1.10)...... 132

SPECIAL TERMS AND CONDITIONS (4.1.11)...... 133

SIGNED FORMS (4.1.12)...... 134

RFP REQUIREMENTS CHECKLIST (4.1.13) ...... 135

APPENDIX A: ADDITIONAL CORPORATE QUALIFICATIONS ...... 146

APPENDIX B: STAFF RESUMES ...... 166

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Executive Summary (4.1.4)

In a successful effort to constrain the growth of Medicaid expenditures while improving the quality of health care services provided to Medicaid beneficiaries, the Department of Health and Human Resources – Bureau for Medical Services (BMS or the Bureau) implemented full- risk managed care contracting in 1996. The State’s primary care case management program, the Physician Assured Access System (PAAS), was joined with the full-risk capitated program under one combined 1915(b) waiver in 2004. The programs are now collectively known as Mountain Health Trust (MHT) and together serve over 180,000 West Virginia beneficiaries.

Today, West Virginia is moving closer to the goal of having a statewide, comprehensive managed care program. Over the next six years the Mountain Health Trust program has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. Opportunities and challenges now facing the State include:

 Ensuring that the State is purchasing the best value service for the best price;  Successfully completing the implementation of major program changes and effectively monitoring the expanded program;  Preparing for federal health reform; and  Continuing to operate the program and serve beneficiaries currently enrolled.

As the incumbent contractor and a nationally-recognized Medicaid policy firm with best-in- class capabilities, The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities. We have supported the Bureau with the development, implementation, and operation of the program since its inception, and over the past 15 years, Lewin has gained deep experience with West Virginia, as well as with other Medicaid programs across the country. Our team is personally committed to the success of the program: Lisa Chimento, Lewin’s chief executive, has supported MHT since its inception, and several additional project members have assisted MHT for more than a decade. Our partnership has resulted in significant successes for the West Virginia Medicaid program:

 Expansion of the MCO model statewide, with at least two MCOs offering members a choice in 42 of the State’s 55 counties;  Increased use of appropriate preventive health services and corresponding decreases in emergency room visits, hospitalizations, and other unfavorable health outcomes;  High levels of member satisfaction, with 92 percent of MCO parents rating their children’s personal doctors at 7 or above (10 being the highest possible), higher than the national Medicaid average, and 83 percent of adult beneficiaries reporting high satisfaction with their personal doctor or nurse;  Performance above the national average for Medicaid programs in the areas of cervical cancer screenings, controlling high blood pressure, comprehensive diabetes care, adult access to preventive and ambulatory care, and timeliness of prenatal and postpartum care; and

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 Over $25 million in cost savings since the inception of the Medicaid MCO program by slowing the growth in the use and cost of medical services and administrative efficiencies.

We are proud of our long term relationship with West Virginia and the growth of the program over the last several years. We understand the needs of the Bureau and are prepared to meet these needs.

Bureau for Medical Services Needs The Lewin Group Capabilities A consulting team with detailed and long term As the incumbent contractor, we have a knowledge of the West Virginia Medicaid strong working relationship with the Bureau program, that can begin work immediately and deep knowledge of the program as well as upon contract award effective working relationships with other entities that regulate and operate the program, including CMS, the MCOs, and other MHT vendors Skilled actuaries and a rate-setting team to Our team’s rate-setting expertise in West ensure that West Virginia Medicaid funding is Virginia and experience in over 30 other states spent efficiently and MCOs are paid accurately provides the basis for designing and securing approval of more sophisticated payment arrangements, including risk adjustment and pay-for-performance Consulting partners to assist the State in As a firm, we are at the forefront of health preparing for program expansion and other reform modeling and implementation efforts program requirements as it prepares for a and can provide timely and credible support major program expansion in 2014 under health to the State reform National experience and innovative ideas to We bring to bear knowledge and experience ensure that program improvements and other from many other successful state Medicaid quality improvement activities are at the managed care programs, including former forefront of Medicaid policy State Medicaid Directors, and leverage best practices from around the country to benefit the MHT program

Having a team with sufficient depth to handle the technical challenges in the Scope of Work as well as sufficient breadth to ensure timelines are met is critical to the successful execution of this engagement. This scope demands a variety of expertise in areas such as rate-setting, policy analysis, procurement support, quality monitoring, data analysis, and regulatory compliance, and a team that is integrated among the disciplines in order to solve complex problems.

Lewin offers a large team of cross-trained staff able to support multiple activities at varied levels of intensity across each contract year. Our team structure has allowed us to meet the specific requirements of the Scope of Work and support a host of other BMS needs including:

 Responding to unexpected events, such as major changes in program direction and MCO entry into or departure from the program;

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 Adapting to changing requirements such as developing capitation rates for additional benefits, modifying program documents to address new federal rules around benchmark benefits, and adjusting program expansion timelines; and  Supporting BMS in a variety of emerging policy and operational issues, such as pharmacy carve-in and additional federal reporting requirements.

We propose the same highly-trained team for this effort, with new additions to meet the program’s growing needs. We will maintain our current strategy for senior leadership of the project, with Lisa Chimento and Moira Forbes acting as co-Project Directors. To appropriately address the four task areas included in the RFP, we have Our key staff are personally assembled four teams, each with a lead and support staff. vested in the ongoing success of Jennifer Tracey will continue to be responsible for overall this program and look forward management of the teams, as well as serving as the co-team to the opportunity to fully lead for the Operations Plan task. Chris Park and Tom engage in supporting BMS with the further maturation of the Carlson, FSA, will continue to lead our rate-setting work, Mountain Health Trust program. with input from Jeff Smith, a nationally-recognized risk adjustment expert, as appropriate. Our subcontractor, Michael Madalena, will continue to work with Lewin, BMS, and the MCOs on encounter data activities, with oversight from Steve Johnson, Ph.D., a Lewin senior staff member. Dr. Johnson has over 30 years of experience working with health plan data, including 10 years overseeing similar activities for the State of New York, and will serve as team lead for the Program Management and Improvement task. Jessica Boehm, who has supported the Bureau in several capacities over the past several years, will serve as team lead for the Federal Regulatory Compliance and Project Evaluation and Improvement tasks. Other staff with previous experience supporting the MHT program will remain on the team, and we will draw on our extensive team of policy experts, data analysts, and Medicaid/CHIP experts as needed to support regular and ad hoc tasks.

Our proposed team will provide the Bureau with unmatched experience gained in West Virginia and other states, as well as continuity and the ability to launch a full effort immediately upon contract award. Our nationally-recognized experts and experienced, dedicated West Virginia team will be able to assist the Bureau in assessing a range of emerging issues and implementing a variety of program innovations, including:

 Evaluating the appropriateness of risk adjustment or other payment methodologies;  Refining the program monitoring dashboard to provide robust management information;  Assisting BMS in considering the “pros” and “cons” of competitive bidding approaches;  Modeling the potential size and utilization of health reform expansion populations; and  Adopting additional quality improvement and performance incentive strategies.

We understand that the Medicaid world is changing constantly and West Virginia may require additional, ad hoc services as part of this contract. As we have for the previous 15 years, our team is prepared to be flexible in meeting the needs of the program and providing required assistance.

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Vendor’s Organization (4.1.5)

Business name and address:

The Lewin Group 3130 Fairview Park Drive, Suite 800 Falls Church, Virginia 22042 703-269-5500

Subcontractor detail:

The Lewin Group will continue to partner with Michael Madalena, located at 551 Justabout Road, Venetia, Pennsylvania, 15367. More detail on Mr. Madalena’s role is included in Section 4.1.10.

Financial information:

The Lewin Group, incorporated in North Carolina on April 12, 1996, became a wholly-owned subsidiary of Ingenix in June of 2007. Ingenix, a wholly-owned subsidiary of UnitedHealth Group (UHG), was founded in 1996 to develop, acquire and integrate the world's best-in-class health care information technology capabilities.

The Lewin Group’s financial information is not provided at the Lewin level; it is consolidated at the Ingenix business segment level and reported to UnitedHealth Group for consolidated SEC reporting/filing. UHG's latest audited 8-K & 10-K (links provided below) itemize the Ingenix business segment financial information - of which The Lewin Group is a part. Excerpts from the UHG filings describing the Ingenix business segment and its respective financial results are provided below.

UHG Form 8-K First Quarter 2009: http://www.unitedhealthgroup.com/invest/2009/8.4176Apdf

UHG Form 8-K First Quarter 2010: http://www.unitedhealthgroup.com/invest/2010/70148A.PDF

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UHG Form 8-K First Quarter 2009 Ingenix Excerpts:

#523964 RFP #MED11010 Managed Care Administration

UHG Form 8-K Second Quarter 2009: http://www.unitedhealthgroup.com/invest/2009/24468A.pdf Ingenix Excerpts:

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Additional RFP Requirements:

1.2.4 Disaster Recovery Plan

As required in Section 1.24 of the RFP, Lewin has a disaster recovery plan in place. A copy of the plan is attached here. As indicated, the disaster plan includes periodic testing of the plan.

3.3 Special Terms and Conditions

3.3.1 Bid and Performance Bonds: Non-applicable

3.3.2 Insurance Requirements: The Lewin Group will provide proof of insurance at the time of contract award.

3.3.3. License requirements: The Lewin Group’s Certificate of Authority to do business in West Virginia is attached. We are seeking a Certificate of Good Standing from the Insurance Commissioner.

3.3.4. Litigation Bond: Non-applicable

3.3.5: Debarment and Suspension: The Lewin Group is not debarrered or suspended.

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Location (4.1.6)

The Lewin Group is located at 3130 Fairview Park Drive, Suite 800, Falls Church, Virginia, 22042.

The Lewin Group’s offices feature comprehensive facilities that enable thorough and efficient project support. The Lewin Group offices in Falls Church cover three floors of a modern office building. The headquarters is easily accessible by car or Metro, and is 20 minutes from downtown Washington, DC, and within a half an hour from both major airports. Additionally, Lewin is close to both the Baltimore and Washington, DC locations of the Centers for Medicare and Medicaid Services. Our location offers relative proximity to Charleston, West Virginia.

The Falls Church office provides the amenities and convenience typical of the work space used by leading professional services firms. All floors have two or more fax machines and several printers and copiers (both color and black and white). Twelve conference rooms are available within Lewin’s office space for hosting meetings for groups of up to 20. An additional large conference seats 90 auditorium style, and can hold 130 standing. Each conference room has at least one conference telephone, as do all offices. In addition, one of the smaller conference rooms has been installed with a certified video teleconferencing system, which is 98 percent compatible with all other videoconferencing centers/equipment in the United States and worldwide.

The Lewin Group will continue to partner with Michael Madalena, located at 551 Justabout Road, Venetia, Pennsylvania, 15367.

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Vendor Capacity, Qualifications and Relevant Experience (4.1.7)

Today, West Virginia is moving closer to the goal of having a statewide, comprehensive managed care program. Over the next six years the Mountain Health Trust (MHT) program has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. Opportunities and challenges now facing the State include:

As the incumbent contractor and a nationally-recognized Medicaid policy firm with best-in- class capabilities, The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities. We have supported the Bureau with the development, implementation, and operation of the program since its inception, and over the past 15 years, Lewin has gained deep experience with West Virginia, as well as with other Medicaid programs across the country. Many of our proposed team members have worked with the Bureau for a decade or more and have a personal commitment to the ongoing success of the program. Our specific capacity and qualifications to support the Bureau in these important endeavors are described in more detail below.

The Lewin Group Organizational Structure

The Lewin Group is a premier national health and human services consulting firm with 40 years of experience delivering objective analyses and strategic counsel to public agencies, non-profit organizations, and private companies across the United States. Lewin has worked with over 40 states, including West Virginia, on a variety of Medicaid and state health reform initiatives and has both deep and broad expertise in the development, implementation, and operation of Medicaid managed care programs. The firm is renowned for its objectivity, analytical capability, strategic vision, and commitment to client satisfaction. Lewin helps clients to:

 Improve policy and expand knowledge about health and human services systems;  Enact, run, and evaluate programs to enhance delivery and financing of health care and family services;  Deal with shifts in health care practice, technology, and regulation;  Optimize performance, quality, coverage, and health outcomes; and  Create strategies for institutions, communities, governments, and people to make health care and human services systems more effective.

The Lewin Group has a well-earned reputation for delivering significant value to its clients. This value comes from our professional and experienced staff, our insights into the issues that clients face, our rigorous approach to analyzing and solving problems, and our commitment to

#523964 RFP #MED11010 Managed Care Administration independence, innovation, and integrity. The Lewin Group’s more than 110 consultants are drawn from industry, government, academia, and the health professions. Many are national authorities whose approaches to advancing health care and human service systems stem from personal experience with imperatives for change. The proposed project co-directors, Lisa Chimento and Moira Forbes, are both recognized experts in Medicaid managed care and their insights in this field have recently been sought by the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) and the Centers for Medicaid and Medicare Services (CMS).

The Lewin Group is a wholly-owned subsidiary of Ingenix Public Sector Solutions, Inc., which in turn is a wholly-owned subsidiary of UnitedHealth Group. Ingenix, whose focus is on knowledge and information lines of business, develops, publishes, and licenses data management and decision support tools and also provides clinical and health services research, development and marketing services on a global basis. Ingenix is one of UnitedHealth Group’s independent wholly-owned operating companies. The Lewin Group operates as a separate corporate entity, with its own operational structure and management.

Experience and Capabilities

The Lewin Group is the market leader in the field of Medicaid and Medicaid managed care consulting. Our experience in this realm goes back nearly two decades and includes more than half the states in the nation. Our senior staff have decades of professional experience as consultants, health plan executives, and state Medicaid agency officials. Much of our professional focus is on assisting states in creating, implementing, enhancing, and broadening Medicaid managed care programs. As shown in Figure 1 below, we have worked in almost all of the states and with numerous private sector entities on a variety of Medicaid initiatives.

Figure 1. The Lewin Group’s National Medicaid Experience

State or local gov’t Private organization(s) Both gov’t and private

We combine real world experience with a broad, national perspective on public policy to address areas including:

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 Design and implementation: evaluating local circumstances to determine the ideal managed care program configuration, developing overall program designs, specifying managed care program features, drafting waiver applications, facilitating stakeholder consensus building, and supporting program implementation and administration.  Program reimbursement: designing program reimbursement and risk-sharing arrangements, developing actuarial methodologies, and setting capitation rates.  Procurement: planning procurements, drafting Requests for Proposals (RFPs), crafting evaluation criteria and methodologies, training review teams, participating in proposal efforts, and developing contracts.  Monitoring and evaluation: evaluating programs, performing ongoing quality monitoring, developing and implementing external quality review strategies, conducting provider and beneficiary surveys, and developing quality standards.

In addition to our work with state Medicaid agencies, Lewin assists Medicaid health plans in a variety of activities, including designing service delivery arrangements, devising policies and procedures consistent with state requirements, and developing approaches to serving members with special needs. Lewin also assists health plans in preparing applications and proposals for competitive awards of risk contracts. Additionally, we work with providers of specialized services who wish to organize health plans for Medicaid sub-populations with unique needs, such as children with special health care needs and persons infected with HIV/AIDS. This private-sector experience gives our firm distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector managed care and allows us to bring cutting-edge innovation to our state Medicaid clients. Lewin’s multi-faceted expertise will be valuable as we guide the State of West Virginia in furthering the development of the Mountain Health Trust program.

Below, we detail Lewin’s experience for each task delineated in West Virginia’s RFP. In Appendix A, we include a matrix listing selected states and other clients for which we have provided that experience, and additional descriptions for each of those clients, specific to the project.

Task 3.2.1: Yearly Operations Plan, including rate setting and contracts

The Bureau requires support in the management and implementation of the Mountain Health Trust program, including development of a robust Operations Plan that will enable the Bureau to efficiently and effectively administer and manage the program. Key components of this task are procurement, rate setting, contract negotiation, program management, and ongoing monitoring of program vendors and performance. The Lewin Group has assisted West Virginia in all of these areas since 1995 and performed similar activities in a number of other states, as described in more detail below.

Subtask 3.2.1.1: Yearly capitation rates Since 1995, Lewin has set rates for West Virginia’s MHT program and will be able to continue this work immediately upon contract execution. Lewin has a detailed understanding of West Virginia’s eligibility and claims systems, in addition to our knowledge of the specifics of West Virginia’s Medicaid program (i.e., eligibility categories, fee-for-service (FFS) payment methods,

#523964 RFP #MED11010 Managed Care Administration benefits packages) which allows us to set rates accurately. We understand the current Medicaid Management Information Systems (MMIS) requirements and specifications for the monthly data transmissions. Over the past two years, Lewin has incorporated numerous changes to the program, including: changes in Mountain Health Choices (MHC) benefit limits under the new State Plan Amendment; the removal of Section 1931 Parents and Caretakers/relatives from mandatory enrollment in the benchmark authority; the behavioral health and children’s dental expansion; and the expansion to Supplemental Security Income (SSI) beneficiaries. As West Virginia’s Medicaid program continues to face new changes and challenges, our knowledge of the provider community and service delivery system will help to inform the design and analysis of the impact of programmatic changes.

Lewin has established Medicaid managed care capitation rates in 12 states: Colorado, Connecticut, Delaware, the District of Columbia, Iowa, Kansas, Massachusetts, Montana, New Mexico, New York, Oregon, and West Virginia. In several of these states, Lewin has established capitation rates for multiple comprehensive physical health and specialty carve out programs over multiple years. Lewin developed the capitation rates using either Medicaid FFS claims data, managed care organization (MCO) encounter data, or both. Our standard rate setting work involves designing needed data requests; programming claims and eligibility files; performing data validity checks and correcting data as needed; establishing appropriate rate cohorts; adjusting the raw claims data for claims completion, retrospective eligibility periods, and other factors; and developing inflation trend factors. We have developed rate setting methodologies that have incorporated individual or aggregate reinsurance, risk sharing and risk corridor arrangements, and incentive payment structures. Therefore, we are highly familiar with the actuarial process of establishing capitation rates that meet federal requirements and contrasting capitation rates to FFS cost levels.

Lewin has worked with several states to develop capitation programs for specialty services, behavioral health, dental health, and mental health programs; we have also worked with state Medicaid agencies on individual and aggregate reinsurance and risk sharing arrangements to protect the State and plans. In addition, Lewin has closely worked with CMS and other states regarding the changing nature of Medicaid managed care cost-effectiveness. Through our experiences with the Bureau and with other states, Lewin has developed a reputation for strategic approaches to rate development and high quality technical analyses needed to accurately calculate rates.

Subtask 3.2.1.2: Procurement The Lewin Group has extensive experience designing and managing procurements and has worked with numerous states, the federal government, and several private-sector organizations on various procurement tasks, including developing overall procurement strategies, drafting RFPs, developing scoring criteria and review guides, training state evaluation teams, participating in proposal review, analyzing provider networks, developing site visit protocols, and conducting site visits to MCOs. Lewin has conducted Medicaid managed care procurements in Connecticut, Florida, Maryland, Montana, New Mexico, New York, Texas, and West Virginia. Lewin has also assisted in other purchasing activities such as conducting market analyses and negotiating with selected contractors.

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Lewin developed the original RFP for the MHT program, managed the procurements of MCOs for the program, and developed the revised MCO contracts that will serve as the basis for future procurements. For the past 15 years, Lewin has supported the Bureau in efforts to encourage additional MCOs to participate in the MHT program, and has developed cooperative relationships with key decision-makers at several of these plans. These relationships, as well as Lewin’s familiarity with Medicaid MCOs in other states and specialty health plans, were advantageous in attracting an additional MCO, WellPoint (UniCare), to the State.

Lewin has developed RFPs and managed procurements for other contractor types as well. In New Mexico, New York, and West Virginia, Lewin assisted in selecting and contracting with an enrollment broker and an external quality review organization. Lewin also assisted the Texas Medicaid program in the selection of a claims processor for the Medicaid FFS program. Lewin is currently working with the State of Missouri to develop an RFP for a contractor to oversee the state’s expanded Medicaid direct school-based services and administrative claiming program as well as developing tools for the state to utilize in proposal review.

Finally, Lewin has provided extensive procurement support to clients arranging health care delivery and administrative services for other populations, including state employees, general assistance recipients (e.g., California County Medical Services Program), and CHAMPUS (the Department of Defense’s TriCare program).

Subtask 3.2.1.3: Develop MCO contracts The Lewin Group has experience drafting entire contracts and contract amendments for fully- and partially-capitated Medicaid health plans, as well as other alternative arrangements (e.g., a consortium of community health centers, special needs plans). For the States of West Virginia, New Mexico, New York, and Texas, Lewin worked with State staff to prepare Medicaid managed care contracts, ensuring that contract language complied with federal regulations and guidelines and State requirements, and participated in discussions with CMS staff, incorporating their comments as needed.

For West Virginia, Lewin has assisted the Bureau in implementing and operating a full-risk managed care contracting program, including the operations of MHT’s contract negotiations. Lewin also assisted Delaware, New Mexico, and Texas with all aspects of contract negotiations, including meetings with health plan representatives and their legal counsel.

In the past, Lewin has assisted the Bureau in bringing the MCO contract into full compliance with federal regulations, and Lewin understands the future implications of health reform to continue to assist the Bureau. In addition, Lewin has strong relations with the MCOs and other MHT vendors, as well as the Philadelphia Regional Office of CMS, who is responsible for monitoring MHT, which will help the Bureau gain approval of contract changes and amendments.

Subtask 3.2.1.4: MCO contracting strategy Lewin’s experience with performance-based contracting will help the Bureau develop a strategy that meets the combined challenges of promoting a competitive managed care contracting system while simultaneously encouraging MCO performance improvements in key areas and supporting traditional Medicaid providers as important elements of West Virginia’s health care

#523964 RFP #MED11010 Managed Care Administration delivery system and safety net. As contracting strategies change over time, our team is prepared to work with the Bureau to understand current best practices in the field and to tailor these to West Virginia’s needs.

The Lewin Group has experience developing performance-based contracting strategies in numerous states, with particular focus on ensuring that the areas of focus are measurable and meaningful to both the state and the contractor. While it is often tempting to include all of the various types of behaviors or health system and status improvements in the incentive system, a long list of measures and goals can dilute the particular reward associated with any one of them. Lewin’s experience in Massachusetts and Florida focused on financial incentives tied to improving performance rather than merely meeting stated goals as a way of encouraging continuous progress and minimizing gaming of the system. In Connecticut, Lewin developed a system to reward health plans with auto-assignment for providing additional services. In Minnesota, we worked closely with State staff, its contractors, and the MCOs to develop a performance contracting system. We spent considerable time gathering best practices from other states and meeting with the MCOs and with state staff to develop a program tailored specifically for Minnesota.

In West Virginia, our detailed understanding of the Bureau’s goals and the current strengths and shortcomings of the MCOs’ performance in West Virginia, as well as the strong relationships we have developed with the MHT MCOs, are especially critical to the successful completion of this task. One of the most important components of the performance incentive system will be the MCOs’ confidence in the measurement system and how it will be applied. Lewin’s credibility with the MCOs, our reputation for analytic quality and objectivity in our work in West Virginia and elsewhere, and our collaborative approach are important strengths that we bring to this task.

Subtask 3.2.1.5: Provider networks analysis and monitoring We understand that provider networks are at the heart of a successful MCO program and have devoted substantial expertise to this effort in other states. The Lewin Group has developed network evaluation tools for numerous states that enroll TANF and SSI beneficiaries, including Connecticut, New Mexico, New York, Texas, and West Virginia. Our network adequacy model uses defined time and distance as well as provider composition access standards and ratios as the standard by which networks are judged. We use our model to ensure that access, measured by numbers of points of access, is improved; to comply with federal guidelines regarding equal or better access as compared with FFS Medicaid and waiver terms and conditions; and to give Medicaid enrollees choices of providers within networks. Lewin’s network adequacy models have been accepted by CMS to demonstrate that state Medicaid managed care programs meet or exceed the federal requirement that managed care enrollees be provided with access to providers that is equal or greater than FFS.

In addition to our experience with the network adequacy models described above, Lewin’s background in Medicaid managed care and significant experience developing managed care programs for various special needs populations provides us unique insights into the critical access requirements of Medicaid beneficiaries. Similarly, Lewin has developed and evaluated network criteria for CMS to include the Special Needs Plans (SNPs). We supplement our mapping and database analysis of provider networks—which generally focus on ratios and

#523964 RFP #MED11010 Managed Care Administration points of access within specific provider types—with a desk review of MCOs’ overall provider network capacity to ensure that important state goals, such as the inclusion of traditional Medicaid providers, are met.

The Lewin Group uses Microsoft’s MapPoint software to conduct mapping and geographic analyses for a variety of clients including state Medicaid agencies, hospital systems, MCOs, and public health agencies.

Task 3.2.2: Program Management and Improvement

The Bureau requires support in the ongoing management of the Mountain Health Trust program, its expansion, and continuous improvement. Major activities in this task include encounter data analysis and related reporting and development of options for program expansion. The Lewin Group has supported the Bureau for Medical Services for over 15 years in ongoing program management, including numerous program expansions and modifications. We have also consulted with numerous states on a variety of tasks related to program management and improvement, including providing day-to-day support for state agency staff, providing ongoing and ad hoc technical assistance, and assisting in program monitoring and evaluation activities. We have supported many state Medicaid managed care programs, including West Virginia, in identifying options for program changes, assisting in the selection and refinement of appropriate options, developing implementation plans, and assisting in the realization of selected program design options.

Subtask 3.2.2.1 Ongoing program management The Lewin Group has significant experience assisting states in the ongoing management of Medicaid managed care programs. Our most important engagement has been assisting the Bureau for Medical Services with the ongoing management of MHT. Since 1995, this engagement has included working closely with Bureau staff as well as representatives from other Department of Health and Human Resources (DHHR) agencies, the enrollment broker, the external quality review organization (EQRO), the encounter data analyst, the Medicaid fiscal intermediary, the Physicians Assured Access System, and other stakeholders in the MHT program.

For more than a decade, Lewin has helped design and implement large-scale health programs for Medicaid agencies in 16 additional states: Arizona, Connecticut, Delaware, the District of Columbia, Florida, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Montana, New Mexico, New York, Ohio, Oregon, and Texas. Many of these projects are of a long-term nature — for example, we worked for the State of West Virginia from 1995 to the present and the State of New York from 1999 to the present. We have also worked on multiple contracts across the years for Connecticut, New Mexico, Ohio, Maryland, Texas, and the District of Columbia. These and other long-term engagements generally began as shorter term contracts that were extended for multiple contract periods—a testament to our clients’ satisfaction with our work.

Lewin has also worked with numerous private sector entities to develop responses to state Medicaid managed care initiatives. This added experience gives us distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector

#523964 RFP #MED11010 Managed Care Administration managed care programs. Lewin’s multi-faceted expertise will be valuable as we assist the Bureau in furthering the development of its collaborative partnership with the State’s MCOs.

a. Subtasks 3.2.2.1.2 – 3.2.2.1.10: Encounter data analysis and related reporting Since 1995, Lewin has specialized in the development and application of analytic and operational processes to maximize the value of information obtainable from health care data. Lewin has over 15 years of experience gathering encounter and claims submissions from MCOs, reviewing them, and producing data reports; we also have expertise analyzing the data in order to develop provider profiles, legislative presentations, and other ad hoc analysis. As the MHT program continues to expand, it is crucial for the Bureau to make sure that health care services are being provided efficiently in order to minimize Medicaid expenditures and to ensure that members are receiving high quality care. Lewin’s understanding and experience with MHT’s major ongoing operational activities, including the development of performance monitoring reports, will help Lewin effectively assist MHT with program management and monitoring and ensure that regular operational activities are accomplished in a timely and satisfactory manner.

b. Subtask 3.2.2.11: Program expansion options Lewin has helped design and implement large-scale health programs for Medicaid agencies across the country. Our experience in states such as West Virginia, Oregon, Montana, Kansas, Kentucky, Maryland, Texas, and New Mexico has provided us with an understanding of the specific issues that rural states face in the expansion of Medicaid managed care systems. Lewin staff are very familiar with developing innovative methods for managed care arrangements to increase access and coordination of care in rural areas. The goal of these innovative arrangements is to take advantage of existing delivery systems and encourage cooperation between public and private health care provider organizations, who often feel at odds over such issues as access and finance.

Lewin designed and implemented full and partial-risk contracting models in numerous other states as well as for the Department of Defense. Our experience includes procuring Florida’s disease management contractors, New York’s special needs plans, Connecticut’s provider- sponsored partial-risk plans, and Maryland’s 1115 waiver MCOs, and developing actuarially- sound risk adjusters for high-risk populations, including Delaware’s Diamond State Cares initiative which includes seriously mentally ill, elderly, dually eligible, and institutionalized beneficiaries. Lewin has worked with several other states to implement SSI enrollment under federal 1115 waivers with stringent evaluation components, most notably Delaware, Maryland, and New York.

Task 3.2.3: Program Evaluation and Improvements

As the Mountain Health Trust program has expanded and matured, the need for increasingly sophisticated oversight and monitoring has grown, and this need will amplify with the planned program expansions in 2011. As such, the Bureau requires assistance in designing and implementing a Managed Care Improvement Plan (MCIP) that identifies program modifications through systematic, ongoing, and periodic program monitoring activities.

The Lewin Group has significant experience in many states with ongoing program monitoring activities and has conducted comprehensive program evaluations for several waiver programs

#523964 RFP #MED11010 Managed Care Administration that include plans for improvements. For example, Lewin has surveyed beneficiaries enrolled in several state Medicaid managed care programs and other specialized public health insurance programs in New York and used the findings to identify improvements and refinements for the respective programs, particularly in the areas of program oversight. Lewin has conducted multiple retrospective waiver evaluations for both 1915(b) and 1915(c) waivers and used the findings to help states identify ways to improve access, quality, and program monitoring.

Lewin has also worked with state agencies and blue-ribbon commissions on special projects to identify potential program modifications to help states accomplish new program goals (e.g., expanding prescription drug coverage to the elderly) or maintain coverage levels during budget difficulties. Lewin worked closely with the State of Rhode Island (RI) to analyze data and financial projections under the current program design and under the proposed Global Consumer Choice 1115 waiver application, which sought to transform RI Medicaid into a block grant program. Lewin has prepared cost and savings estimates for a wide variety of policy and operational proposals.

Subtask 3.2.3.1: Program improvement The Lewin Group has helped research and develop processes that have improved the efficiency and effectiveness of Medicaid services in states across the country. For West Virginia, Lewin has worked on a variety of engagements that include developing enrollment estimates for Medicaid eligibility changes and working with the West Virginia Health Care Authority to develop options to reduce the number of uninsured in West Virginia under a state planning grant from the Health Resources and Services Administration. In efforts to improve the delivery of health care, Lewin has supported the Bureau to identify areas for improvement using a systematic feedback approach, which includes “dashboard” reports. Through analysis of various program components (i.e., health outcomes, beneficiary satisfaction, quarterly reports, network access, CMS feedback, bi-annual beneficiary survey results), Lewin has detected areas for improvement. Lewin has also worked with the EQRO regarding performance monitoring. Lewin’s experience will continue to inform work with the Bureau in identifying and prioritizing program improvement opportunities and implementing the necessary program modifications.

Subtask 3.2.3.2: Program evaluation Lewin has analyzed utilization and cost data for multiple state Medicaid programs and a variety of public and private sector clients. For the last 15 years, Lewin has supported the Bureau in program evaluation efforts such as efficiency of health care delivery, costs, and quality of care. Lewin has accomplished these tasks through analysis of utilization and cost measures by demographics and program eligibility. Lewin has experience analyzing eligibility, cost, and utilization data to evaluate the performance of Medicaid managed care programs and other public sector health reforms.

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Task 3.2.4: Federal Regulatory Compliance

Successful operation of a Medicaid program requires in depth understanding of the detailed requirements in federal Medicaid law and regulation, including the provisions of the Affordable Care Act that will impact Medicaid. The Bureau for Medical Services requires support in maintaining compliance within the evolving environment of federal regulatory requirements. Lewin has assisted the Bureau for Medical Services (and numerous other states) since 1995 in working with the federal government to develop and implement program strategies, contracting mechanisms, and financing arrangements that comply with all applicable laws, policies, and guidance.

Our team is especially qualified to provide expertise, policy analysis, strategic guidance, and knowledge to West Virginia that is grounded in our many years of experience in Medicaid programs throughout the country. We provide up-to-date expertise on all current health care issues and are capable of quickly processing the implications of new policy changes and legislation. We have worked with states and the federal government to understand and respond to every major piece of federal legislation affecting the Medicaid and CHIP programs over the past 15 years, including the Balanced Budget Act of 1997 (BBA), Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Deficit Reduction Act of 2005 (DRA), American Recovery and Reinvestment Act of 2009 (ARRA), Children’s Health Insurance Program Reauthorization Act of 2009 The Lewin Group has demonstrated our understanding of the intricacies of federal (CHIPRA), and the ACA. We have in- legislation by providing analysis of national and depth knowledge of Medicaid and CHIP state-level estimates of the impact of the recently laws, regulation, and policies, a strong enacted Patient Protection and Affordable Care understanding of how states and the Act (ACA) and the Health Care and Education federal government relate to one another in Reconciliation Act (HCERA) utilizing the Health Benefits Simulation model (HSBM), a micro the Medicaid and CHIP context, and simulation model developed at Lewin. These familiarity with existing evaluations, state estimates, based on the final health reform bill, guidance materials including State analyzed four areas related to health reform Medicaid Director and State Health Officer coverage and insurance market reforms: 1) the letters, regulations, and other policy- number and demographic distribution of people in related documents. families who become covered by Medicaid or receive premium subsidies; 2) the number and demographic distribution of people in families Lewin has developed waivers for a number covered by firms that receive small business tax of states, including 1915(b), 1115, and credits; 3) the number of people in families that Health Insurance Flexibility and benefit from the out-of-pocket limits specified in Accountability (HIFA) waivers, and has the reform plan; and 4) the number of people worked with CMS to obtain approval for a potentially benefitting from guaranteed issue of number of innovative and unique program coverage and eliminating pre-existing condition exclusions. designs. Our strong working relationships with CMS staff in the central and regional offices benefits states that rely on our assistance to gain federal approval for state-sponsored initiatives.

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Subtask 3.2.4.1: Quality assessment and performance improvement strategy and implementation plan The Lewin Group has assisted many states, including California, Connecticut, Maryland, Montana, New Mexico, New York, Oregon, Texas, and West Virginia in developing Medicaid managed care quality oversight and improvement programs. In these states, Lewin worked with state and MCO staff, stakeholders, and CMS to develop quality and reporting requirements that met state needs for monitoring and oversight and complied with federal policies and regulations. In Connecticut, Montana, New York, and West Virginia, Lewin developed the initial standards for quality assurance programs and reviewed MCO quality plans. Lewin then developed options and recommendations for strategies to monitor and evaluate the care and services provided to enrollees, including specific monitoring tools and data reporting requirements. Lewin has also worked with health plans in many states, including Pennsylvania, and we are familiar with some of the innovative strategies used nationally.

Lewin has also helped states develop revised quality strategies to take into account changes in federal guidance (such as the introduction of CMS’s Quality Improvement Standards for Managed Care, which replaced the earlier Quality Assurance Review Initiative guidelines) and changes in state-of-the-art managed care oversight. For example, Lewin has helped states, including West Virginia, redefine performance standards to comply with Medicaid HEDIS® and redesign beneficiary surveys to become more comparable to the widely-adopted Consumer Assessment of Health Plans Survey (CAHPS) protocol. Additionally, Lewin helped Minnesota develop a performance incentive system for Medicaid MCOs.

Most important to this task, however, is Lewin’s strong understanding of program needs and the Bureau’s and MCOs’ capabilities, which will facilitate the development of this plan. Lewin drafted revised standards for internal quality assurance for Mountain Health Trust MCOs to comply with changes in federal regulations, presented the standards to the MCOs, worked with them to ensure that the final standards were reachable by the MCOs while continuing to meet the State’s expectations, and developed final standards that were included in the new MCO contract. We also conducted the independent evaluation of the program, which included a special focus on State oversight of the program and recommendations for improved program quality improvement. As part of its ongoing assistance with the operation of the Mountain Health Trust program, Lewin has continuously worked with the Bureau to ensure the program’s compliance with the final Medicaid managed care regulations. Lewin has also helped the Bureau prepare numerous documents for CMS, such as the State’s plan for ensuring quality and access for children with special health care needs (CSHCN) and the State’s Strategy for Assessing and Improving Managed Care Quality. Lewin’s strong experience with the MHT program and other states’ MCO programs provide a strong foundation to assist the Bureau in developing an innovative and flexible approach to a variety of quality initiatives and program changes.

Subtask 3.2.4.2: Program monitoring The Lewin Group has played a critical role in assisting states in post-implementation and contract monitoring activities. Our general goal during this period has been to determine whether significant changes are needed in the level or type of resources devoted to the various activities, the delegation of authority for decision making, the communications mechanisms

#523964 RFP #MED11010 Managed Care Administration between contractors, or other features of program management and operations. Specifically with respect to monitoring the performance of health plan contractors, Lewin has significant experience reviewing periodic implementation reports submitted by health plans and conducting post-implementation site visits, in addition to maintaining ongoing telephone contact with designated health plan representatives. Areas of emphasis have included provider contracting, marketing, enrollment issues, ongoing network adequacy, and changes in utilization management and quality review procedures necessary to comply with the requirements of the new program.

The Lewin Group has extensive experience in developing, administering, and reporting findings of program monitoring protocols. For example, in West Virginia and Connecticut, Lewin conducted audits of managed care providers’ compliance with appointment scheduling timeframes and after-hours coverage requirements. Lewin designed and fielded large-scale enrollee surveys designed to assess satisfaction and access to care of both mainstream and special needs Medicaid enrollees in West Virginia, Connecticut, and New York. In developing these surveys, Lewin worked closely with state staff to identify specific survey objectives and design focused surveys. Lewin also conducted comprehensive retrospective evaluations of quality, access, and cost-effectiveness for the West Virginia, Texas, and Connecticut Medicaid managed care programs. Furthermore, Lewin has developed a program monitoring strategy for the MHT program that includes dashboards that provide clear, timely communication and analyses so that the Bureau can meet its management, oversight, and reporting responsibilities.

Many states also have been required, through the terms and conditions of their waiver approvals, to monitor and report to CMS on specific aspects of program performance. For New York, Lewin assisted in the administration of linguistically-appropriate enrollee focus groups related to outreach and enrollment. In addition, Lewin assisted New York in preparing and submitting reports to CMS to demonstrate compliance with waiver terms and conditions. Lewin redesigned certain aspects of West Virginia’s quarterly MCO reports to gather information on complaints and grievances filed by or on behalf of CSHCN and assisted the Bureau in compiling the annual statistical report on these grievances as required by the terms and conditions of the previous waiver.

The current CMS 1915(b) waiver application requires states to actively monitor program performance in a variety of areas and report on the results of the monitoring activities in the next waiver application. As part of a prior waiver renewal process for West Virginia, Lewin reviewed the requirements of the revised 1915(b) waiver application, identified all of the areas that the State is required to monitor, and determined how the State and its vendors were fulfilling them. Lewin has assisted the Bureau in these monitoring activities by reviewing MCO reports, annual EQRO studies, periodic encounter data reports, and monthly enrollment broker reports on an ongoing basis. For the most recent waiver renewal process, we prepared a summary of all monitoring activities and results from the previous waiver period, as well as a cost effectiveness analysis, and drafted the State's renewal in accordance with the current CMS template. We have also prepared a plan for West Virginia’s compliance with the terms and conditions of the most recent waiver approval from CMS.

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Subtask 3.2.4.3 Waiver and state plan preparation The Lewin Group has developed waivers or portions of them (e.g., prospective and retrospective cost effectiveness analyses) for several states in addition to West Virginia, including Connecticut, Delaware, District of Columbia, Florida, Iowa, Kansas, Louisiana, Massachusetts, Montana, New York, New Mexico, and Texas. Lewin’s staff are knowledgeable about ongoing CMS developments in the waiver submission process, including the combined 1915(b) waiver form and requirements, and are able to quickly and efficiently draft waivers that meet federal requirements and minimize the degree of back-and-forth needed in the federal approval process. Lewin has also prepared applications to modify existing waivers. For example, in West Virginia, Lewin prepared a waiver amendment to allow the State to mandate enrollment in counties with only one MCO (the “Options” program) and also prepared an amendment to implement the single-plan rural option allowed under the final Medicaid managed care regulation, which has since been approved.

While Lewin has not yet had the opportunity to assist a State in developing a state plan amendment—due to the relatively recent introduction of this option for states developing Medicaid managed care programs—Lewin has worked with many states to design and gain approval for innovative, not-yet-tested approaches toward health care delivery. Lewin prepared the waiver application for the State of Oregon’s groundbreaking demonstration program to use savings from managed care to expand Medicaid coverage to uninsured persons. Lewin assisted New Mexico with the development of a waiver to cover uninsured adults under the HIFA waiver option, and assisted West Virginia with its uninsured reform efforts.

Our waiver development work has included participating in negotiations with CMS and the Office of Management and Budget (OMB) to secure waiver approval. We have worked for several years with staff from the CMS Philadelphia Region III office as part of engagements for West Virginia, Delaware, Maryland, and the District of Columbia. Our prior experience with the Bureau for Medical Services and with other states has yielded positive feedback from both CMS and OMB.

With the impeding changes brought forth by the ACA and other state or federal requirements (e.g., quality measurement, program integrity, data reporting), Lewin is prepared to provide West Virginia with strategic support in the preparation of the renewal waiver applications and any state plan amendment. We are uniquely qualified to perform this task for the Bureau given our experience developing the initial and four subsequent waivers for Mountain Health Trust as well as our work with 1915(b) and 1115 waivers in other states.

Task 3.2.5: Additional Services

Over the next several years, it is likely that the Bureau will require assistance with a variety of ad hoc analyses, impact studies, oversight requests, and implementation tasks. For example, many of the potential impacts of the ACA are unknown at this time but are likely to have significant impacts on state Medicaid program administration. The Bureau requires a vendor with a strong understanding of both the State’s current environment and potential capacity as well as the implications of health reform in order to conduct necessary data and policy analyses, study the potential implications for the State and for MHT, and help develop and implement appropriate responses.

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The Lewin Group has extensive experience in research and evaluation tasks, and on-demand and as needed requests, for both state Medicaid agencies and a wide variety of public and private sector entities. Our experience is broad and extensive, including experience in analyzing a variety of eligibility, cost, utilization, and programmatic data for the purpose of designing, implementing, and evaluating Medicaid managed care programs and other public sector health reforms. Through our past projects, Lewin is able to leverage best practices from around the country to benefit the MHT program, including our experience with actuarial analysis, development and implementation of risk-sharing methodologies, financial projections, analysis of the impact on future funding streams, and micro-simulation of different health care reform initiatives. Lewin has expertise spanning all aspects of health care reform and policy, health care financing, and health care delivery systems.

Subtask 3.2.5.1 – 3.2.5.4: Data analysis With recently enacted legislation including the ACA, ARRA, and CHIPRA, there is great need for analysis of statistical and program data in order to project the impact of potential policies and programs and understand the effectiveness of specific legislative, regulatory, or policy changes on beneficiary enrollment policies, program retention rates, and quality of care. For example, the recently enacted health reform legislation includes a number of opportunities for states and providers to fundamentally change the way that health care is provided and paid for through publicly-funded health care programs, including a Medicaid Global Payments Demonstration, a Bundled Payment Demonstration, and a new Medicaid State Plan option that allows states to make payments to Health Homes for enrollees with chronic conditions.

Program data analysis is also necessary to determine whether these programs are advancing the State’s goals of assuring access to high-quality efficient health care for Medicaid beneficiaries and controlling costs. This may include analysis of provider network data and comparison across MCOs and to FFS as well as encounter data analysis to support innovations in delivery, coordination, and payment for chronic care/disease management services. The Bureau may also find value in comparisons of services provided across subsets of Medicaid enrollees and across programs.

Through our Medicaid capitation rate-setting and cost-effectiveness evaluation work in 12 states, The Lewin Group has extensive experience with Medicaid fee-for-service claims data and managed care encounter data. In addition, Lewin has developed a number of nationally recognized economic models and data analysis tools, putting Lewin at the forefront of health reform modeling.

Lewin has conducted numerous data analyses to identify areas for performance improvement. Lewin has analyzed utilization data to measure outcomes in state Medicaid managed care programs, such as our work in Minnesota, and other demonstration programs, such as a CMS demonstration to improve care for persons with end-stage renal disease. Lewin has developed data analyses for performance incentive development projects, federal reporting requirements, and internal program monitoring and improvement projects.

Lewin will work closely with Michael Madalena to provide these analyses as requested by State staff. Both Lewin and its consultants have extensive experience with operational systems, including claims processing, utilization management, and eligibility. The Lewin team is skilled

#523964 RFP #MED11010 Managed Care Administration in the processing and analysis of health care data and has developed several databases and applications. These applications range from quality and financial reporting to simulation models that predict selection bias.

Subtask 3.2.5.5: Policy research The Lewin Group is well equipped to conduct policy research to identify promising approaches in a range of areas of interest to the Bureau, create recommendations, and provide technical assistance, including developing relevant tools and guidance, to help BMS adopt and implement recommended approaches. Through Lewin’s work in knowledge transfer, comparative effectiveness research for public and private sector clients, and policy consulting for state governments, foundations, and associations, we have extensive experience evaluating various program options, surfacing best practices, and translating findings into actionable recommendations.

The Lewin Group has expertise spanning all aspects of health care reform and policy, health care financing and health care delivery systems. Our public and private sector clients include federal, state, and local agencies, hospitals, health systems, MCOs, insurers, and physicians. We have conducted significant research into all major public health programs, including the Title V/CSHCN program, maternal and child health programs, the Children's Health Insurance “Complete professionalism and responsiveness to the consumer’s needs. Program, Medicaid, Medicare, Effective communication, attention to DoD/CHAMPUS, primary health care detail and quality producers of programs, and programs to care for the deliverables.” uninsured. Lewin has published leading State Benefit, Employment and Support research in all of the areas identified in this RFP, Services Division Staff including chronic care/disease management, pharmacy, eligibility and coverage, quality improvement, rural health delivery, and provider access, as well as a broad range of other health-related issues.

Lewin has extensive experience working with public and private sector clients, including state agencies, blue ribbon commissions, and state legislatures. For the federal Agency for Healthcare Research and Quality (AHRQ), Lewin led a learning network of 17 State Medicaid disease management and care management programs. Through the learning network, Lewin compiled State experiences with Medicaid care coordination (encompassing disease management and other care management initiatives), and worked with the States to improve and evaluate their programs. In addition, Lewin has researched the trends and key components of successful disease management programs and assisted in the design of Medicaid disease management program for enrollees with asthma, diabetes mellitus, and HIV/AIDS. Lewin projects in West Virginia, Idaho, and for the Center for Health Care Strategies focused on researching and presenting findings related to Medicaid pharmacy benefits and pharmacy expenditures, using both quantitative and qualitative research methods. Lewin assessed the impact of modifying Medicaid eligibility and coverage standards in West Virginia, California, Idaho, Washington, and North Carolina, of all which are affected, at least in part, by rural health care delivery issues. Each state study took into account that state’s unique features, including programmatic goals, delivery systems, health care needs of eligible populations, and historical program costs. After health reform is fully implemented, the Bureau can expect significant programmatic changes as well as a sizeable influx of new beneficiaries. With a strong understanding of

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ARRA’s policy and implication on the MHT program, Lewin is prepared to assist the Bureau in refining its strategy for MCO contracting.

Lewin’s detailed understanding of MHT and the health care delivery issues affecting West Virginia and its citizens make Lewin particularly capable of carefully focusing its research to answer the questions most pertinent to West Virginia and to develop recommendations that are politically and operationally feasible.

Subtask 3.2.5.6-8: Policy impact analyses and support Policy impact analysis is essential to identifying gaps or best practices in current policies, evaluating the costs and benefits of various policy options, and estimating the effectiveness of existing programs, including determining where existing policies fall short of policy goals, identifying new approaches, and estimating the potential effects of proposed changes. Policy impact analysis involves consideration of the advantages and disadvantages of different approaches supported by research and data analysis findings. Lewin is able to identify a range of policy options, estimate the cost implications for the Bureau to consider, and translate these into implementation and operational strategies that might ultimately be implemented. Depending on the goals and requirements of a specific request by BMS, Lewin can draw upon a wide range of data collection and analytic methods.

The Lewin Group has unparalleled experience and expertise in analyzing policies and regulations and assessing their impact. Lewin’s staff is well-versed in a wide range of policy issues and provides the Bureau with a wealth of knowledge in state and federal health policy, coupled with our long-standing experience with West Virginia’s health care financing mechanisms and delivery system. We have monitored changes in state and local laws and regulations related to the health care system, the shift in responsibilities from the public to the private sector, and the devolution of responsibilities from the federal to the state and local levels. The Lewin Group objectively analyzes the impact of policy decisions using rigorous quantitative analysis and broad knowledge of macro and micro health care issues. We have worked with clients at all levels of the public and private sector, conducting analyses and evaluations of Medicaid and other public programs.

Lewin staff have prepared documents and memoranda on many topics, including: federal requirements related to geographic and provider expansion of existing state programs; CMS guidance on marketing and enrollment procedures; mandatory enrollment and lock-in; contracting with alternative managed care models, such as health insuring organizations, partially-capitated plans, preferred provider organizations, and community-based models; procedures for obtaining necessary waivers; guaranteed eligibility; quality assurance and utilization management; and the role of Federally-Qualified Health Centers (FQHC) and family planning providers.

Lewin has worked with numerous public and private entities to build collaborative partnerships to develop distinct local plans designed to ensure the proper balance between quality, cost, access, resources, and local needs. Many of our projects have involved meeting with advisory groups, providers, consumer advocacy groups, legislators, and the public to solicit feedback. Lewin staff have presented at these meetings, responded to questions, and reflected feedback in proposed program designs. Our public consensus work does not take the

#523964 RFP #MED11010 Managed Care Administration form of public relations or lobbying, but rather involves intense work to solicit public opinion, involve stakeholders in a meaningful fashion, forge community consensus, and support decision-making by public officials.

Lewin’s experience assisting states in implementing new policy options, including preparing work plans, developing contractor specifications, producing detailed actuarial and related analyses, conducting initial and ongoing program monitoring, and developing necessary evaluations for state or federal reporting has been described in detail in other parts of this section of the proposal.

Lewin has prepared detailed analyses for the Bureau on a wide variety of topics. Our understanding of the political environment in West Virginia, in addition to our relevant experience in other states, uniquely qualifies Lewin to continue to conduct policy analysis in West Virginia.

Lewin has assisted numerous states in estimating the impacts of changes in reimbursement structure, including changes to existing payment systems and the introduction of new payment methods such as pay for performance and bundled payments. Lewin worked with the Kentucky Hospital Association to assess the Medicare-type DRG system recently implemented by the Medicaid Department and compare the adequacy of the Medicaid payment rates for Kentucky hospitals relative to payment levels in neighboring states. Lewin evaluated the equity of payment rates across hospitals in the state under the new Medicaid DRG system and recommended modifications to the payment system to make the payment system more equitable across the states’ hospitals. Additionally, Lewin has worked with the New York State Health Foundation to develop a roadmap to cost containment for New York with practical approaches to reducing health care costs, including scenarios involving the promotion of accountable care organizations (ACO) and medical homes, hospital pay for performance, bundled payments for episodes of care, and rebalancing of long-term care.

Lewin also has experience in addressing and planning for state and federal changes in law, rules, and regulations. For the New York State Health Foundation, Lewin helped address opportunities for containing health care costs throughout the New York State health care system. The goal of the engagement was to identify up to 10 specific cost containment scenarios that could be modeled by Lewin to determine the potential for future cost containment and health care system improvement. The project was modeled after the highly successful “Bending the Curve” national analysis conducted by Lewin and The Commonwealth Fund and was the first-of-its kind state-level endeavor.

To support the Bureau’s continued compliance with the evolving state and federal regulations, Lewin will provide additional services as needed and identified by the Bureau. Lewin’s staff can capably address an enormous range of issues that might arise throughout the engagement. Our states and payers practice group has approximately 30 professional consultants – throughout the past decade roughly half of this group’s consulting work has involved direct engagements with State Medicaid agencies. We have vast experience working with states to evaluate, develop, and strengthen Medicaid coverage and programmatic initiatives. We are privileged and excited to help Medicaid cover as many needed persons as possible, and have an equally strong interest in extending any level of available Medicaid dollars to provide as much benefit as possible.

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Quality Management System: ISO 9001:2008

Lewin’s proven ability to satisfy a broad range of clients depends on our ability to ensure rigorous quality control. Our approach to quality control is driven by two concerns: 1) knowing exactly what the client wants; and 2) assuring that we provide it. The table below reflects the mechanisms that the Lewin team puts in place to assure quality control.

Key Elements of The Lewin Team’s Quality Assurance Strategy . Regularly scheduled conference calls and on-site meetings with the Project Officer Know . Documentation of discussions of meetings and deliverables what's . Project staff and consultants experienced with complying with agency and other expected government regulations . Use of project management software to track task progress and expenditures . Well trained, high quality staff . Clearly defined project structure with oversight of all tasks by Project Director and Project Manager Provide . All deliverables reviewed/approved by Project Director or Project Manager what's . Review/approval by PO of all materials, especially those shared externally expected . Adherence to Lewin’s quality management system procedures and monitoring practices . Regularly scheduled reviews of deliverables for quality and timeliness by Lewin senior leadership

The Lewin Group is certified to the ISO 9001:2008 standard for quality management systems (QMS). We sought ISO certification to ensure that Lewin consistently uses the strong quality procedures and systems in place to provide products of high quality, on time, and on budget. Lewin’s QMS includes a number of activities that senior project managers are required to perform to ensure the timely and successful performance of multiple simultaneous project tasks (Figure 2).

Requirement QMS Activity . Review proposal, final client contract and other relevant documents to identify client requirements Management . Develop detailed project work plan control . Convene regularly scheduled top management meetings to review QMS records and metrics to assess effectiveness of QMS processes and identify opportunities for continuous improvement . Perform regular review of project activities against project work plan − task progress − budget − deliverable schedule Management . Revise work plan or contract, as appropriate oversight . Review and approve deliverables: − meets acceptance criteria − accurate and concise . Release to client

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Requirement QMS Activity . Client satisfaction survey Meeting − Annually, if period of performance is longer than 12 months client − At project close expectations . Client feedback sought outside the survey process is a standard practice in meetings, during calls and through e-mail correspondence throughout the life of the project

As we have demonstrated throughout this section, The Lewin Group is the market leader in the field of Medicaid managed care consulting, and the consultant with the most extensive experience with the Mountain Health Trust program, having worked with it continuously and extensively since its inception. Furthermore, our national experience includes Medicaid managed care project work in more than half the states in the nation. We look forward to the opportunity to continue our work with Bureau staff on the Mountain Health Trust program.

References

West Virginia Department of Health and Human Resources, Bureau for Medical Services Medicaid Managed Care Program Development and Support (1995-Present) Point of Contact: Brandy Pierce, Director of Managed Care and Procurement Services, Office of Medicaid Managed Care Phone: (304) 558-1706

Email: [email protected] Address: 350 Capitol Street, Room 251, Charleston, WV 25301-3708 The Lewin Group is assisting the West Virginia Bureau for Medical Services with the ongoing operation and expansion of its Medicaid managed care program, Mountain Health Trust. Lewin is working with the Director of Managed Care and Procurement Services to ensure that regular program activities are accomplished in a timely and satisfactory manner. Lewin develops managed care capitation rates for participating MCOs for each annual rate period and updates the MCO contract each year. Lewin also assists with preparation of the 1915(b) waiver renewal application and supports Bureau staff in responding to written questions from CMS. In addition, Lewin assists the Bureau in its efforts to expand the managed care program to include SSI beneficiaries and behavioral health and children’s dental services, including designing a detailed implementation strategy, evaluating MCO readiness, coordinating with CMS, and responding to stakeholder concerns. Other tasks include assessing and evaluating network adequacy, monitoring MCO performance, surveying beneficiaries, preparing quarterly “dashboard” performance monitoring reports, reviewing MCO marketing materials, and coordinating with other vendors to administer the Mountain Health Trust program. The Lewin Group has assisted the Bureau for Medical Services in the development and implementation of the Mountain Health Trust program since the program’s inception in 1995.

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California Department of Health Care Services California HITECH Strategy and Planning (2009-2010) Point of Contact: Toby Douglas, Chief Deputy Director for Health Care Programs Phone: 916-440-7400 Email: [email protected] Address: PO Box 997413, MS4711, Sacramento, CA 95899 The Lewin Group led a team to develop a strategy and implementation plan for Medicaid electronic health record (EHR) incentive program payments to providers in the State of California. Lewin conducted an environmental scan of Medi-Cal providers, a provider and vendor analysis on the current penetration of EHR use, and interviews with a sample of providers. We developed a proposed staffing structure and job descriptions for DHCS oversight of the program as well as a detailed strategic plan for the Incentive Program with discrete performance targets. The team also developed a Campaign Plan to reach providers who will implement EHRs and Medi-Cal beneficiaries and defined key components of an operational implementation plan with recommendations on technical assistance to facilitate provider adoption.

Missouri Department of Social Services Missouri Medicaid Review (2009-2010) Point of Contact: Ian McCaslin, Division Director Phone: 573-751-6922 Email: [email protected] Address: 221 W. HIgh Street, P.O. Box 1527, Jefferson City, MO 65102 For the State of Missouri, Lewin conducted a comprehensive review of the Medicaid program with recommendations on how the State can achieve short-term Medicaid savings, providing detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. Lewin developed a series of reports as well as supporting materials, and Lewin’s analyses were used by State policymakers to craft the state fiscal year 2011 budget as well as guide decisions about future Medicaid program design and operations. Specific areas of analysis included short-term cost containment opportunities, long-term care, pharmacy, care management, non-emergency medical transportation, and overall program financing and operations. Our final report provided a series of recommendations regarding the structure and operation of the program, performance metrics to guide program management, and proposed approaches and priorities for enhancing the quality and efficiency of care to advance value-based purchasing and care coordination.

#523964 RFP #MED11010 Managed Care Administration

Colorado Department of Health Care Policy and Financing Colorado Medicaid and CHP HMO Rate Setting (2008 and 2010) Point of Contact: Jed Ziegenhagen, Rates and Analysis Division Director Phone: 303-866-3200 Email: [email protected] Address: 1570 Grant Street Denver, CO 80203 The Lewin Group is assisting Colorado with their rate setting for Medicaid programs enrolled in managed care. Working with the Department of Healthcare Policy and Finance, The Lewin Group has conducted the following activities: reviewing programming logic for data collection and summarization, calculating and establishing trend rates, reviewing calculation of risk adjustment which was used for trend calculation and rate adjustment (for HMOs only), modeling the rate setting process in compliance with CMS rate setting guidelines, discussing assumptions and results with participating HMOs and establishing capitation rates and actuarial certification for the program. The Lewin group is setting rates for four programs, HMOs, Behavioral Health, CHP+, and PACE.

#523964 RFP #MED11010 Managed Care Administration

Project Approach and Solution (4.1.8)

Statement of Understanding

The Department of Health and Human Resources – Bureau for Medical Services (BMS or the Bureau) implemented a full-risk managed care contracting program in 1996 and there are now over 165,000 beneficiaries enrolled in managed care organizations (MCO) in nearly every county in West Virginia. The State’s primary care case management program, the Physician Assured Access System (PAAS), was joined with the full-risk capitated program under one combined 1915(b) waiver in 2004. The programs are now collectively known as Mountain Health Trust (MHT) and together serve over 180,000 West Virginia beneficiaries.

The Mountain Health Trust program still has more to do, both to build on past successes and to manage emerging challenges to positively affect the program in the future. The Lewin Group has supported the Bureau with the development, implementation, and operation of the program since its inception and looks forward to the opportunity to continue to work with West Virginia as it moves closer to the goal of having a statewide, comprehensive managed care program. Opportunities and challenges now facing the State include the following:

 Ensuring that the State is purchasing the best value service for the best price. Given the changes that are in development (e.g., enrollment of 55,000 Supplemental Security Income (SSI) beneficiaries in 2011, addition of behavioral health services and children’s dental services to the capitated benefit package), and potential for significant numbers of new beneficiaries (largely adults) following implementation of health reform, the Bureau must refine its strategy for MCO contracting. The Bureau can take advantage of the maturity of the program and resulting opportunities for performance-based contracting to develop a strategy that meets the combined challenges of: o Promoting a competitive managed care contracting system; o Encouraging MCO performance improvements in key areas; and o Supporting traditional Medicaid providers as important elements of West Virginia’s health care delivery system and safety net. As part of this strategy, the Bureau may want to consider implementing risk adjustment and/or pay-for-performance strategies to ensure sufficient payment to maintain MCO participation while still inducing MCOs and providers to manage care efficiently without compromising quality. The State could also consider contracting directly with Accountable Care Organizations that may form in the state in response to Medicare directives under health reform. The chosen vendor must be experienced in the development and implementation of sophisticated payment methodologies and be able to assist the Bureau in developing performance targets, incentives, and penalties for MCOs that are tailored to West Virginia’s specific needs.

 Successfully completing the implementation of major program changes during 2011 and effectively monitoring the expanded program. To complete the roll-out of the SSI expansion and inclusion of behavioral health and children’s dental services into the MHT benefit package, the Bureau must complete a variety of implementation, readiness, and operational activities. To oversee the expanded MHT program with more complex

#523964 RFP #MED11010 Managed Care Administration

populations and benefits, the Bureau requires increasingly sophisticated oversight and monitoring capabilities, including a comprehensive Managed Care Improvement Plan that supports the identification of program improvement opportunities through systematic, ongoing, and periodic program monitoring activities. At the same time, the West Virginia Health Improvement Institute (WVHII) has taken on a key role in working with stakeholders to determine what the behavioral health integration model should look like. It will be important for the Bureau to continue to participate in WVHII workgroups to support transparent dialogue in identifying opportunities for collaboration and continuously soliciting input and feedback throughout the planning, implementation, and post-implementation processes. BMS requires a vendor that knows the State, the Bureau, the program, and various stakeholders and can bring knowledge of best practices in other states in order to: o Assist with implementation and monitoring of a comprehensive Medicaid managed care program, with particular focus on oversight during the immediate post- implementation period; o Be able to rapidly identify and respond to emerging issues, develop program monitoring strategies that minimize burden on the MCOs, while providing clear, timely communications and analyses (such as a “network dashboard”) so that the Bureau can meet its management, oversight, and reporting responsibilities; and o Provide recommendations for ongoing quality assurance and program improvement that are commensurate with the overall approach to administering and enhancing the program and meet the requirements set forth in federal regulations.  Preparing for federal health reform implementation. The recently-passed health reform legislation will greatly expand the number of people who are eligible for Medicaid coverage. The Lewin Group estimates that between 2014 and 2016, an additional 150,000 persons will become eligible for Medicaid in West Virginia, primarily parents and childless adults, and the Bureau will need to be prepared for this expansion of Medicaid and the managed care program. Issues to consider will include current MCO capacity, provider coverage in rural areas, the potential for new MCOs to enter the state market, and the timelines and cost implications of managed care program expansion. The Bureau will also require support in strategically addressing the potential impact of the Affordable Care Act (ACA) and other state or federal requirements as they arise (e.g., quality measurement, program integrity, data reporting). BMS will also need to work with the health benefit exchange to facilitate transitions between subsidy programs and Medicaid. The Bureau requires a vendor with a strong understanding of both the State’s current environment and potential capacity as well as the implications of health reform in order to help develop expansion strategies, examine options for program expansion in detail, study the potential implications for the State and for MHT, and help with the implementation of program expansion.

 Continuing to operate the program. While the program continues to expand, the Bureau must still efficiently and effectively administer and manage the MHT program in compliance with all state and federal regulations, and do so in an environment of

#523964 RFP #MED11010 Managed Care Administration

constrained budgets and competing staff responsibilities. Major ongoing operational activities include procurement, rate setting, contract negotiation, management, and ongoing monitoring of program vendors and performance, including monitoring of both MCOs and physicians providing primary care case management services through PAAS. BMS requires a vendor that is intimately familiar with the MHT program and can effectively assist with program management and monitoring and ensure that regular operational activities are accomplished in a timely and satisfactory manner without requiring a ramp-up period. The vendor must also bring knowledge of other states’ practices and the technical skills to adapt to the changing environment. The vendor must also have the staffing flexibility to provide increased support to Bureau staff as program needs dictate. The Lewin Group is ideally and uniquely equipped to assist the Bureau for Medical Services in responding to all of these challenges and opportunities:

 As the incumbent contractor, we have a strong working relationship with the Bureau and deep knowledge of the program. We also have effective working relationships with other entities that regulate and operate the program, including CMS, the MCOs, and other MHT vendors.  We bring to bear knowledge and experience from many other successful state Medicaid managed care programs and non-risk care management programs, and can leverage best practices from around the country to benefit the MHT program.  Our staff’s rate-setting expertise in West Virginia and experience in over 30 other states provides the basis for designing and securing approval of more sophisticated payment arrangements, including risk adjustment and pay-for-performance.  Lewin is at the forefront of health reform implementation efforts and can provide timely and credible support to the State as it prepares for a major program expansion in 2014.  Our team is personally committed to the success of West Virginia’s Mountain Health Trust program. Lisa Chimento, Lewin’s chief executive, has supported MHT since its inception and has provided numerous hours of support herself during 2010. Several additional project members have assisted MHT for more than a decade. Collectively, our team has provided more than 6,000 hours of support to the Bureau in 2010.

Finally, The Lewin Group has many innovative ideas to assist the Bureau and a flexible approach that allows us to support the Bureau with a variety of initiatives and program changes, as discussed further in our approach to the Scope of Work below.

#523964 RFP #MED11010 Managed Care Administration

Scope of Work: Yearly Operations Plan (3.2.1)

The Lewin Group is ideally suited to assist the State with all of the yearly operations listed in the RFP including Medicaid rate setting, health plan operations, and state administration of Medicaid managed care programs. The overall goal of Task 3.2.1 is to support the Bureau in the management and implementation of Medicaid services in compliance with all state and federal regulations. The result of this task will be a robust yearly Operations Plan that will enable the Bureau to efficiently and effectively administer and manage the Medicaid program from one year to the next. Key components of this task will include those related to procurement, rate setting, contract negotiation, management, and ongoing monitoring of program vendors’ performance. Lewin has repeatedly demonstrated our expertise in all of these areas with our clients, especially with West Virginia.

We bring breadth and depth of experience and knowledge of the Bureau and the Centers for Medicare and Medicaid Services (CMS) to support successful management and program operations, which is of particular importance given the implications of both health reform and the planned 2011 program expansion. Our team has deep experience with Medicaid managed care and associated payment models. Lewin has helped to design, implement, operate, and evaluate capitated Medicaid programs in more than 20 states. These projects have encompassed many Medicaid eligibility subgroups. We have assisted multiple states with programmatic issues targeted to specific subgroups, including:

 Connecticut, New Mexico, and West Virginia for the TANF population;  Rhode Island, Delaware, California, New York, and Texas for adults with special needs;  District of Columbia and California for children with special health care needs; and  New York for persons infected with HIV and persons with mental illness.

Most of our Medicaid managed care work has focused on a comprehensive capitated benefits package, although we have assisted states with specific initiatives such as pharmacy and mental health carve-outs. We also have experience evaluating a range of payment mechanisms including a “pay for performance” withhold/bonus system for Minnesota, incentives for utilizing select provider groups in West Virginia, and others. When California was considering expanding mandatory managed care for people with disabilities and chronic illnesses, we helped develop purchasing specifications and performance measures, recommended strategies for monitoring contract compliance, and developed a tool to assess the readiness of MCOs to serve a large influx of new beneficiaries with disabilities and chronic illnesses.

The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the Operations Plan. We will update this plan as needed throughout the course of the project.

#523964 RFP #MED11010 Managed Care Administration

Figure 2. Task 3.2.1 Work Plan and Timetable for 2011-2015

The details of our proposed Operations Plan, including specific detail on each subtask, are outlined below.

Development of annual capitation rates (3.2.1.1)

The objective of this task is to develop and implement yearly Medicaid capitation payment rates that are actuarially sound and ensure the viability and cost efficiencies of the Mountain Health Trust (MHT) and Mountain Health Choices (MHC) managed care programs for the State. Lewin is ideally suited to perform this task; we have broad experience from working with numerous states on Medicaid managed care engagements, including 15 years of West Virginia specific experience. Lewin develops capitation rates in an actuarially sound manner which provides sufficient payment to maintain MCO participation while still providing a payment structure that induces the MCOs and providers to operate efficiently without compromising quality.

For West Virginia, The Lewin Group will derive capitation rates based on the most recent, complete MCO encounter and financial data for the Temporary Assistance for Needy Families (TANF) population and use the most recent fee-for-service Last year, when CMS issued a (FFS) claims data for the Supplemental Security Income (SSI) final rule limiting the mandatory population. The most recent FFS claims will also be used to enrollment of TANF 1931 parents estimate the cost for behavioral health and children’s dental and caretaker/relatives into services to support the MCO expansion for these services in benchmark benefits plans, Lewin the upcoming fiscal year. Once the SSI, behavioral health, worked closely with the Bureau to and children’s dental expansions are fully implemented and identify options preserve the Mountain Health Choices the MCOs build sufficient claims experience with these program and assisted in the benefits and populations, we will incorporate the MCOs’ development of the State’s encounter and financial data into the rate setting process. We current strategy. Within a short may consider adopting more innovative rate setting amount of time, Lewin revised the techniques as the MHT program evolves; we discuss some of State’s 1915(b) waiver submission to comply with the these innovative options below. The capitation rates and new regulations and revised the associated method will be certified by project member Tom SFY 2011 capitation rates to Carlson, who is a credentialed Member of the American reflect the new approach for Academy of Actuaries, as being actuarially sound and enrolling this population. meeting all of the federal requirements and guidelines. The rate setting documentation will be developed in a form that meets CMS requirements, and Lewin staff will be available to assist the Bureau in responding to any CMS questions regarding the rates or certification.

#523964 RFP #MED11010 Managed Care Administration

Lewin is intimately familiar with West Virginia’s MHT and MHC programs and our long- standing experience and history with MHT, the State’s data, and our relationships with staff from both the State and other contractors will allow us to perform capitation rate development quickly and efficiently with no ramp-up time needed. Our experience and personal relationships allow us to work effectively with State staff, which greatly reduces the amount of time that State staff must invest in this work to achieve high quality results. Our historical knowledge of the MHT and MHC programs, covered populations, and benefits often allows us to bolster the knowledge of state staff who do not have the same tenure that Lewin has with the program. Our understanding of the State’s eligibility and FFS claims data and MCOs’ encounter data allows us to make accurate adjustments to the capitation rates to reflect programmatic changes.

In addition to our vast experience with West Virginia’s current program, Lewin has extensive Medicaid experience with other states and health plans, which make us the best choice to guide the Bureau through future programmatic changes. With the passage of health care reform under the Affordable Care Act (ACA), states will have to deal with the expansion of the Medicaid program to populations for Our nationally recognized health whom the state has little experience in providing services. reform modeling experts, John Lewin is the market leader in performing actuarial and Sheils and Randy Haught, will micro-simulation analyses of the cost and coverage impacts play a critical role in helping to determine the impact of health of program expansion and health reform proposals. Our reform on West Virginia. Initial national health care model is considered the “gold standard” Lewin estimates anticipate as for estimating the effects of health care policy, and we have many as 150,000 new West recently developed national and state-level estimates Virginia Medicaid beneficiaries regarding the number and demographic distribution of by 2014. Our health reform experts will assist the rate members who will become covered by Medicaid under the setting team with determining ACA. We will leverage Lewin’s considerable experience in the health care needs of this modeling the impacts of health reform to develop estimates population and quantifying the of the size and costs of the Medicaid expansion population impacts of these additional that will need to be factored into the capitation rate beneficiaries to ensure that the calculations for 2014, when much of the expansion will take State’s capitation rates are adjusted accordingly. effect.

With the SSI population now included in MHT, there are some new considerations that must be addressed in the rate setting process. The SSI population is generally less healthy than the existing TANF population, and with this additional acuity comes the potential for health plans to experience significant variation in overall population acuity. Many states currently employ risk adjusted payment systems to modify capitation payments to MCOs based upon the acuity of their enrolled SSI population. Risk adjusting the SSI rates can benefit the State in several ways. It can reduce the overall growth of the cost of the SSI program by more appropriately paying plans that enroll members with higher cost health conditions and less to those with less risky members. Risk adjustment will also support continued health plan participation by helping to manage the financial risk associated with enrolling the SSI. Because typical risk adjustment methodologies rely on encounter data, moving to a risk adjusted capitation rate will provide a strong incentive to the participating health plans to improve their encounter data reporting. Given the Government Accounting Office’s (GAO) recent report criticizing CMS for

#523964 RFP #MED11010 Managed Care Administration its laxity in overseeing states data, the Bureau may want to consider implementing risk adjustment for its TANF program, too, as a way to improve encounter data reporting. 1

Lewin staff have worked extensively with multiple state Medicaid programs that have implemented risk adjusted payment systems and can assist BMS in ensuring that capitation payments to MCOs match the acuity of their enrolled SSI population. We will prepare a detailed presentation for State staff outlining the options they have when risk adjustment is introduced into the rate setting process. There are a number of options that need to be evaluated including: choice of system, frequency of updates, and the lag between the time period used to determine risk scores and the payment period. Should the Bureau want to move towards risk- adjusted rates, the Lewin team includes risk adjustment experts who have developed and implemented risk adjustment processes in many states including Maryland, New York, New Jersey, and Pennsylvania. Our experts fully understand the pros and cons of different risk adjustment models and will guide West Virginia’s decision making process.

Deliverables: Task 3.2.1.1 Development of Capitation Rates . Capitation rates, rate setting methodology, and CMS documentation submitted to the Bureau by March 1 of each year

Overview of approach Lewin is the best choice to implement the most seamless and efficient rate setting process given recent changes in the MHT and MHC programs. We already are intimately familiar with the behavioral health and children’s dental expansion and phased-in roll-out of the SSI population. Our historical knowledge of the program, state staff and program vendors, and previous experience in developing the capitation rates allows us to provide continuity as well as the flexibility to quickly adapt to any additional changes required moving forward. Our rate setting process entails the eight steps displayed in the diagram and detailed below.

1 Medicaid Managed Care, CMS’s Oversight of States’ Rate Setting Needs Improvement, GAO Report to Congressional Committees (GAO-10-810), August, 2010

#523964 RFP #MED11010 Managed Care Administration

Figure 3. Rate Setting Process

Gather/validate Monitor federal data and information activity (Step 1) (Step 2)

BMS review and feedback

Update Develop Present to methodology capitation BMS (Step 3) rates (Step 5) (Step 4)

Present capitation rates to MCOs for comment and feedback (Steps 6)

CMS review and approval

Present capitation rates and methodology to CMS (Step 7)

Plan for future rate setting efforts (Steps 8)

Step 1: Gather and validate data and information Upon the start of each rate setting cycle, beginning July 1 of each year, Lewin will prepare memoranda to the Bureau and the participating MCOs outlining the data and information that Lewin requires for the rate setting process. Our understanding of the program, including recent changes, allows us to appropriately update the rate setting memoranda to describe how the rate methodology will take the recent changes into account. We will update our established procedures for receipt of monthly data pulls, including claims, eligibility, enrollment, and provider data from the fiscal intermediary and encounter data from the MCOs. This arrangement will not only allow us to initiate the rate setting work in a timely manner but also enhance our ability to respond to other analytic tasks as well. As part of the data collection process, we will review the FFS claims and MCO encounter data against control totals to ensure the validity and completeness of the data received.

Lewin will work collaboratively with Bureau staff to assure that the recent changes in the programmatic, policy, and budgetary environment at the Bureau are accurately reflected in the rate setting process and to identify potential changes to the managed care program that require data analysis. We will identify programmatic changes, including fee schedule updates and benefit changes, to assist State staff in identifying what new or additional data may be needed. To assist State staff in evaluating potential changes to the managed care program, we will generate data analyses examining the impact of potential changes in eligibility and/or benefits on capitation rates using the data gathered under this and other tasks.

#523964 RFP #MED11010 Managed Care Administration

Once we have submitted the information request to the Bureau and the MCOs, we will follow up with the respective parties to review the information and ascertain whether there are issues that we should consider in refining the rate setting methodology. Our established working relationship with Bureau staff and the MCOs should facilitate the process of gathering necessary data and information and minimize the impact on BMS staff time.

Step 2: Monitor Federal Activity Lewin will monitor federal legislation and mandates to assess their implications on the rate setting process. As Lewin reviews the existing rate setting methodology, we will identify the provisions within the ACA and other federal legislation and regulations that will affect the design of the MHT and MHC programs and the derivation of the capitation rates, including the regulations contained in 42 CFR 438.6. For example, provisions within the ACA require that Medicaid pay primary care providers at 100 percent of Medicare rates for calendar years 2013 and 2014 – this will impact both the Medicaid FFS fee schedule as well as the capitation rates for the three managed care contract years that fall across those two calendar years. We will crosswalk the requirements of these policies to the existing rate setting methodology and identify the changes needed. Lewin will ensure that BMS fully understands the implications of new legislation and regulations and will collaborate with BMS to identify the options available to BMS to stay in compliance with any new regulations. Although this step is displayed on our timeline as occurring in the initial months of each rate setting cycle, our focus on federal activity will be continuous and we will alert BMS of issues and opportunities as they arise.

One opportunity created by the ACA is the equalization of drug rebates for Medicaid MCOs. The ACA has extended the federally-mandated drug rebates to prescriptions provided by Medicaid MCOs. Lewin has provided ad-hoc analyses around the prescription drug carve-in option over the past three years and recently updated that analysis to account for the rebate equalization under the ACA. With the rebates equalized, there are now opportunities for the Bureau to leverage the MCOs’ ability to increase generic drug use, lower dispensing fees, and reduce overall utilization of prescription drugs. For these reasons, the Bureau may want to consider carving the prescription drug benefit into the managed care benefits package in the future.

Step 3: Update methodology Each year at the beginning of the rate setting process, Lewin reviews the details of the previous year’s rate setting analyses, considers what was learned the previous year, and makes refinements to the methodology. Lewin will work to update the rate setting methodology to reflect any changes in the State Medicaid program and incorporate any new guidelines for capitation rates that have recently been established in federal regulation, as identified in Step 2.

Lewin will use as its starting point our current methodology created for the Bureau for the development of the SFY 2011 capitation rates for the TANF and SSI populations. This SFY 2011 methodology has been reviewed and accepted by CMS and demonstrates the strengths of Lewin’s previous rate setting work and our ability to update the rate setting methodology to reflect numerous changes to the managed care program over the previous year. In addition to developing capitation rates for the behavioral health, children’s dental, and SSI expansion, the SFY 2011 TANF capitation rates necessitated several changes to account for regulations governing the populations included in the MHC program. Pregnant women, the medically

#523964 RFP #MED11010 Managed Care Administration needy, and dually enrolled Title XIX/Title V children with special health care needs were moved under the MHT program and Section 1931 Parents and Caretaker/relatives were no longer mandatorily enrolled in MHC. Additionally, a new State Plan Amendment changed many of the benefit limits on services provided to children under the MHC program. Based on these major changes to the populations included under MHC and MHT and changes in benefit design under MHC, Lewin collaborated with BMS to develop rate cohorts that provided a comprehensive rate structure to account for the populations covered under MHT and the option of the 1931 Parents and Caretaker/relatives to enroll in either MHT or MHC.

With the SSI population scheduled to transition into managed care, BMS may want to consider implementing a risk adjusted payment methodology, for reasons described previously. The Lewin team has extensive knowledge of various risk adjustment methodologies and models used by other states and have designed and implemented the risk adjustment programs in nine states. Should BMS want to explore risk adjustment, we will evaluate each plan’s performance in comparison to its case mix, network design, administrative costs, and utilization trends to assess whether any risk adjustment is necessary. If the MCOs’ experience and financials exhibit a significant differential in risk, we can advise BMS on the risk adjustment options and which would be the most effective method of addressing risk differentials between the MCOs. Regardless of the method chosen, any risk adjustment will be calculated in accordance with CMS requirements and other applicable federal regulations.

Step 4: Develop capitation rates Step 4 of the capitation rate development entails processing and analyzing the claims and eligibility files received from the fiscal intermediary; analyzing MCO financial statements and encounter data to develop utilization and administrative adjustments; incorporating trend and other adjustment factors; and estimating final capitation rates. The most important features of Lewin’s approach to this step are careful attention to the details of the claims and eligibility files and our quality review process.

Throughout this process, Lewin’s team will carefully examine the claims and eligibility files as a part of our quality review process. We will review each set of tabulations for accuracy at multiple levels and compare the results to available state benchmark data and other sources to verify consistency. Senior actuarial members of the Lewin team will also conduct a thorough review of the data and formulas included in the spreadsheets resulting in the final capitation rates.

The process of establishing actuarially sound capitation rate ranges during Step 4 will include the following general tasks:

 Developing a rate update model that includes the current base period costs, usage, and covered months by type of service and demographic rate cohort, program enrollment (e.g., TANF Basic, Enhanced, Traditional Packages, SSI) and region within the capitated package.  Revising rate adjustment factors used in the prior year’s rate setting effort and updating these factors, if there is evidence of the need to modify these adjustments (e.g., for MCO administrative costs we annually examine MCO financial reports, recalculate regional

#523964 RFP #MED11010 Managed Care Administration

cost factors each year, and evaluate selection bias annually to determine any changes that are appropriate).  Trending the base period costs forward to the necessary rate periods using a combination of historical FFS and MCO experience, scheduled price updates for West Virginia’s Medicaid fee schedule, CMS Office of the Actuary National Health Expenditure Projections, and other national and regional trend sources.  Developing managed care efficiency adjustment factors to account for the efficiencies of the MCOs in delivering care over the existing FFS program.  Assuring that the overall rate setting process, as well as the resulting set of rates, is actuarially sound and meets all requirements specified in the Medicaid managed care regulations and CMS rate setting checklist.

Step 5: Present documentation and preliminary rates to the Bureau and MCOs Once a preliminary set of capitation rates has been produced and Lewin has assessed the impact of the new capitation rates, we will submit to the Bureau a deliverable providing the technical documentation for our implementation of the rate methodology, preliminary capitation rates, and an analysis of the impact of the rates. The organization of the documentation will facilitate comparison to the CMS rate setting checklist to verify full compliance. The documentation will be extremely specific in terms of selection criteria, algorithms used to match the eligibility and claims data, methods and assumptions used to develop price and utilization trends, benefits adjustments between Basic, Enhanced, and Traditional packages, and other adjustments such as the managed care and regional factors.

Lewin will update the rate methodology and assumptions, the resulting capitation rates, and the impact analysis as appropriate based on comments received from Bureau staff. Then, the revised versions will be submitted to the Bureau.

The certified actuary for this project, Tom Carlson, will be involved in updating the methodology and in making key decisions during the rate development such as determining the methods for managed care adjustments and trending. Mr. Carlson has worked on MHT capitation rates for the past two years and is familiar with the MHT program and the MCO contractors. Once final capitation rates are developed, Mr. Carlson will provide the Bureau with a statement as to the appropriateness of the methodology and capitation rates. This statement will meet the actuarial soundness and certification requirements established by CMS.

Step 6: Present final rates to the MCOs Once the capitation rates have been finalized, Lewin staff will prepare written documentation and give a presentation to MCOs, highlighting changes in the rate setting method and providing an analysis of how the updates to the capitation rates will impact the MCOs’ projected revenue for the upcoming year. Lewin will solicit feedback from the MCOs regarding the development of the capitation rates. Having worked with the participating MCOs over the past fourteen years, Lewin is familiar with their concerns regarding the capitation rates and will work with BMS to incorporate any reasonable adjustments into the final capitation rates.

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In addition, Lewin will provide support to BMS, as needed, to discuss the capitation rate setting methodology with other MCOs interested in entering the program. Over the past couple of years, Lewin has supported BMS by answering questions and providing additional information to Centene as it explores possible entry into West Virginia’s managed care program.

Step 7: Support CMS review Lewin staff will prepare detailed documentation for the rate setting methods, including the actuarial certification of the rates. The documentation will be prepared to conform to the most current version of CMS’ capitation rate setting checklist, so that the CMS regional office will be readily able to verify compliance. In addition, we will prepare a detailed exhibit for the MCO contract describing the rate development and final rates. In conjunction with the capitation rate setting process, Lewin will prepare all analyses and documentation required for the upper payment limit and cost effectiveness section of the state’s current 1915(b) waiver.

Throughout this task and subsequent submission to CMS of the demonstration of cost- effectiveness for the state’s waiver renewal, Lewin will be available to respond to questions from CMS. Because The Lewin Group was the Bureau’s original contractor for the rate setting task and the originator of the existing methodology, we believe that CMS’s familiarity with the methodology and our understanding of the specific issues will be invaluable to ensuring that future upper payment limit, capitation rates, and methodologies are consistent with the waiver and the federal guidance we have received over the years. For the most recent waiver renewal in 2010, our intimate knowledge of the managed care program allowed us to quickly adjust both the capitation rates and waiver cost effectiveness calculations in response to recent federal regulations regarding the State’s benchmark authority. The late establishment of this final rule required Lewin to quickly adjust the cost effectiveness analyses to include a projection for the parents and caretakers/relatives who opt out of MHC.

In addition, our prior experience with the Bureau and with other states has yielded positive feedback from both CMS and OMB. Because our approach to rate development and the integrity of our analyses are known and respected throughout CMS regional and central offices and OMB, we expect that any issues raised will be quickly and easily addressed. Our approach will be modified, if necessary, based on cost effectiveness guidelines released by CMS in the future.

Step 8: Plan for future rate setting efforts After the capitation rates have been finalized, Lewin staff will review the methods used in the prior year’s rate setting efforts and consider whether there are areas where the data or methods for rate setting could be improved through a long-term effort. Lewin expects that efforts such as this may be important to improving the data and methods used in rate setting efforts in the future.

Implementation The Lewin Group will develop the capitation rates and submit the methodology and CMS documentation to the Bureau for Medical Services by March 1 of each year. The figure below summarizes the specific work steps required for 2011. This task will repeat annually through the course of the contract.

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Figure 4. Task 3.2.1.1 Sample Work Plan and Timetable for 2011

Development of requirements for participation and agreement specifications (3.2.1.2)

The objective of this task is to assist the Bureau in obtaining provider agreements to participate in the Mountain Health Trust program, to develop requirements for participation and agreement Lewin provided extensive training to the State of Washington, under a contract for specifications, as necessary and appropriate, and to the Agency for Healthcare Research and support the Bureau in evaluating and reviewing Quality, in preparation to evaluation of a proposals. West Virginia must ensure participating Medicaid care management procurement. MHT plans meet network sufficiency and quality The training agenda included: standards prior to contracting. With at least one 1. General evaluation guidelines MCO in each of the 55 counties in the State and two 2. Scoring guidelines or more MCOs in 42 counties, increasing the number 3. Evaluation tool and score sheet of MCOs may no longer be a primary contracting 4. Overview of RFP requirements goal for the Bureau. However, given the projected 5. Evaluation schedule increase in Medicaid enrollment due to the ACA, the Bureau may now want to focus on the recruitment of MCOs that have experience serving the Medicaid population in other states. The addition of MCOs with Medicaid experience will improve beneficiary choice of MCOs and providers and will provide another mechanism for the transfer of best practices from other Medicaid programs to the State of West Virginia.

Lewin has extensive experience working with MCOs to enter the Mountain Health Trust program. Upon establishment of the program, Lewin assisted the Bureau with conducting the initial readiness assessments to determine if The Health Plan and Carelink were prepared to begin enrolling beneficiaries. Since that time, Lewin has also assisted the Bureau in reviewing UniCare’s readiness to serve MHT program enrollees. Currently, Lewin is supporting the Bureau in preparing application materials and other requirements for Centene’s participation, which involves review of Centene’s policies and procedures for meeting the program’s operational and network requirements, assessment of the provider network, and on-site reviews. The Lewin Group will work with this and other interested MCOs, review and update existing provider agreements, and assist the Bureau with additional contracting as needed.

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Deliverables: Task 3.2.1.2 Development of Requirements for Participation and Agreement Specifications . Prepare and submit agreement materials within 30 days of request by the Bureau for Medical Services. . Provide other agreement support as requested.

Overview of approach The Lewin Group will provide comprehensive MCO procurement support as requested by the Bureau. Currently, West Virginia allows MCOs to submit an application for participation in MHT at any time. For MCOs that are interested in joining the program, Lewin will provide appropriate materials, including an application, readiness review criteria, and onsite guides, as well as work with the MCO and the Bureau to ensure procurement requirements are met.

Develop Procurement Materials Lewin will work closely with the Bureau to develop a comprehensive set of materials to procure new participants to the Mountain Health Trust program. The Bureau needs a procurement process that uses materials that ensure MCO applicants fully demonstrate readiness to serve MHT enrollees, while In November 2010, Lewin making sure that MCOs are not unduly burdened by assisted BMS with restructuring procurement activities that duplicate Department of the State’s Mountain Health Insurance (DOI) requirements and that do not duplicate Trust Medicaid MCO Provider Application to incorporate key requirements contained within the MCO’s contract with the programmatic elements to State. Key procurement materials will include the State’s ensure that new MCO entrants Mountain Health Trust Medicaid MCO Provider are well prepared to serve SSI application, as well as the development of a request for beneficiaries and deliver proposals or request for applications if the Bureau decides behavioral health and children’s at a later point to conduct a competitive MCO procurement. dental services upon the planned program expansion in 2011. In addition, Lewin will use its experience assisting the Bureau with the upcoming managed care expansions in 2011 to develop additional provider agreement requirements as well as readiness review criteria and onsite guides for new entrants into the MHT program. Lewin will also work closely with the DOI, through the Bureau, to coordinate review of materials such as provider agreement contract templates.

New provider agreement content may include additional monitoring requirements and reports, outreach and member services requirements, staffing ratios, or hiring requirements given the addition of SSI members, behavioral health services and health reform requirements. Lewin will also research procurement approaches that have worked in other states and may be effective for West Virginia. With the potential of over 150,000 new Medicaid beneficiaries to be covered in managed care due to the SSI expansion and coverage expansions from health reform, evaluating and improving the procurement process may attract new MCOs to the MHT program.

Provide Assistance to Evaluation Teams, Site Visit Support, and Network Reviews To support the Bureau’s evaluation teams and review of applications, Lewin will develop a comprehensive evaluation tool to provide reviewers with guidance on reviewing MCO

#523964 RFP #MED11010 Managed Care Administration documentation for key operational areas. Lewin will also provide technical assistance to Bureau staff in reviewing these materials and evaluating sufficiency. Given the current non-competitive approach to contracting, we assume that the Bureau will wish to continue its approach of working with potential vendors to come into compliance in areas in which the initial documentation is insufficient. Lewin will support the Bureau in efforts to help potential vendors understand and comply with program requirements, including providing technical assistance to potential vendors as requested by the Bureau. If the Bureau decides in the future to move to a competitive procurement for MCO services, Lewin can assist the State with developing a proposal evaluation tool to include a detailed scoring methodology.

Lewin will develop a site visit protocol based on key areas of interest to the Bureau and any areas of concern identified during the document review. We will discuss the framework for onsite reviews and coordination with the EQRO and CMS as needed. Lewin will focus on whether MCOs have systems in place to serve complex members and coordinate between physical As the West Virginia Medicaid managed health and behavioral health. Evaluation of care program continues to expand, both with SSI enrollment in the short term and readiness will include components of network with health reform in the long term, the member services such as materials, outreach and Bureau may consider reassessing the education, quality, care management, utilization optimum number of MCOs to participate. management, IT resources, and overall staffing. We It will be critical for BMS to balance will review an applicant’s policies and procedures contracting with more MCOs to maximize beneficiary and provider related to these areas and assess the MCO’s network choice and provide stability in the case to provide and deliver services. As needed, Lewin of an MCO exit, while minimizing BMS will conduct follow-up calls with MCOs to address coordination and management time and outstanding issues. MCO administrative expense. We will work with the Bureau to achieve the right Lewin will assist the Bureau in conducting site visits balance, taking into consideration that each plan must have an adequate to MCO offices to evaluate readiness for number of enrollees to manage risk and contracting. If necessary, Lewin will conduct follow- ensuring two or more MCOs in each up site visits to re-evaluate outstanding areas of county where that is required. concern. Lewin will provide the Bureau with a written summary of the findings of the site visit and our contracting recommendations.

As a key part of the readiness process, Lewin will review provider networks to ensure that new MCOs can provide the range of services required by the contract and meet provider ratio requirements, particularly in primary care and key specialty areas. (See Subtask 3.2.1.5 for more detail on Lewin’s approach to evaluating provider networks.)

Finally, Lewin will assist Bureau staff in negotiating contracts with selected managed care organizations and then planning for implementation of enrollment in conjunction with Bureau staff and the program’s enrollment broker.

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Implementation Following is a summary of the work steps required for 2011. This task will repeat throughout the course of the contract, as needed.

Figure 5. Task 3.2.1.2 Work Plan and Timetable for 2011

Development and maintenance of provider/MCO and other vendor agreements/contracts (3.2.1.3)

The objective of Subtask 3.2.1.3 is to develop and maintain vendor contracts in accordance with current and future federal regulations and guidelines. Lewin will develop new vendor contracts as necessary and will Lewin is currently assisting the Bureau with identifying review and update contracts if federal contract requirements additional requirements that the are amended or newly promulgated. Existing MHT vendor State may want to consider contracts that may require review and updating include, but adding to the current External are not limited to, the Bureau’s contracts with its MCOs, Quality Review Organization PAAS providers, the external quality review organization (EQRO) Request for Proposal. (EQRO), and the enrollment broker. Lewin examined federal requirements which guide the reviews and examined the Lewin has the expertise needed to successfully perform this content of other states’ EQRO task, including well-established relationships with the proposals to propose additional MCOs and CMS and an in-depth historical knowledge of content to increase the State’s West Virginia’s Medicaid services. We have been an integral purchasing power. resource for the Bureau for over 15 years; our understanding of the program’s history and our knowledge of the MHT expansions will be valuable resources in updating the contracts. We also have a detailed understanding of key timeframes and challenges associated with approval and finalization of contracts.

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Deliverables: Task 3.2.1.3 Development and Maintenance of Provider/MCO Agreements . Lewin will develop federally required information and agreements within 30 days of request by the Bureau.

Overview of approach Lewin will develop any new vendor contracts as requested by the Bureau, commensurate with relevant federal regulations, within specified timeframes. Lewin will use its detailed knowledge of the MHT program to determine the information to include in provider agreements. We will work closely with the Bureau to ensure contracts fully capture the vendor Scope of Work, including integrating lessons learned from the planned 2011 program expansions, as needed. Lewin will also assist the Bureau in presenting and obtaining feedback from vendors on new contracts and subsequently making necessary changes. The Lewin Group will finalize vendor contracts, present such contracts to CMS, and make revisions to ensure CMS approval, if needed. This subtask may occur on an ongoing basis, depending on the Bureau’s needs.

Monitor Federal Regulations and Requirements for Contract Adjustment Implications Lewin will monitor federal promulgation of requirements and regulations that affect MHT vendor contracts and develop necessary contract modifications and addenda, which is a critical task given the recent passage of health reform legislation. At a minimum, Lewin will use its contacts at CMS, including the West Virginia CMS project officer, central office staff at the Center for Medicaid, CHIP, and Survey & Certification (CMSC), the CMS website, and other publicly available resources, such as the Federal Register and the National Association of Medicaid Directors website, to monitor the promulgation of federal requirements on an ongoing basis. Lewin has developed a database to In 2009, Lewin alerted BMS to the track pertinent Medicaid and health reform federal upcoming changes related to Mental requirements and will provide updated analysis of Health Parity, prior to the release of new regulations on a bi-weekly basis, assessing their formal CMS guidance, and the impact on the Bureau, the MHT program, and the potential impact on Mountain Health Choices. Lewin was able to interpret Mountain Health Choices program. Lewin will attend the legislation to determine the briefings (to the extent feasible) on regulations to impact it would have on the Mountain ensure maximum understanding of such regulations. Health Choices benefits package. Because of this, BMS was able to Similar to our approach in guiding the Bureau on better prepare for needed modifying vendor contracts to comply with the Paul programmatic changes, which Wellstone and Pete Domenici Mental Health Parity eventually impacted beneficiary benefits and MCO reimbursement. and Addiction Equity Act of 2008, Lewin will review requirements and regulations expected to affect MHT and develop a brief overview of the impact of the regulation and degree to which contract changes will be required. When requirements and regulations necessitating changes to vendor contracts are identified, Lewin will promptly notify the Bureau and develop a specific work plan and timeline to develop contract modifications.

Track Contract Changes Over Time Monitoring changes to the MCO contract over time in a single location will help the Bureau easily identify trends and document the rationale for MCO contract provision changes. This

#523964 RFP #MED11010 Managed Care Administration database can also be used to track desired changes to the MCO contract for the upcoming fiscal year. Specific elements of the database will include, but may not be limited to, contract reference (e.g., section, paragraph), previous contract language, revised contract language, rationale for change, and requestor.

We will review the database with the Bureau twice annually, or more frequently if critical issues are identified. As appropriate, we will discuss significant changes with CMS and the MCOs throughout the year to gain buy-in from MCOs and other important stakeholders and help to keep program updates on schedule. We also will share the contract review schedule with MCOs and CMS, including drafts and review timeframes at beginning of each year. Lewin will work on getting feedback from MCOs early in the contract review process to determine where clarifications and updates should be made for future contacts.

Complete Contract Review and Applicable Changes Lewin suggests starting the contract review early for fiscal year 2011 to build in adequate time for review by the Bureau, CMS, and MCOs given the potential for significant changes in Mountain Health Choices in light of the recent program expansions. Lewin can also assist the Bureau with revamping the contract structure moving forward if the expansions identify significant new issues that do not have a place in the current contract. Tracking changes to the MCO contract over time will allow the Bureau to Lewin will present amended contracts to vendors and develop a single repository for both obtain their feedback on contract changes. After previous MCO contract changes and revising the contracts to appropriately reflect vendor planned MCO contract changes for the upcoming fiscal year, as well as comments, we will work to ensure MCO acceptance of identify contracting trends. Lewin will the revised contract language. The Lewin Group will develop the database, continuously then present the revised contract to CMS and upon update it, and review the database receiving feedback, will refine the contracts as needed with the Bureau. The database will to win approval by CMS. We are currently using this serve as a critical tool for updating the MCO contract and documenting process to review and revise MHT MCO contracts in MCO contract changes from year to preparation for possible program expansions or year. changes in areas including SSI and behavioral health. Moving forward, Lewin will continue to closely review MCO contracts to ensure all federal regulations are met.

Implementation Upon fulfilling the requirements of this task, a comprehensive contract for the Mountain Health Trust program will be developed that will account for all relevant federal and state regulations, address the concerns of CMS, set the stage for programmatic expansions and monitoring efforts, and provide a roadmap for MCO performance and setting the Bureau’s expectations. The figure below summarizes the specific work steps required for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

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Figure 6. Task 3.2.1.3 Sample Work Plan and Timetable for 2012

Development of strategy for MCO contracting (3.2.1.4)

The objective of Subtask 3.2.1.4 is to assist the Bureau in refining its strategy for MCO contracting, taking advantage of the maturity of the program and resulting opportunities for performance-based contracting. The Bureau must have a managed care strategy that meets the combined challenges of promoting a competitive managed care contracting system while simultaneously encouraging MCO performance improvements in key areas and supporting traditional Medicaid providers as important elements of West Virginia’s health care delivery system and safety net. The Bureau must continue to engage the MCOs currently participating in the managed care program while paving the way for new MCOs to participate in West Virginia, a Lewin previously assisted the Bureau with conducting research to determine significant challenge due to the rural nature of the options for imposing financial state (entry of new MCOs into the managed care penalties for late reports submitted by program is discussed in Subtask 3.2.1.3). Lewin will the MCOs, as required by the MCO help to manage the evolution of the program given the contract. Our staff researched the significant programmatic changes that are in range of financial penalties imposed by other states and reviewed sample MCO development (e.g., enrollment of 55,000 SSI contract language to provide individuals in fiscal year 2011), and potential for recommendations to West Virginia. significant numbers of new beneficiaries after health Lewin assisted the Bureau with reform is fully implemented. determining the best option and then subsequently revised the MCO contract One critical decision the State must make is to to include a financial penalty of $250 determine how many new MCOs to bring into the per calendar day for each day a report is late. program now, with the inclusion of the SSI population, and later, with the expansion driven by the ACA. Too few new MCOs may overtax the existing capacity and result in inadequate access to care, improper delivery of services, and poor health outcomes. Too many new MCOs could result in insufficient enrollment to sustain efficient operations, leading to unnecessary pressure to increase capitation rates or, ultimately, MCO withdrawal from the program or financial

#523964 RFP #MED11010 Managed Care Administration failure. Lewin staff have worked with a number of state Medicaid programs to develop criteria to determine the ideal number of new MCOs to bring into the program to strike a balance between providing sufficient member choice and efficient program operations. The state will want to protect itself from the chaos that comes from unwanted MCO withdrawal while having to manage as few MCOs as possible. The Lewin team has extensive experience with states in designing procurement provisions to meet the state’s goals, including RFP development and scoring and the use of a competitive bid strategy.

Deliverables: Task 3.2.1.4 Development of Strategy for MCO Contracting . The Lewin Group will develop a contracting strategy for submission to the Bureau within 30 days of request.

Overview of approach

Leveraging Lessons Learned and Best Practices Lewin is able to leverage lessons Lewin will perform a detailed review of the lessons learned from our experience learned from program expansions in State Fiscal Year 2011 working with the Bureau over the last 15 years such as: for use in subsequent program expansions to include . Increased oversight of MCO additional beneficiaries (e.g., enrollment of additional subcontracts beneficiaries due to the ACA) and services (e.g., pharmacy . Engaging stakeholders early services). Specifically, we will propose recommendations in the process for improvements based on MCO reports on the utilization . Allowing MCOs enough lead of services, grievances and appeals, exemptions to seek time to develop sufficient care from out-of-network providers, provider complaints, provider networks incident reports, and surveys of TANF and new SSI beneficiaries regarding their experience and access to services. Some of the lessons that Lewin has already identified include increased oversight of MCO subcontractors and their contracting strategies, engaging affected stakeholders early in the process prior to public announcement of the changes, and providing additional lead time for the MCOs to develop sufficient networks. Lewin also will study the potential impact of new federal legislation on the managed care program, including the impact of CHIPRA requirements on quality measurement and the impact of ACA requirements on program integrity Members of our team assisted the and data reporting. State of Maryland with the development of a payment incentive to encourage Medicaid MCOs to Lewin will help the Bureau benefit from experiences continue statewide delivery of in other states by conducting a literature review and managed care. The development of leveraging our prior experience in other states to the incentive payment was in response identify additional best practices and lessons learned, to several MCOs desiring to contract avoiding approaches that may be unsuccessful. After their service areas and only remain in the program expansion, Lewin will closely evaluate more urban areas of the State. The payment incentive was successful in the provision and coordination of behavioral health encouraging MCOs to maintain their services. We will evaluate service encounter data, statewide service areas to ensure that MCO quarterly reports, and provider networks to Medicaid beneficiary access was not evaluate beneficiary access to services and identify adversely impacted. areas for improvement. Lewin will also track and evaluate the timeliness of required MCO reports. Our

#523964 RFP #MED11010 Managed Care Administration experience and research findings will help to develop performance targets, incentives, and penalties for MCOs tailored to West Virginia’s specific needs. Lewin has long-established relationships with the MCOs serving the managed care program, which we can leverage to get buy-in from the MCOs into new program initiatives.

Building on Lewin’s Monitoring and Evaluation Expertise As discussed in Section 4.1.7, The Lewin Group brings strong experience in monitoring and evaluating MCO initiatives in other states to the Mountain Health Trust program. We recently evaluated a pay-for-performance program for Pennsylvania’s Medicaid MCOs. Lewin’s team Members of our team assisted the determined whether the MCOs achieved minimal or State of Alabama with creating a pay- for-performance system for the State’s optimal performance based on a series of HEDIS primary care case management quality measurements including regular cancer system. The program created financial screenings, diabetes care, and cholesterol incentives to reward primary care management. We also reviewed MCO performance physicians for reaching targets scores to determine which plans would receive bonus associated with increased office visits and decreased emergency room payments and the size of those payments. The pay- utilization, as well as increased use of for-performance payments provided the MCOs with generic medications. an incentive to not only improve their services, but also to maintain their high level of services for beneficiaries. Our staff has also designed pay- for-performance programs including the selection of measures, processes to measure the performance of participating providers on a risk-neutral basis, and development of a scoring algorithm to determine a provider’s portion of shared savings.

We will work closely with the Bureau and the EQRO on any potential clinical improvement performance targets and gathering performance data, including identifying overall improvements to the managed care program. We previously worked collaboratively with the EQRO to develop targets for the State’s strategy for improving quality in the managed care program, working to select HEDIS measures that reflect program goals.

MCO Performance Scorecards Another monitoring strategy Lewin can assist the Bureau in developing and implementing is publishing MCO performance scorecards for public release. Both advocates and legislators have recently requested that performances measures of the Mountain Health Trust program be posted on the Bureau’s website on a Working with one large state’s managed Medicaid program, service utilization data was summarized regular basis. Although the Bureau’s and compared to NCQA quality standards. The Annual Report provides some HMOs were graded on their overall performance and information on MCO performance, their relative performance and any improvement publishing scorecards containing shown. If they achieved target performance and information on MCO performance in the improvement the HMO received a bonus payment areas of access and quality, as well as key from the state. This program applied existing industry accepted quality measures (from NCQA) and paid clinical measures, would be a valuable out amounts that had been withheld from the monthly tool for demonstrating the effectiveness of HMO capitation, which made the program credible the program expansion and would offer and budget neutral. beneficiaries an additional tool by which to select an MCO.

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Implementation The figure below details the specific work steps required to further implement performance- based targets for MCO contracting for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

Figure 7. Task 3.2.1.4 Sample Work Plan and Timetable for 2011

Perform analyses and ongoing monitoring of MCO provider networks (3.2.1.5)

The objective of this subtask is to ensure that the Mountain Health Trust MCOs continue to provide beneficiaries, via adequate provider networks, the level of access required by the program waiver and necessary to achieve program goals. Quarterly analysis of MHT provider networks within each health plan enables the Bureau to quickly identify and address any significant changes that could negatively impact enrollees’ access to care. These analyses will be increasingly important as the SSI population is phased in, as SSI beneficiaries generally require more frequent provider visits as well as a greater range of physician specialties, and as the single-plan rural option continues to be implemented, to ensure the beneficiaries without a choice of plans continue to have appropriate access to services within a single MCO’s network.

Successful performance of this task will lead to:

 Updated standards and regular monitoring of provider networks;  An automated method for MCO provider network submissions; and  A transparent process and sharing of information with BMS in a standardized quarterly report.

Bringing the Bureau the Benefit of Lewin’s Extensive Experience In addition to extensive network review experience in West Virginia, Lewin has conducted analyses of provider networks for a variety of state Medicaid agencies including Texas and New York. Lewin worked jointly with CMS on a first-of-its kind effort to develop and establish a set of national provider and facility network criteria for the Medicare Advantage program. As part of this significant undertaking, Lewin analyzed approximately 30 physician specialties and 20 facility types to create county-level requirements for new MCOs entering the Medicare Advantage marketplace. The criteria included creating the minimum number of providers an MCO must have in its network to enter a county and the creation of time and distance requirements. CMS used the criteria in 2010 for the first time to standardize and automate the evaluation of provider networks for new Medicare Advantage plans across the country. A sample of the types of criteria developed by Lewin, by designated county types, is included

#523964 RFP #MED11010 Managed Care Administration below. In developing the nationwide network criteria, Lewin utilized its relationship with GeoAccess® and Ingenix to produce detailed network analysis maps and overall access reports to ensure that time and distance criteria were appropriate to meet the needs of the Medicare Advantage population.

Figure 8. Sample CMS Medicare Advantage National Network Criteria

Geographic Type

Specialty Large Metro Metro Micro Rural Time Distance Time Distance Time Distance Time Distance (minutes) (miles) (minutes) (miles) (minutes) (miles) (minutes) (miles) Primary Care 25 5 25 10 30 20 45 30 Allergy & Immunology 35 15 45 30 70 60 85 75 Cardiology 25 5 30 21 45 35 75 60

In West Virginia, Lewin is extremely familiar with the counties and the individual facilities and providers who participate in Mountain Health Trust. We have many years of experience working with provider network data from West Virginia and we have built strong partnerships with the major stakeholders for this task, including the MCOs, our data subcontractor Michael Madalena, and the fiscal intermediary for West Virginia Medicaid. Lewin’s proposed innovative monitoring approaches of MCO provider networks will provide the following benefits to the Lewin has several ideas to improve and streamline Bureau: the monitoring of MCO provider networks. One of . Standardized data collection formats the main challenges with MCO monitoring is that as . Centralized provider database time passes and more beneficiaries enroll in Mountain Health Trust, utilization of fee-for-service . Online submission portal for MCOs providers can no longer be used as the baseline to measure MCO provider network adequacy. Lewin will work to develop better methods to identify network providers using encounter data. We will use service volume to set TANF and specialty standards. We will work to create standardized data collection formats including defined provider types. Lewin will provide guidance on how to crosswalk provider types into different categories, which also will help promote standardization and transparency. We will also consider new methods for MCOs to submit network data for review including the potential for an online submission portal.

Deliverables: Task 3.2.1.5 Perform Analysis and Ongoing Monitoring of MCO Provider Networks . The Lewin Group will prepare and submit network analyses to the Bureau on a quarterly basis, within 45 days of the end of each quarter. . Lewin will submit expansion county network analyses within 45 days of request.

Overview of approach Assessing Plan Networks The Lewin Group will perform a complete comparative analysis of the FFS and health plan networks in the 55 MHT counties on an annual basis, in addition to quarterly analyses of network reports. We will also evaluate MCO networks in additional expansion counties as they

#523964 RFP #MED11010 Managed Care Administration are identified, when a new population (such as SSI) is to enter the program or when a new MCO seeks to contract with the MHT program. Lewin will compare MCO provider networks against new sets of network standards that are transparent to MCOs and based on new methodology. The new methodology will meet the requirements for network analysis required under the CMS 1915(b) waiver form. As part of the network reviews, Reviews will focus on TANF-specific and SSI-specific Lewin will request that the MCOs submit National Provider networks to ensure that access to needed providers, Identifiers (NPIs) for each particularly specialists, is adequate in each county for each provider in the network and map MCO. We will prepare network adequacy for individual NPIs to provider specialty codes MCO reports and the full program. To further assist with as required by the program analyzing access, Lewin staff will use MapPoint software to integrity requirement of the examine network adequacy by mapping providers and federal health reform law. facilities across the State to ensure adequate coverage. Lewin will generate maps depicting providers, clinics, and hospitals by specialty and location. These maps will facilitate the identification of areas where networks could or should be improved. A sample map is included below, demonstrating that beneficiaries in Region 11 have access to dentists within driving time. The blue shading depicts the actual region; the red line depicts driving time.

Figure 9. Sample MCO Network Adequacy Map

As another component of the network reviews, Lewin will obtain copies of the initial and most recent Medicaid provider network directories from each MCO, as well as the quarterly MCO primary care provider (PCP) and specialist panel reports provided to the Bureau. We will use these data and current FFS network information to review provider ratios against the ratios established in the Network Adequacy Methodology. These data will allow us to make a comparison of PCP and key specialist availability in each county prior to and during waiver cycles. It will also help to monitor access during the upcoming program expansion in 2011.

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Formalize Regular Reviews Conducting regular reviews with MCOs will become increasingly important given the planned expansions and phase-in of SSI. To support the Bureau in this effort, Lewin will develop and share with MCOs a schedule for regular network reviews that will include initial submissions, follow-up reviews, and additional communication regarding deficiencies. Formalizing this process will help establish it as part of the ongoing MCO monitoring activities and elevate network adequacy as a more important issue for CMS and other stakeholders. Lewin also will explore the feasibility of creating a “network dashboard” to keep MCO, CMS, and others informed about network monitoring developments.

Monitor Access In addition to evaluating network adequacy at the onset of this contract and as the program is expanded, Lewin will conduct quarterly reviews of each MCO’s network to monitor access to providers. Using information contained in quarterly reports submitted by each MCO, Lewin also will review (on a county level):

 Ratios of PCPs and key specialists to members;  Quarterly changes in panel size;  Types of PCPs available; and  Numbers of specialist referrals.

Lewin will determine which PCPs are in multiple networks and aggregate the panels to determine if any are approaching the panel size limit of 1,500. If ongoing network problems are detected (e.g., a particular PCP loses large numbers of members during several consecutive quarters), Lewin will request that the MCO and/or enrollment broker provide evidence of measures taken to investigate the reason for the changes, and, if any access or quality issues are detected, evidence of actions that plan took to resolve the problem and prevent recurrences.

As the MHT program expands into additional counties or new populations are added to the program, Lewin will evaluate the provider network of each MCO entering the expansion county to ensure access to needed providers is adequate. Also, when a new MCO applies to participate in the program, we will provide a Medicaid provider list by county to assist the MCO in establishing its provider network. Lewin will lay out a schedule for submitting networks for each SSI phase-in region and the final dates for approving and credentialing the MCO provider networks.

Implementation The Lewin Group will submit network analyses to the Bureau within 45 days of the end of each quarter. Lewin will submit expansion county network analyses within 45 days of request by the Bureau. The figure below summarizes the specific work steps required for one year. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

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Figure 10. Task 3.2.1.5 Sample Work Plan and Timetable for 2011

Scope of Work: Program Management and Improvement (3.2.2)

The focus of Task 3.2.2 is on activities related to the ongoing management of the Mountain Health Trust program, its expansion, and continuous improvement, including participation in Task Force activities, encounter data analysis and related reporting, and options for program expansion. Each of these activities will be used to inform the Managed Care Improvement Plan, described in Task 3.2.3. The Lewin Group has supported the Bureau for Medical Services for over 15 years in ongoing program management including numerous program expansions and modifications. Lewin has the capacity and expertise needed to fully support the Bureau in updating and implementing its Managed Care Program Management Plan, with the goal of providing high quality services that meet all state and federal regulations.

Lewin has conducted numerous analyses to identify areas for performance improvement. For example, Lewin has analyzed utilization data to measure outcomes in Medicaid managed care programs and other demonstration programs, such as a CMS demonstration to improve care for persons with end-stage renal disease. Lewin has developed data analyses for performance incentive development, federal reporting requirements, and internal program monitoring and improvement. For example:

 Lewin conducted an independent assessment of New Mexico’s managed care program, Salud!, and behavioral health managed care program including access, quality, and cost- effectiveness. Lewin reviewed state contractual requirements, provider networks, satisfaction surveys, national performance standards, HEDIS results, CAHPS scores, and financial reports. We also conduct performance reviews of various organizations, collecting and analyzing cost and utilization data for multiple payers.  The Lewin Group is currently working with AHRQ to provide evidence-based technical assistance to 24 Chartered Value Exchanges (CVEs), community coalitions that must have active participation by representatives from providers, purchasers, health plans and consumer organizations. CVEs are charged with measuring and reporting on physician or hospital practice in a meaningful and transparent way to influence value-based decision- making by consumers and purchasers of health care.

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Performance measures are only as good as the data and analysis used to develop the numerators and denominators. An effective performance measurement program requires an effective information technology infrastructure, valid analysis methodology, and a direct clinical relationship to practice guidelines. Our team can bring this expertise in addition to our experience with state clients in the quality improvement arena.

The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the Managed Care Program Management Plan. We will update this plan as needed throughout the course of the project.

Figure 11. Task 3.2.2 Work Plan and Timetable for 2011-2015

The details of our proposed Managed Care Program Management Plan, including specific details on each subtask, are outlined below.

Participate in ongoing program management activities (3.2.2.1)

Lewin will work with the Bureau to develop a comprehensive program management strategy for the Medicaid managed care program that will align with the Managed Care Improvement Plan outlined in Task 3.2.3. Lewin will develop a strategy that will allow the Bureau to assign significant portions of program operations management to Lewin. We have strong experience in monitoring Medicaid managed care programs in West Virginia as well as 16 other states. Lewin has over 15 years of experience working with BMS and the MCOs that administer the managed care program, including setting managed care rates and managing several managed care initiatives such as analyzing pay for performance models, developing dashboards for

#523964 RFP #MED11010 Managed Care Administration monitoring MCO performance, ongoing reevaluation of MCO network adequacy, and identifying program improvement opportunities based on beneficiary survey results. We have also worked with numerous private sector entities to develop responses to state Medicaid managed care initiatives. This added experience gives us distinctive and realistic perspectives on the needs and capabilities of providers and MCOs regarding public sector managed care programs. Lewin’s multi-faceted expertise will be valuable as we assist the Bureau in furthering the development of its collaborative partnership with the State’s MCOs and support the Bureau’s ongoing management of the MHT program.

Overview of approach The Lewin Group will assist the Bureau with ongoing program management activities, ad hoc requests, and small research projects. Lewin will assist the Director of Managed Care and Procurement Services in ensuring that regular program activities are accomplished in a timely and satisfactory manner. Examples of the types of ongoing activities for which Lewin has provided assistance in the past (and expects to perform similarly in the future) include responding to CMS requests for information on specific aspects of the MHT program, such as EPSDT compliance rates, providing summary information on the MHT program for new agency staff, clarifying contract and benefit package terms for vendors, preparing comments on proposed federal regulations that will impact the MHT program, investigating complaints and grievances, and reviewing MCO materials.

Working sessions As a part of our management strategy, Lewin will schedule regular communications with the Bureau in the upcoming year to prepare for the implementation of expanded coverage in the managed care program. To support the most efficient use of Bureau staff time and resources, Lewin will bring key decision points to leadership in briefings and memos. Lewin will also conduct working sessions that include key vendors such as the enrollment broker, the fiscal intermediary, and the EQRO to help develop a partnership with all BMS vendors. These meetings will continue into 2012 to address implementation issues or concerns.

The working sessions with key vendors will likely cover several topics including the discussion of key dashboard and other programmatic data, the need for greater coordination on stakeholder feedback, discussions of lessons learned throughout the implementation process, and preparation for future managed care expansions. Lewin will also receive updates on key vendor activities. These working sessions will ensure that all contractors actively contribute to the monitoring of the managed care program. Lewin will also assist BMS with the planning and scheduling of quarterly MCO task force meetings, including drafting agendas and ensuring participation by key staff from the MCOs and BMS’ other vendors.

Technical assistance and program monitoring Lewin will leverage its current working relationship with the MCOs to offer technical assistance and follow-up. The types of assistance that Lewin has provided in the past (and expects to perform in the future) include reviewing MCO member materials for compliance with contract terms, reviewing revised enrollment applications for the enrollment broker to ensure compliance with federal requirements, and reviewing proposed standards for MCO quality assurance programs for the EQRO.

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Lewin understands CMS’ recent concerns about Mountain Health Choices within the Medicaid managed care program and is cognizant of the areas in which CMS wants to see improvement. Given CMS’ recent concerns about MHC and in light of the upcoming expansion, monitoring is even more important than in previous years. Lewin can elevate key issues for BMS to review and use quarterly reports and network analyses to determine issues facing the managed care program as well as following up on any stakeholder concerns that reach BMS. Lewin can leverage its relationships with the MCOs to determine the validity of these stakeholder issues and develop strategies to resolve them.

We will continue to develop our role in program evaluation, including expanding our monitoring dashboard to include additional measures for SSI, dental, and behavioral health. For example, we will work on incorporating additional trend analysis (e.g., multiple year data) into the dashboard. We will also examine what information other states collect and conduct analysis that is sensitive to the concerns of stakeholders.

Other program management activities Lewin will attend other meetings as requested. These may include meetings with potential MCO contractors to solicit their participation in the MHT program, other state agencies and programs (e.g., HealthCheck) to discuss areas of mutual concern, state agency staff and/or legislators to provide briefings and updates of the status of the program, CMS or other external auditors to discuss the ongoing operations and future direction of the program, or any other meetings requested by the Bureau.

Lewin will coordinate with other state contractors as requested and appropriate to support ongoing coordination for the Bureau. Since the program’s inception, Lewin has worked with the enrollment broker and the external quality review organization, frequently interacting with the MHT contract managers at those organizations on issues related to the ongoing management of Mountain Health Trust. Lewin will review materials and reports provided by other vendors, report to the Bureau as requested, and incorporate findings into broader program monitoring activities. We will also work with other state contractors such as the Medicaid fiscal intermediary, as requested or required.

Lewin will help with the coordination of the Physician Assured Access System (PAAS) and will assist with the development of mechanisms and materials to evaluate and compare performance across both MHT and PAAS. This may include reviewing draft waiver materials for both programs to ensure that the designs complement each other; designing, conducting, and/or analyzing surveys for enrollees of both programs; and developing comparison materials for potential enrollees or CMS. Lewin will assist the Bureau in identifying areas where coordination is necessary and ensuring that sufficient coordination takes place.

Summary Program management and monitoring may be an overwhelming job, particularly in 2011, with resources of the Bureau, MCOs, and other vendors focused on major expansions. As such, The Lewin Group will assist BMS in all program management activities. We will conduct working sessions with the Bureau to prepare for program expansions, provide technical assistance to the MCOs and other vendors, and coordinate with other State contractors and agencies to support ongoing program management and improvement across programs. Lewin will work to ensure

#523964 RFP #MED11010 Managed Care Administration that data collection is sufficient to track MCO performance and that of the MHT program overall, without placing excessive burden on the Bureau, MCOs, or other contractors. We will leverage our strong experience working in West Virginia and the relationships we have established with MHT stakeholders to support the Bureau throughout ongoing management activities of the program resulting in the efficient and effective administration of managed care services for beneficiaries.

Implementation The Lewin Group will participate in ongoing program management activities. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 12. Task 3.2.2.1 Sample Work Plan and Timetable for 2011

Capture encounter, claims and eligibility data on a monthly basis (3.2.2.2)

The objective of this task is to collect and analyze encounter data on an ongoing basis to enable the Bureau to conduct regular program monitoring.

Overview of Approach In order to develop an efficient methodology to gather the claim/encounter data, we will work collaboratively with the Bureau and each of the entities that submit data. During this process, existing data extracts and other information sources will be examined for completeness. Following this The data submission requirements of the ACA represent significant challenges to assessment, the sources of data will be compared to participating entities. For example, NDC the needs and requirements of the Bureau. codes will be required to be submitted Modifications to source data extracts will be for all service line items for injectable negotiated with each of the data sources (if materials. Historically, plans have necessary). Once necessary modifications are disregarded NDC codes during the completed, data receipt will begin. adjudication process and relied solely on HCPCS codes for pricing and adjudication. Because of our long history The following summarizes the steps in this process: and extensive experience with the participating plans, information such as 1. Meet with BMS to discuss the outputs and NDC codes for injectable materials will analyses required. Review the sources of rapidly become actionable information. data with BMS. 2. Review existing data extracts for completeness and capability to meet the data requirements of the Bureau. The sources of data to be reviewed in this step include:  MCOs  Fiscal intermediary

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o Eligibility extract o Claims extract (includes PAAS, fee-for-service Medicaid, and carve-out services provided to MCO enrollees). 3. Begin source data revision process with each of the data sources (if necessary) and establish data transmission methodologies. 4. Receive test data submissions from each source and review for accuracy, completeness, and data quality. Test data transmission methodology determined in Step Three as well. 5. Provide feedback to each of the data sources including required revisions (if necessary). Steve Johnson, Ph.D, Program 6. Receive and process replacement test data Management and Improvement Team from sources that were required to make Lead, is a nationally-recognized risk modifications. adjustment expert with over 36 years of experience working with health care data, 7. Provide feedback to each of the data sources primarily focusing on the analysis of that supplied replacement data including Medicaid data. He developed two interactive support tools that states can required revisions (if necessary). use to evaluate the completeness of the 8. Execute production (full file) tests with each encounter data they receive from their of the data sources. MCOs and the efficiency of MCOs in providing services to their members. 9. Review test production and make revisions, if necessary. 10. Production schedule (monthly receipt) commences.

Implementation The Lewin Group will capture encounter, claims and eligibility data from participating MCOs, the PAAS program, and the fiscal intermediary on a monthly basis. MCO data will be consistent with UB92 and CMS1500 formats. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 13. Task 3.2.2.2 Sample Work Plan and Timetable for 2011-2015

#523964 RFP #MED11010 Managed Care Administration

Review encounter data (3.2.2.3)

Accurate and complete encounter data is a vital resource for evaluating the performance of providers in the MCO and PAAS program. The encounter data received from these providers must be extensively evaluated to determine if there are any errors or omissions in the data.

Overview of Approach The Lewin Group will give immediate feedback to MCO and PAAS providers if our evaluation studies identify any problems with the encounter data, so that corrected data can be submitted on a timely basis. By closely monitoring the encounter data submitted by MCO and PAAS providers, The Lewin Group will ensure that an accurate and complete encounter database is created.

Once the processes for receiving data have been completed, the processes that will be used to validate and load the production data will be implemented. This process has a number of steps, with each step building upon its predecessor:

1. Media verification – is the input source (tape, CD, electronic file transfer) machine readable without uncorrectable errors. 2. Control total verification – the number of records on each file will be compared to the control totals provided on the data transmission sheet, and if the data are claims, the financial totals will be checked against the data transmission sheet. 3. Physical data verification – does the file “line up” with the specified record layout (e.g., patient date of birth is in positions 70 through 77 ). 4. Edit verification – once the encounter data file has passed the first three verification steps, the data will be subjected to a rigorous set of edits to validate the accuracy of the data: a. Valid values – each data element will be tested against valid values for that field, and invalid data values will be flagged as errors. b. Eligible recipients – member ID numbers will be matched against the eligibility file to verify that the member was enrolled with the provider submitting the encounter and eligible for Medicaid on the date of service. c. Registered Providers – the provider ID number on the encounter will be matched with the provider file to verify that the provider was enrolled and authorized to provide the service on the date of service. d. Internally Consistent- the data will be edited for internal consistency to verify that reported diagnoses and procedure codes are consistent with the member’s age and gender (e.g., hysterectomies are not being performed on 5 year old males). 5. Data completeness – a series of validation checks will be conducted to verify that the encounter and claim data is complete. The total number of claims/encounters and unduplicated recipients will be computed for each month for each category of service. These counts will be used to determine if the volume of data received is consistent over time. This process will identify months with lower than expected volume for follow-up

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discussions with MCO and PAAS providers. Data completeness will also be evaluated by comparing the volume of encounters submitted by each MCO against the other MCOs. To control for variations in demographic mix, this analysis will be conducted separately for TANF adults and children. The completeness of the encounter data will also be evaluated by comparing the utilization and financial totals from the MCO encounter data with their financial filings with the Department of Insurance. 6. Update the encounter database – Accurate and complete files that pass the completeness and edit verification tests will be added to the encounter database.

At any point in the update process, any anomalies will be discussed at length with the data source’s technical contact. Issues that cannot be resolved with discussion and analysis will generate a replacement submission by the source.

Implementation The Lewin Group will review encounter data for completeness and inconsistencies, conduct validation of data, and consult MCOs and the PAAS program to address any data issues. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 14. Task 3.2.2.3 Work Plan and Timetable for 2011-2015

Produce monthly, quarterly, and annual encounter data reports (3.2.2.4)

A comprehensive reporting strategy is essential for monitoring the performance of the MCOs and comparing their performance with PAAS and other public programs. The completeness of encounter data must be monitored on a monthly basis to identify data problems quickly and permit timely follow-up with the MCOs. Monthly and quarterly reports will be used to track key measures of data completeness and program efficiency so that trends in these measures can be monitored. Annual reports will create a more comprehensive view of program performance, including measures of plan quality and efficiency.

Overview of Approach In developing the reporting package, Lewin will work collaboratively with the Bureau in all phases of report development. As a starting point, existing reports will be reviewed with BMS to inventory existing measures. In addition to this review, we will make recommendations to BMS for additional measures to be considered for inclusion in the reports. Once the draft package is completed, we will present it to BMS staff for comment. The reporting package will be revised based upon comments received during the review process. The review and revision process will continue until BMS has a reporting package that achieves the goal of helping the Bureau understand the utilization patterns and trends of the population it serves.

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Once the package of reports is designed and periodicity of the measures (e.g., monthly, quarterly, annually) determined, we will implement the reporting package. As part of this implementation phase, we will suggest external comparative measures to evaluate program performance. For example, the annual report will include the rate of a preventative service such as well child visits among the participating MCOs. Along the with rate of the service by MCO, the state may wish to display the same rate for the PAAS and fee-for-service programs or commercial HMO rates, as well as rates for other West Virginia public payers. To the extent that such measures are available, they will be incorporated into the BMS reporting package.

To deliver reports and analyses to BMS, we will utilize a series of applications based on the Cognos suite of business intelligence tools (Cognos Connection, Report Studio, Query Studio, Analysis Studio, and Event Studio).

Figure 15. Cognos Connection Screen Shot

Using the database of encounters, claims, and eligibility as a basis, Lewin will implement a metadata dictionary that allows for end users to construct production reports and ad hoc queries as well as perform analysis using online analytic processing (OLAP) tools. We will construct a series of reporting objects to facilitate reporting and analysis:

 Combined claims and encounters (MCO and FFS);  Fee-for-service medical and dental detail (includes ad-pays and other adjustments);  Inpatient encounters ( MCO and FFS);  Enrollment detail (MCO and FFS);  Enrollment summaries (MCO and FFS);  Prescription drugs (MCO and FFS); and  Provider detail.

#523964 RFP #MED11010 Managed Care Administration

Report Studio is a full-featured report writer that includes sophisticated scheduling as well as output delivery options such as recipients and format.

Figure 16. Report Studio Screen Shot

Report Studio includes a number of pre-defined formats (e.g., lists, crosstabs Pivot tables, and graphics) as well as analytic functions (e.g., mathematic, statistical, data manipulation). User interaction is primarily drag-and-drop and includes custom programming capabilities. Reports implemented in the BMS catalogue include:

1. Financial / claims summaries a. Lag charts b. Paid claims c. Enrollment d. Access measures (provider and patient crosstabs) 2. Type of service utilization a. Inpatient days/encounters b. Outpatient encounters c. Physician office encounters d. Episodes of care 3. Diagnostic utilization a. Inpatient hospital b. Outpatient hospital c. Physician office d. Other

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4. Prescription drugs a. Utilization by classes b. Utilization and cost by classes by disease state classification c. Cost by classes d. Generic penetration

Query Studio, like Report Studio, is primarily a drag-and-drop tool. Query Studio is designed for ad hoc interrogation of data. Since Query Studio and Report Studio share the same metadata repository, variable and definitions are identical. Queries developed in Query Studio can be imported into Report Studio as needed for more advanced development and deployment.

Figure 17. Query Studio Screen Shot

Analysis Studio is an OLAP tool that is designed for business user level integration of the claims/encounter database. Cubes (or OLAP objects) are presummarized views of database objects. The cube in the graphic below is a summarization of the combined MCO and FFS claims database back to SFY 2004 SFY. Because the data are represented in a summarized, highly indexed file, massive amounts of data can be analyzed and reported very rapidly with a few drags of a mouse and several mouse clicks.

#523964 RFP #MED11010 Managed Care Administration

Figure 18. Analysis Studio Screen Shot

1. Custom medical, pharmacy, and eligibility extracts have been delivered to third parties at BMS direction. Examples of such file construction projects are the datasets delivered to West Virginia University to analyze the effectiveness of Mountain Health Choices; inpatient hospital utilization datasets to the West Virginia Health Care Authority and West Virginia Hospital Association; and combined West Virginia public payer files to independent actuaries to study the impact of potential health care reform initiatives. 2. Internal analyses delivered to BMS. Examples of such applications include compliance analysis of Mountain Health Choices participants, CMS reporting reconciliation, inpatient hospital days reporting, and custom eligibility analyses and reporting. 3. Rate setting files and analyses. Extracts have been developed to support the development of capitation rates and payments to participating MCOs based on the encounter data submissions. As more services are included in the MCO service package (e.g., SSI population, dental, and behavioral health), the extract process will be modified to accommodate the expanded scope of services. 4. As risk adjustments are introduced to the rate setting process, the database will support those calculations. We have extensive experience using the database to support proprietary risk analysis tools, 3rd party commercial software (e.g., Adjusted Clinical Groups, DxCG) and public domain tools (e.g., CDPS, HCC).

In addition to the software tools described above, we are always ready to assist in whatever fashion the situation dictates whether that be training/support on Cognos tools, performing sophisticated analysis at BMS direction, or developing turnkey analytic applications.

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Implementation The Lewin Group will produce monthly, quarterly, and annual encounter data reports for the Bureau that incorporate encounter data and FFS program data. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 19. Task 3.2.2.4 Sample Work Plan and Timetable for 2011-2015

Provide technical assistance to the MCOs on data issues (3.2.2.5)

The submission of clean, consistent data by the MCOs is critical to the ongoing success of MHT. At the Bureau’s request, Lewin will utilize a number of technical assistance methodologies to support MCOs and other vendors, including, but not limited to, written and electronic documentation, telephone, electronic mail, knowledge management tools (such as Wiki, portals, and bulletin boards) and face-to-face meetings at the Bureau’s direction. The types of assistance that Lewin has provided in the past (and anticipates to perform similarly in the future) include reviewing MCO member materials, MCO agreements with subcontractors, and marketing requests for compliance with contract terms; reviewing revised enrollment applications for the enrollment broker to ensure compliance with federal requirements; support with FFS claims data or encounter data from the enrollment broker; assisting MCOs in interpreting MCO Contract requirements; and reviewing proposed standards for MCO quality assurance programs for the external quality review organization. Lewin’s long standing history with West Virginia and our strong existing working relationships with the MCOs and other vendors will enable us to most effectively meet their technical assistance needs and provide a coordinated response so that required data is collected in a timely and efficient manner.

Implementation The Lewin Group will provide technical assistance to the MCOs on data issues. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary.

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Figure 20. Task 3.2.2.5 Sample Work Plan and Timetable for 2011-2015

Transmit monthly electronic reports to the MCOs on pharmacy utilization (3.2.2.6)

We will use the existing pharmacy extract format as a starting point to provide carved-out prescription drug claims to each of the participating MCOs. Discussions will take place with the plans to determine what modifications, if any, are needed to the current format. Once a format is developed that is agreeable to both the MCOs and the Bureau, we will design, implement, test, and put into production a process that either delivers, or makes available for delivery, the appropriate prescription drug data. Possible delivery methodologies include, but are not limited to, CDROM, DVD, encrypted email, and secured FTP (push and pull). We will work with each of the plans to determine which methodology is acceptable. Currently, plans are receiving drug data using SFTP (push), FTP with PGP encryption (pull), and FTP with ZIP (256 bit AES) encryption (pull).

Implementation The Lewin Group will transmit monthly electronic reports to the MCOs on pharmacy utilization for their enrolled members as long as pharmacy is carved out of the MCO capitation rates. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary.

Figure 21. Task 3.2.2.6 Sample Work Plan and Timetable for 2011-2015

Conduct analysis of Medicaid EPSDT program (3.2.2.7)

As an organization, we have had considerable experience with EPSDT programs from both analytic and operational perspectives. In the past, we have participated in both the production of 416 reports as well as providing the data necessary to other entities that are responsible for EPSDT and other required reporting. In addition to serving in an analytic capacity, we have also been involved with setting reimbursement rates and modeling the impact of proposed reimbursement rates.

In order to fulfill this requirement, we will meet with the appropriate BMS and DHHR staff to determine what level of support is required. Based upon those discussions, we will design, implement, test, and put into production data extracts and/or reporting tools that measure EPSDT program performance. EPSDT reporting has been developed such that custom subsets

#523964 RFP #MED11010 Managed Care Administration as well as customization of definitions are supported. For example, while 416 reporting to CMS is performed at the program level, plan or delivery mechanism level reports are available as well. Lewin will use these reports to respond to state and federal requests for information as needed.

Implementation The Lewin Group will conduct analysis of the Medicaid EPSDT program and create custom extracts to respond to state and federal requests for information on program performance. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary.

Figure 22. Task 3.2.2.7 Sample Work Plan and Timetable for 2011-2015

Produce PAAS provider profiles on key services that are health care cost drivers (3.2.2.8)

Physicians providing primary care case management services through the Physician Assured Access System (PAAS) play a key role in ensuring that Medicaid beneficiaries receive necessary medical care services. These physicians also play an important role in making sure that their patient panels do not utilize unnecessary medical care services or receive services in a more expensive setting when lower cost alternatives are available. Profiling the utilization of health care services by the panels of physicians participating in the PAAS program can assist MHT in identifying those physicians that are successfully fulfilling their primary care case management role. Reviewing these profiles with PAAS physicians will help them to understand those areas where they are performing their case management role successfully and areas where they can improve their performance.

Lewin will create provider profile reports for PAAS physicians by summarizing the annual utilization of key health care cost drivers including: emergency room visits, inpatient hospital admissions, prescription drugs, and diagnostic lab and x-ray services by members enrolled in their panel. For each health care service, Lewin will summarize the units of service and total paid dollars for each member of a physician’s panel. Lewin will also summarize the total member months of eligibility for each physician’s panel. The provider profile reports will combine the health care services utilization measures with the member month data to compute average annual utilization rates and the cost per member per month (PMPM) for the physician’s panel. The annual utilization rates and PMPM costs can be used to compute the relative performance of each PAAS physician.

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To control for differences in the demographic mix of a provider’s panel, Lewin will compute annual utilization rates and PMPM costs separately for TANF Adults, TANF Children, SSI Adults, and SSI Children. Lewin will also assign each PAAS physician to one of the following peer groups: Pediatricians, Family/General Practitioners, Internists and Other Practitioners. To evaluate the relative performance of each physician, the utilization of his or her panel will be computed for each of the four eligibility categories and compared to the average utilization for each eligibility category for his or her peer group.

Lewin will update provider profile reports on a quarterly basis and evaluate the utilization of health care services for the most recent complete annual period. Lewin will create a manual describing the measures included in the reports and how these measures should be interpreted by PAAS physicians to evaluate their performance. The profiles will be mailed to PAAS physicians, and physician inquiries on report content will be addressed using telephone, FAX, email, or written correspondence via mail.

We will also review the results of the analysis with BMS staff. In particular, providers with significantly different results from their peers will be analyzed further, allowing for corrective action as well as the monitoring of provider behavior.

Implementation The Lewin Group will produce PAAS provider profiles on key services that are health care cost drivers, mail the reports to providers, and respond to provider’s questions related to the profile. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as necessary.

Figure 23. Task 3.2.2.8 Sample Work Plan and Timetable for 2011-2015

Produce annual report on PAAS provider performance (3.2.2.9)

Lewin will create a comprehensive annual report to monitor the performance of each PAAS physician. The annual report will provide BMS with a comprehensive profile that the Bureau can use to evaluate the performance of each PAAS physician.

The annual report will include all of the relative health care utilization measures and costs per member, per month, described in the response to Task 3.2.2.8. In addition, the annual report will include an efficiency index to evaluate the relative total cost of members in each PAAS physician’s panel. To create the efficiency measure, the total cost per member, per month, will be computed for each panel member. To account for the acuity of each physician’s panel, a Chronic Disability Payment System (CDPS) risk score will be calculated for each member. The risk scores will be used to compute the average acuity for each panel for each of the following

#523964 RFP #MED11010 Managed Care Administration four eligibility categories (e.g., TANF Adult, TANF Child, SSI Adult, SSI Child). The average total cost PMPM will also be computed for each of the four eligibility groups. By dividing the total cost PMPM by the average risk score for each eligibility group, Lewin will compute a risk neutral cost PMPM for each of the four eligibility groups. The risk neutral cost PMPM for each physician’s panel will then be compared to the risk neutral cost PMPM for the entire eligibility group to compute an efficiency index for each eligibility group. The efficiency indices for each of the four eligibility groups will be combined to compute an overall efficiency index for a physician.

The annual report will also include a care coordination measure for each physician. For each member, we will create indicators to identify whether they were seen by their PCP, other primary care physicians, other specialty physicians, a free standing clinic, hospital-based outpatient department, or emergency room. These indicators will be used to classify members based upon whether they were seen by their primary care physician, seen by other primary care physicians, seen by other specialists, seen in a clinic or outpatient department, only seen in an ER, or had no visits in an outpatient setting. The coordination care efforts of a physician will be measured by evaluating the percentage of their panel that they treated, the percentage seen by other physicians or in a clinic setting, the percentage only seen in the ER, and the percentage that were not treated in an outpatient setting.

BMS can use the annual report to identify physicians whose panel is utilizing excessive health care services, have high relative cost based upon their relative efficiency index, and/or are performing poorly in coordinating care for their panel. The annual report will also identify physicians who are doing an excellent job coordinating care and providing services efficiently.

Implementation The Lewin Group will build on Task 3.2.2.8 to produce annual reports on PAAS provider performance. The figure below summarizes a sample timeline with annual reports delivered each year of the contract.

Figure 24. Task 3.2.2.9 Sample Work Plan and Timetable for 2011-2015

Develop additional profile reports for inclusion in monthly and annual reports (3.2.2.10)

Lewin will create additional profile reports for inclusion in monthly and annual reports, after consultation with MHT to address new and emerging areas of interest. Potential profile areas will be presented to BMS for approval. Once a topic area has been identified and approved by BMS, the profile implementation process will begin using the previously described methodology.

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The utilization measures, efficiency indices, and coordination of care measures discussed in the responses to Tasks 3.2.2.8 and 3.2.2.9 can be used to evaluate the performance of PAAS physicians in directing the care received by those members identified in these new areas.

Deliverables: Task 3.2.2.10 Develop Additional Profile Reports for Inclusion in Monthly and Annual Reports . The Lewin Group will submit waiver renewal documents to the Bureau 90 days before expiration of the current waiver in 2012. . Lewin will prepare interim waiver amendments or state plan amendments within 45 days of request by the Bureau.

Implementation The figure below summarizes the specific work steps required for the 2012 waiver renewal process and a sample interim amendment request. This task will repeat as needed for future renewals and amendment requests.

Figure 25. Task 3.2.2.10 Sample Work Plan and Timetable for 2012

Develop options for program expansion and assist in implementing program expansion (3.2.2.11)

The Lewin Group will work with the Bureau to continue to expand the managed care program. Lewin will help develop expansion strategies, examine options for program expansion in detail, study the potential implications of expansion, and help with the implementation of program

#523964 RFP #MED11010 Managed Care Administration expansions. Managed care program expansion is often considered as a cost saving measure, but it must be approached cautiously and deliberately, with complete understanding of the likely impacts. Lewin has experience performing necessary analyses for a variety of states. For example, in 2005 the Illinois Legislature commissioned a study, competitively awarded to Lewin, to assess a wide range of Medicaid managed care approaches. Our work included interviews with various stakeholders, extensive data analysis, and a detailed assessment of both the qualitative and quantitative strengths and weaknesses of each Medicaid managed care model. We presented our findings in both a detailed written report and during an on-site legislative committee hearing in Springfield. Our findings are often cited during debate in the Illinois General Assembly on expanding the use of managed care in the Illinois Medicaid program.

In a two-phased project, The Lewin Group developed a comprehensive set of cost estimates for potential expansion of Texas' Medicaid managed care programs. The study included a projection of potential savings as a result of implementing various managed care expansion options (such as capitation and exclusive provider arrangements), as well as a geographic analysis of potential expansion regions and population subgroups (e.g., TANF, disabled). The study also took into account the potential effects managed care expansion would have on other programs and benefits, such as pharmacy. The Lewin Group then assisted the Texas Health and Human Services Commission staff with an assessment of technical issues involved in designing an expanded Medicaid managed care program. As part of this work, we modeled expected costs and savings of various options the commission was considering, including benefit package service options, expanding eligibility, and effects of cost sharing. Technical options for inclusion of long-term care and mental health services were presented as well as research on other innovative eligibility program designs in these areas. The technical assistance aided the Commission staff in preparing a briefing for the Texas Legislature. Lewin staff also provided testimony at a special joint meeting of relevant legislative committees.

Deliverables: Task 3.2.2.11 Develop Options for Program Expansion and Assist in Implementing Program Expansion . The Lewin Group will develop proposals outlining options for program expansion for areas without managed care entities and as SSI eligibility is expanded across the State as requested by the Bureau. The Lewin Group will develop any required materials and CMS documentation within 45 days of request from the Bureau for Medical Services.

Overview of approach Upcoming managed care expansions Lewin will continue to assist the state with the expansion of SSI, behavioral health, and children’s dental coverage including:

 Helping with the preparation of implementation timelines;  Communicating with MCOs and key stakeholders;  Reviewing managed care networks;  Operational readiness reviews;

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 Answering questions MCOs have about expansions prior to going live;  Supporting BMS by handling ad hoc requests; and  Monitoring changes to federal regulations and determining if there is any impact on expansion plans.

Lewin will perform the tasks mentioned above by identifying areas of concern through quarterly monitoring efforts, surveys and focus groups, and analyzing complaints and grievances by beneficiaries. Lewin will develop solutions to mitigate problems found with the expansions, working together with BMS and the MCOs.

Lewin will help with post-implementation assessments of the success of the program expansions along with areas for improvement, by conducting beneficiary focus groups and surveys and getting feedback from MCOs and other key stakeholders. Lewin will create separate summary briefings for BMS on each expansion effort and also will report findings to CMS. Lewin’s experience and knowledge of the managed care program will provide assurance that upcoming expansion implementations will be successful despite the ending of the Mountain Health Choices program.

Identifying new opportunities for expansion Beyond the currently planned expansions, the Bureau may wish to identify expansions to additional populations or the provision of Lewin may analyze the benefits of implementing additional benefits in the capitated benefit a pharmacy carve-in for managed care. With the package (e.g., pharmacy, non-emergency implementation of the new health reform medical transportation). Potential expansions legislation, pharmacy rebates are similar may be statewide or piloted on a regional whether or not pharmacy services are carved-out basis and may be provided through a full- of the managed care program or included within risk MCO or other vendors. As with all it. Federal rebates now available for drugs provided through a managed care program, and expansion options, we will work with the there are clear benefits for carving pharmacy Bureau to prepare memoranda and other services into the managed care: documents to assist the Bureau in identifying and implementing expansions.  Benefit coordination by one entity;  Improved beneficiary outcomes; and Impact of health reform legislation  Management of the pharmacy benefit by The recently-passed health reform legislation the MCOs leading to cost savings. will greatly expand the number of people who are eligible for Medicaid coverage. Lewin will provide analysis and assistance to BMS Lewin will use its detailed knowledge of the in determining how to proceed and the impact of health reform legislation to analyze federal the pharmacy carve-in on payment rates. Lewin will also analyze other potential service areas to and state requirements to estimate the carve-in to the managed care program including potential number of new members in services for dual eligibles, non-emergency Medicaid and the capacity of the current medical transportation, and long-term care. MCOs to handle additional members by the time the legislation is totally implemented in 2014. The state will need to be prepared early for the expansion of Medicaid and the managed care program, and will need to collaborate with current MCOs to promote program expansion.

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There are many issues that need to be examined to expand the managed care program. The state must consider the capacity of MCOs to handle expansion and to enroll new members, how to provide coverage in rural areas, the potential for new MCOs to enter the state market, the outreach required to promote program growth, and the timelines and cost implications to expand the managed care program. Lewin also will examine the potential of using health exchanges as an alternative method to expand coverage.

Implementation Lewin will summarize the findings of these reviews and analyses in a memorandum to the Bureau, outlining each option related to overall program goals and cost implications. The memorandum also will address administrative implications (e.g., coordination with other state programs, legal and regulatory constraints). Next, Lewin will prepare appropriate waiver, contracting, and MCO assessment materials. These will include the waiver amendment to enable mandatory enrollment into a single MCO in rural areas, Requests for Proposals or Medicaid MCO Provider Applications, addenda to the MCO Scope of Work to account for additional populations and/or benefits that may be included in the expansion, evaluation approaches and criteria, and contracts. Lewin staff will also assist the Bureau in completing the waiver approval process by participating in conference calls and meetings and preparing written responses to questions.

We will then assist the Bureau in implementing the procurements by reviewing written submissions, conducting readiness reviews and site visits, evaluating networks and developing enrollment capacity estimates, preparing written summaries of proposal review findings and contracting recommendations, serving as technical advisors to evaluation committees, and supporting the Bureau in contract negotiations and the actual implementation of the expansion.

Finally, Lewin will analyze and help the state develop the waivers, state plan amendments, RFPs, and MCO contract updates that will be needed to accommodate the expansion of the managed care program.

The figure below summarizes the specific work steps required for one year to develop and then implement the program expansion. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

#523964 RFP #MED11010 Managed Care Administration

Figure 26. Task 3.2.2.11 Sample Work Plan and Timetable for 2012

Scope of Work: Program Evaluation and Improvements (3.2.3)

Through our work in knowledge transfer, comparative effectiveness research for public and private sector clients, and policy consulting for state governments, foundations, and associations, we have extensive experience surfacing best practices and translating findings into actionable recommendations.

Recent research projects have included surveys and analyses of other state programs in innovative areas, such as programs that serve dual eligibles and other special populations, Medicaid managed care performance incentive strategies, eligibility simplifications, Medicaid managed care purchasing specifications, 1115 waivers, and rural options. For example, we conducted research on best practices in monitoring Medicaid managed care programs and developed a paper describing how leading states are using claims and encounter data and other data sources and methods to set capitation rates and monitor and report on access and quality. Lewin and its subcontractors also designed and implemented a study of the impact of Medicaid home and community-based (HCBS) programs and other Medicaid-funded long-term care (LTC) services on quality of life, quality of care, utilization, and cost. We have conducted a review of states’ approaches to monitoring EPSDT services for managed care enrollees; a review of MCO/Behavioral Health Organization (BHO) relationships; and a review of performance incentive approaches used by state Medicaid managed care programs. As a result, we are accustomed to working closely with state staff to develop research agendas and design effective and cost-efficient research approaches.

As the Mountain Health Trust program has expanded and matured, the need for increasingly sophisticated oversight and monitoring has grown, and this need will amplify with the planned program expansions in 2011. As such, the objective of this task is to assist the Bureau in designing and implementing a Managed Care Improvement Plan (MCIP) that identifies program modifications through systematic, ongoing, and periodic program monitoring activities. The Lewin Group will use the Plan, Do, Study, Act (PDSA) continuous quality improvement model as a guiding principle in the development and implementation of West

#523964 RFP #MED11010 Managed Care Administration

Virginia’s MCIP, including coordination with statewide efforts described below and alignment with the Bureau’s QAPI strategy as detailed in Subtask 3.2.4.1.2

Systematic Feedback Loops for Program Improvement Over time, program process changes may be necessary not only if monitoring activities suggest areas in need of improvement, but also if the Bureau chooses to make significant changes to MHT (e.g., program expansion), or as required to come into compliance with the ACA, other federal policies and regulations, or new access and quality standards. Lewin’s strong understanding of West Virginia’s current performance monitoring methods and data intricacies, coupled with our national knowledge of best practices, will enable us to design a comprehensive MCIP that leverages monitoring activities already in place to develop systematic feedback loops for continuous program improvement and to support reporting to CMS as needed.

Figure 27. Managed Care Improvement Plan – Plan, Do, Study, Act Model Lewin will craft the MCIP using a PDSA model, which involves systematic feedback of performance measurement and results into Act program design to continuously improve planning Determine what Plan and program delivery. When measured results are Changes are to analyzed and fed back into planning and decision- be made Change or test making, the Bureau can use the information about how MHT is performing to improve program Study design, deliver more effective services and better Summarize what attain program goals. Lewin will begin by was learned Do identifying all Carry out To better assist the Bureau with current plan ongoing management of the performance MCOs’ performance, Lewin monitoring created a high-level quarterly activities that executive dashboard in 2009 may be which trends key monitoring leveraged as part of a comprehensive MCIP. Program measures such as enrollment, PCP panel size, utilization, performance assessments included in the waiver, quarterly grievances, member/provider reports submitted by the MCOs, EQRO findings, and other service functions, and Mountain monitoring activities are a few examples of performance Health Choices. The data is data resources. The beneficiary survey, recently conducted shared internally at the Bureau by Lewin, is another immediate source of information on to brief executives on Mountain program performance. Lewin will also work closely with Health Trust and identify potential areas for contractors such as the fiscal intermediary, the enrollment improvement. broker, and the EQRO to examine potential issues across each expansion in a systematic, recurring fashion.

2 For more information on the PDSA model, see: Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.]

#523964 RFP #MED11010 Managed Care Administration

In addition, Lewin will combine various elements from the sources above in the existing quarterly executive dashboard (sample analysis shown in the following figure) to provide the Bureau with a comprehensive view of implementation progress and performance. When brought together, these elements and others that we will identify in partnership with the Bureau will provide a rich set of data for ongoing program improvement efforts.

In 2009, Lewin worked closely with the Bureau on the creation of a quarterly executive dashboard to help improve management and oversight of the MHT program by the Bureau. The dashboard graphically presents key monitoring measures collected by the State through the quarterly reports submitted by the MCOs and includes the most recent version of updates to the MCO quarterly reports. Data for measures is trended across quarters to identify any areas for concern or data reporting errors that require follow-up with the MCOs. An example of an issue that Lewin would follow-up on with an MCO includes:

 The average member hold time for MCO A significantly increased this quarter, from 5 seconds in Q1 to 56 seconds in Q2 o This hold time is near the reported hold time for Q4 2009 (58 seconds) o Member calls for MCO A decreased by 4% in Q2  Provider hold times also increased for MCO A, from 7 seconds in Q1 to 66 seconds in Q2

Lewin is in the process of finalizing additional updates to the MCO quarterly reports to address the planned expansion in 2011, and these additional measures will be incorporated into the dashboard moving forward to ensure that the State can appropriate monitor access and utilization as new beneficiaries and services transition into managed care.

Figure 28. Sample Utilization Measure from Quarterly Reporting Dashboard

ER Visits per 1,000 Members, per year, by MCO

2,500

2,000

1,500

1,000

500

0 MCO A MCO B MCO C Q4 - 2009 1,984 2,156 1,906 Q1 - 2010 665 1,648 1,478 Q2 - 2010 705 1,916 1,629

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Collaboration with Statewide Efforts Another source for obtaining continuous feedback includes working with the West Virginia Health Improvement Institute (WVHII), which has taken on a key role in working with stakeholders to determine what the behavioral health integration model should look like. With the Bureau’s impending behavioral health carve-in, it will be important for the Bureau to participate in WVHII workgroups to support transparent dialogue in identifying opportunities for collaboration and continuously soliciting input and feedback throughout the planning, implementation, and post-implementation processes.

The Lewin Group will continue to assist the Bureau in taking an active role in coordinating with WVHII, which has been instrumental in helping to obtain stakeholder feedback related to the planned program expansion. If desired, Lewin can continue to work closely with WVHII post- expansion to continue to gain stakeholder feedback and maintain an open forum for problem- solving and issue resolution. The Lewin Group will continue to support the Bureau in taking advantage of the important opportunity to coordinate with this statewide initiative, helping to ensure a successful transition for all beneficiaries.

Summary In developing a strong Managed Care Improvement Plan, The Lewin Group will enable the Bureau to efficiently identify and prioritize program improvement opportunities and implement the necessary program modifications in a timely manner, resulting in a more agile managed care program that meets the needs of its stakeholders and beneficiaries.

Deliverables: Task 3.2.3 Program Evaluation and Improvements . The Lewin Group will prepare memoranda and issue papers within 45 days of request by the Bureau . Lewin will provide the Bureau with annual summary reports of the MHT program within 45 days of the end of the year

Recommend and develop processes that will improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. (3.2.3.1)

The objective of this task is to assist the Bureau in providing information and developing processes that will improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. To do so, Lewin will work with the Bureau to develop a yearly Managed Care Improvement Plan. This Managed Care Improvement Plan (MCIP) will consider opportunities for clinical quality improvement, as well as opportunities to promote the effectiveness and efficiency of program administration. We have worked with numerous other states on quality improvement initiatives. For example, Lewin recently worked with the State of Missouri to conduct a substantive review of the Medicaid program and developed recommendations on how the State can achieve short-term Medicaid savings, conducted detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program.

#523964 RFP #MED11010 Managed Care Administration

Lewin will support the Bureau in improving delivery of health care to Medicaid beneficiaries. Lewin will collaborate with the Bureau and its contractors to identify areas for quality improvement and program efficiency using a systematic feedback approach, including assessment of the utilization of benefits packages and health outcome status. We will examine data such as beneficiary complaints, quarterly reports, network access, CMS feedback, and bi- annual beneficiary survey results. Lewin will also continue to hold and participate in quarterly calls with the EQRO regarding performance monitoring. Through the MCIP, The Lewin Group will make recommendations and implement new processes to both improve efficiency and effectiveness and enable the Bureau to provide higher quality services to its beneficiaries.

Overview of approach Oversight and monitoring activities are intended to identify program areas in need of improvement to ensure that enrollees have access to quality health care services. Critical to this is the administration of the Medicaid program. Lewin will work with the Bureau to develop a MCIP to:

1. Identify areas for program process changes Lewin works closely with the State’s through ongoing program management EQRO on an ongoing basis to activities, encounter data analysis, review of coordinate monitoring activities to MCO and PAAS provider performance, EQRO ensure that MCOs are delivering reports, and network analysis. quality services and providing appropriate access to Medicaid 2. Prioritize program process changes, in beneficiaries. We facilitate monthly partnership with the Bureau, to establish when calls between Lewin, the Bureau, and and how program improvements will be the EQRO to discuss potential monitoring concerns and areas for approached and whether cost impacts are potential partnership. For example, likely. we recently facilitated a 3. Develop individual Managed Care teleconference to discuss ideas for MCO performance improvement Improvement Plans, including the desired projects and other outcomes outcome, work steps, timeline, and measures in light of the upcoming organization/staff responsible (see Figure 29 expansion of the managed care for an example of a component MCIP). program. We also solicit the EQRO’s feedback on the bi-annual waiver 4. Review and report on the success of renewal and review the EQRO’s improvement strategies and identify lessons annual report. learned for future improvements.

Recommending Program Process Changes Lewin anticipates several areas where the Bureau will need to consider program modifications, as we have described throughout our proposal, including processes to more efficiently gauge quality and access. Certainly, we will continue to work with the Bureau to identify additional opportunities for quality improvement and overall program efficiency. For example, as part of the Conditions of Approval for the State’s 1915(b) waiver renewal, CMS is requiring the Bureau to submit a variety of reports on a monthly basis to demonstrate successful expansion of the MHT program. Lewin is working closely with the Bureau to revise reports submitted by the MCOs on a quarterly basis to include the information requested by CMS. We are building on the existing MHT quarterly reports to maximize efficiency and minimize burden on State and

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MCO staff. Lewin is also coordinating with other State vendors, such as the enrollment broker and EQRO, to ensure that monitoring efforts capture all of CMS’ requirements and are reported in a coordinated effort to CMS.

After the expansion, Lewin will closely monitor provider networks, utilization of services, and grievances and appeals. In addition, we can assist the Bureau in conducting a survey of a sample of TANF and new SSI beneficiaries regarding their experiences and access related to the MHT program, behavioral health, and children’s dental services. This will allow the Bureau to identify any issues and resolve them expeditiously. In addition, in 2011, we will also administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to a sample of all beneficiaries enrolled in the Medicaid program to assess beneficiary satisfaction and identify areas for improvement

Subsequent external quality reviews and evaluations may also be modified to become more performance-based. While the MCOs have performed well on external quality reviews for the past several years, the EQRO audits focus largely on process and documentation and less on results. The Bureau has already required MCOs to conduct more comprehensive quality assurance and performance improvement projects. To accomplish these modifications, Lewin will work with the Bureau to identify and develop recommendations for monitoring the outcomes of those projects. Moving toward a system of performance-based monitoring will ensure that MCOs are effectively implementing the quality strategies detailed in their quality assurance and performance improvement plans. This will become increasingly important as the new regulations in the ACA begin to take effect, including significant expansion in covered lives, an area where Lewin can support the Bureau in planning as discussed in Task 3.2.5.8 below.

Another area that Lewin anticipates the State needing to improve efficiency and consider program modifications is overall beneficiary access to health care services. Given the upcoming behavioral health and children’s dental expansion, as well as the addition of new SSI beneficiaries to the MHT program (as well as the impacts of the ACA in 2014), the Bureau will need to develop new and innovative mechanisms for monitoring access to care in a timely manner. This may involve responding quickly to CMS’ requests for ad hoc network analysis upon the expansion or proactively monitoring MCO provider networks on a monthly basis for up to 90 days after implementation to ensure continued beneficiary access.

The development of a provider database to facilitate the collection of provider network data from the MCOs for determining network adequacy will help the Bureau to proactively monitor access and respond to any concerns that may arise that prevent appropriate access to services. Appropriately and quickly assessing network adequacy data will also enable the Bureau to approve new MCOs for participation in the MHT program and allow program expansions to “go-live” more quickly. Inconsistencies associated with the provider information submitted by MCOs have historically created a strain on Bureau resources as data elements lack standardization, not only between MCOs, but at times even within an MCO’s own data. The development of a provider database through which MCOs would be required to submit provider data in a standard format for network adequacy review would enable the Bureau to more efficiently complete assessments and reduce the strain on resources.

#523964 RFP #MED11010 Managed Care Administration

To assist with the development of the provider database and analysis of specific opportunities for program modifications such as MCO reporting requirements, Lewin would work closely with the Bureau to develop a more detailed MCIP at the beginning of the new contract period. For the purposes of our proposal response, we have developed a sample MCIP addressing the development of provider database below.

Figure 29. Sample Managed Care Improvement Plan – Provider Database

Development and Implementation of an MCO Provider Database

Goal: Collect complete and standardize MCO provider network data efficiently.

Action Steps Outcomes Timeframe 1. Review current data being Comprehensive list of all current Month one collected data elements collected 2. Identify data fields for provider Prioritization of data elements into Month one database standardized fields (e.g., provider name, provider address, Medicaid panel restrictions, provider speciality) 3. Review proposed data fields Feedback is incorporated back into Month two with BMS and MCOs; update as design needed 4. Determine where database will Necessary hosting agreements Month two be hosted complete 5. Beta test database Test results complete Month three 6. Revise fields and functionality Database design is updated Month three as needed 7. Launch provider database for Database goes live Month four MCO use 8. Provide technical assistance to Technical assistance is provided to Month five MCOs MCOs in uploading required data 9. Survey MCOs for feedback Month seven 10. Update and revise as needed Months four through eight

Implementation and deliverables The Managed Care Improvement Plan will provide the Bureau with the capacity to make necessary program modifications efficiently and effectively, which has particular importance given expansion planning and the impacts of ACA.

As part of the MCIP and for other issues, The Lewin Group will submit memoranda and issue papers regarding options for program modifications, including MCIP performance information, cost estimates, and recommendations, to the Bureau within 45 days of request and will submit implementation plans and schedules in a timely manner once specific options have been chosen. Lewin will submit annual summary reports of the MHT program within 45 days of the end of the calendar year. The report will cover the preceding fiscal year and provide an overview of the MHT program, highlighting program successes. Specifically, the report will

#523964 RFP #MED11010 Managed Care Administration describe MHT program enrollment, services available to beneficiaries, cost savings resulting from the program, performance on key quality indicators, and descriptions of MCO outreach and disease management programs, as well as improvements identified and accomplished through the MCIP. A sample of the annual report currently produced by Lewin for the Bureau is included in the figure below.

#523964 RFP #MED11010 Managed Care Administration

Figure 30. Sample Annual Report

#523964 RFP #MED11010 Managed Care Administration

The figure below summarizes the specific work steps required for one year to develop and then implement the Managed Care Improvement Plan and annual report. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

Figure 31. Task 3.2.3.1 Sample Work Plan and Timetable for 2011

Analyze baseline utilization and cost data (3.2.3.2)

Monitoring the performance of the MCO, PAAS, and FFS programs is an important activity in times of tight Medicaid budgets. BMS must make sure that health care services are being provided efficiently in each of its programs in order to manage Medicaid expenditures. An equally important activity is ensuring that members are receiving high quality care in order to detect and treat diseases at an early stage and slow disease progression. To perform these monitoring functions, BMS needs performance reports that can be used to compare expenditures between these three programs and evaluate the quality of care rendered by the providers participating in each program.

Deliverables: Task 3.2.3.2 Analyze Baseline Utilization and Cost Data . The Lewin Group will provide the Bureau with quarterly performance reports and strategies to improve the services.

To accomplish this task, all available claim, encounter, and eligibility data will be loaded into a relational database that allows for a virtually unlimited number of analysis possibilities.

Eligibility is at the heart of the database structure. Services (claims and encounters) are linked to eligibility by a composite key of patient identifier and date of service. To achieve the link, the patient identifier is matched and the date of service is compared to eligibility spans. By including date of service and eligibility span matching in the join logic, a more precise denominator is available for rate and cost of service analysis. Services are linked to a provider object using a similar technique. Because of this approach, as new attributes become available,

#523964 RFP #MED11010 Managed Care Administration they can be logically linked to the appropriate entity. For example, as disease states are selected, these attributes would be added to the eligibility table. This would then allow for analysis of the disease state by any of the specified attributes (e.g., age, sex, and eligibility category) as well as by service (e.g., diagnosis, procedures, place of service), provider (e.g., specialty, type, location), utilization (e.g., encounters, units of service, days of therapy) and cost (e.g., charge and reimbursement). Using the database, a comprehensive baseline of the population will be developed. As part of the AHRQ Medicaid Care Comparisons of the cost effectiveness of the three Management Learning Network, Lewin programs must account for differences in the assisted Wyoming in selecting measures to evaluate performance of its health demographic mix of the populations being served in management program. Specifically, each program. Lewin will create reports profiling the Lewin provided technical assistance cost and utilization of health care services in each related to selecting objectives, program. Separate reports will be created by age, sex, defining measures (e.g., population), and eligibility category. Separate reports will also be identifying data sources (e.g., claims data, self-reported, chart audit), and created using the demographic groups that are used setting targets for improvement. in the rate setting process to capture variations in member mix between the programs.

Lewin will also create profiles that can be used to evaluate the quality of care provided in the MCO, PAAS, and FFS programs. Quality of care can be assessed using a variety of measures including HEDIS measures, care coordination measures, and member outcomes. While clinical data to measure member outcomes is not readily available, proxies can be developed using emergency room visits and hospital admission rates.

Reporting based on HEDIS measures, care coordination measures, and member outcomes will be driven by the relational database. Using these profiles, the program will be monitored on an ongoing basis and potential issues will be communicated to BMS. In addition to monitoring program performance, the database can be used to model the impact of strategies designed to correct deficiencies and other issues.

Implementation To leverage the internal resources of BMS, analytic views of the database will be made available to designated BMS staff and other individuals/entities. Analysts and end users can be trained in the use of the web-based OLAP tools described earlier in this section. By having access to the analysis database, BMS will be able to conduct analyses internally as it sees fit. The figure below summarizes the specific work steps required for one year, occurring quarterly. This task will repeat annually through the end of the contract.

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Figure 32. Task 3.2.3.2 Sample Work Plan and Timetable for 2012

Scope of Work: Federal Regulatory Compliance (3.2.4)

Task 3.2.4 focuses on supporting the Bureau for Medical Services and Mountain Health Trust in its continued compliance with the evolving environment of federal regulatory requirements. As discussed in greater detail in Section 4.1.7 of this proposal, Lewin has assisted the Bureau for Medical Services (and numerous other states) since 1995 in working with the federal government to develop and implement program strategies, contracting mechanisms, and financing arrangements that comply with all applicable laws, policies, and guidance.

Our team is especially qualified to provide expertise, policy analysis, strategic guidance, and knowledge to CMS that is grounded in our many years of experience in Medicaid programs throughout the country. We provide up-to-date expertise on all current health care issues and are capable of quickly processing the implications of new policy changes and legislation. We have worked with states and the federal government to understand and respond to every major piece of federal legislation affecting the Medicaid and CHIP programs over the past 15 years, including the Balanced Budget Act of 1997 (BBA), Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Deficit Reduction Act of 2005 (DRA), American Recovery and Reinvestment Act of 2009 (ARRA), and the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA). We have in-depth knowledge of Medicaid and CHIP laws, regulation, and policies, a strong understanding of how states and the federal government relate to one another in the Medicaid and CHIP context, and familiarity with existing evaluations, state guidance materials including State Medicaid Director and State Health Officer letters, regulations and other policy related documents.

Our in-depth health and human services program experience enables us to help governments understand their constituents’ needs. We provide options to meet those needs within the regulatory, political, and fiscal realities faced by our state and local government clients and analyze the impact on individuals, program management, and budgets. In addition to working directly with states, we frequently work with federal agencies that regulate or oversee the federal-state partnership including the CMS Center for Medicaid and State Operations, CMS Office of Financial Management, and CMS Office of Research, Development, and Information, as well as the HHS Assistant Secretary for Planning and Evaluation, the Substance Abuse and

#523964 RFP #MED11010 Managed Care Administration

Mental Health Services Administration, the Health Resources and Services Administration, and the U.S. Congress.

The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the ongoing compliance with federal regulatory requirements.

Figure 33. Task 3.2.4 Work Plan and Timetable for 2011-2015

Develop a comprehensive quality assessment and performance improvement strategy and implementation plan (3.2.4.1)

The objective of this task is to support the Bureau for Medical Services in developing a coordinated, comprehensive, and pro-active approach to drive quality assurance and performance improvement program-wide by utilizing creative initiatives, monitoring, assessment, and outcome-based performance improvement to meet federal standards set forth in the Medicaid managed care regulations. The result of this task will be a Quality Assessment and Performance Improvement (QAPI) strategy and implementation plan that meets the federal requirement that state Medicaid managed care programs have a plan for assessing and improving the quality of managed care services provided by the MCO. This plan must also ensure compliance with standards established by the state agency with regular, periodic reviews to evaluate the effectiveness of the QAPI strategy. Measuring performance and tracking results through a QAPI will play an important role in the Medicaid managed care program expansion planning and implementation in new service areas, as well as preparing the Bureau for important changes associated with health reform.

Deliverables: Task 3.2.4.1 Develop a QAPI Strategy and Implementation Plan . The Lewin Group will complete a comprehensive Quality Assessment and Performance Improvement (QAPI) strategy and implementation plan yearly, in accordance with all federal requirements

Overview of approach Lewin will begin by reviewing all data used for current program monitoring and analysis activities such as encounter data, quarterly reports, HEDIS measures, and on site reviews conducted by the EQRO. Coupled with Lewin’s long-standing, in-depth knowledge of West Virginia’s monitoring activities, this review will provide important baseline information creating a foundation for a robust QAPI. The Lewin Group will engage key partners and stakeholders, including enrollees through the Medical Services Fund Advisory Council, the EQRO, and the enrollment broker, to obtain input, define objectives, identify targets, and gather recommendations on approaches for improving the quality of services on an annual basis. Through these activities, Lewin will take the lead in coordinating quality improvement efforts

#523964 RFP #MED11010 Managed Care Administration across West Virginia’s vendors, obtaining a greater understanding of the enrollment broker and EQRO’s quality and access monitoring activities.

In drafting the QAPI strategy and plan, Lewin will also leverage working relationships with MCOs to solicit their input in identifying additional areas for quality improvement and design. We will Lewin updated the Bureau’s QAPI implement a formal process to address any identified Strategy and Implementation Plan in April 2010 to include objectives and quality and access issues as they arise, replacing the targets. The State will use them to current ad hoc approach. This will include using a log measures its quality improvement over to track issues identified by each contractor to the next two years. Lewin assisted the support timely recognition of systematic quality and Bureau in identifying objectives related access issues that can be addressed in a more efficient to child and adult access to preventive health services, prenatal and and effective manner. A system-wide tracking log postpartum care, and chronic care. will also serve as a record for how the Bureau has Subsequently, Lewin worked closely historically managed various types of quality issues, with the EQRO to select specific providing an important feedback loop to support targets for related HEDIS measures. QAPI improvement over time, and will be an integral After the State expands the managed part of the strategy and implementation plan that is care benefits package to include behavioral health and children’s dental developed. services, Lewin will evaluate the data to establish baseline measurements Based on our findings, we will prepare a clear and and benchmarks to define quantifiable concise written document describing how the Bureau measures related to these areas. monitors, assesses, and tracks quality and outcomes, including QAPI strategy requirements and implementation activities for MHT. Lewin will work to restructure the existing QAPI to more closely align with CMS’ State Quality Strategy Toolkit for State Medicaid and Children’s Health Insurance Agencies, reflecting a more comprehensive strategy document. Mechanisms to track targets over time to demonstrate the success of quality improvement efforts to CMS will be an integral component of the plan, in addition to other monitoring activities that the Bureau may want to consider in order to strengthen program oversight and comply with waiver requirements. We will prepare a memorandum outlining our recommendations, which will be commensurate with the Bureau’s overall approach to administering and monitoring the program and will incorporate discussion of resource issues that should be considered. Lewin’s proposed QAPI strategy will fully meet requirements set forth in federal Medicaid managed care regulations.

We will then meet with Bureau staff to review the recommended QAPI strategy, discuss any outstanding issues, and work with the Bureau to select a final strategy. Lewin will leverage our existing strong working relationships with CMS to solicit their guidance as we revise the plan. Lewin staff will update the approach and prepare a final comprehensive written QAPI strategy. Following review of the QAPI by the Bureau, CMS regional office staff, and others, Lewin will prepare a corresponding implementation plan. To the extent feasible, the elements of the Bureau QAPI will complement the components of the MCO’s internal quality assurance activities.

Implementation The Lewin Group will complete the comprehensive quality assessment and performance improvement strategy and implementation plan yearly and in accordance with all federal

#523964 RFP #MED11010 Managed Care Administration regulatory requirements. The figure below summarizes the specific work steps required for one year to identify options and recommendations, help the Bureau select a strategy, and develop an implementation plan. This task will repeat annually through the end of the contract, with ongoing tasks repeated as needed.

Figure 34. Task 3.2.4.1 Sample Work Plan and Timetable for 2012

Perform tasks necessary to monitor the federal waiver and prepare required reports and waiver application (3.2.4.2)

The objectives of this subtask are to monitor the federal waiver to ensure compliance with current and future federal regulations and guidelines and to prepare required reports and waiver applications demonstrating West Virginia continued compliance with all of CMS’ requirements. While the next waiver renewal is not due until 2012, Lewin recognizes that if the planned expansion is not implemented in 2011, the waiver will need to be updated. Lewin will maintain a collaborative relationship with CMS to continue to keep abreast of the changing federal regulatory monitoring requirements, which include enrollment and disenrollment, processing of grievance and appeals, violations subject to Sample Monitoring Data sanction, and violations of conditions for federal financial Collection Tools: participation. In addition, Lewin will monitor quality, enrollee satisfaction, and service utilization, as well as . Beneficiary and provider surveys other areas the Bureau might identify, to ensure not only . Disenrollment requests compliance with federal Medicaid managed care regulations, but also that enrollees are receiving services . Grievances and appeals commensurate with the Bureau’s standards. Furthermore, . Enrollee hotlines findings of monitoring activities will facilitate . Geographic mapping identification of areas for ongoing program improvement. . Network adequacy Lewin will work with the Bureau to identify effective . Systems performance review monitoring strategies, as also discussed above, including . Performance improvement the development and administration of surveys, such as projects the MHT enrollee satisfaction survey currently being . HEDIS measures fielded and analyzed by Lewin, the review of MCO report . Utilization reviews and data submission, on-site reviews, and other special analyses requested by the Bureau.

#523964 RFP #MED11010 Managed Care Administration

Overview of approach To assist the Bureau with maintaining the MHT waiver, Lewin will first work to update the existing monitoring plan based on the waiver and new requirements. Monitoring activities will be designed to provide the Bureau with timely information regarding the program’s compliance with federal laws, regulations, and policies, as well as the performance of MHT vendors. Lewin will track any changes to federal monitoring requirements and CMS guidance on a bi-weekly basis and will update the Bureau and the monitoring plan as necessary. Overall findings from the 2009 MHT Beneficiary survey Once the monitoring plan is in place, administered by Lewin include: Lewin will work with the Bureau to develop and update appropriate  The MCOs performed well on the child survey, improving from their 2007 results and meeting or monitoring data collection tools, such exceeding the majority of the 2009 national as beneficiary and provider surveys Medicaid benchmarks much like those Lewin has already  Child and Adult PAAS results were generally positive administered on behalf of the Bureau. and showed improvements compared to their 2007 Lewin staff are prepared to develop results other types of monitoring tools as  While adult MCO results were generally consistent with the 2007 results, they fell short of the 2009 requested by the Bureau. national Medicaid benchmarks and were consistently lower than the adult PAAS ratings Lewin will also review MCO reports  Children with Special Health Care Needs enrolled in and data, such as quarterly reports PAAS and the MCOs experienced lower satisfaction and utilization data, submitted to the with PAAS/their health plan and more difficulties in Bureau. The purpose of monitoring accessing needed care compared to children without this information is to ensure special health care needs continued MCO compliance with federal and state requirements, identify areas of particular achievement or concern, and review them for inaccuracies. Lewin will notify the Bureau of its review findings and will provide expedited notification if findings are of concern. Understanding the trends and experiences of MHT MCOs will enable the Bureau to swiftly address any concerns that may arise.

Lewin will then analyze all data collected based on the CMS waiver preprint, with an additional eye on highlighting West Virginia’s successes in ensuring access to services and quality. We will update the waiver renewal text based on programmatic changes, federal regulations, state initiatives, and any adjustments to the Bureau’s program monitoring approach. Lewin will engage other contractors as necessary to review sections and provide guidance on displaying data in a favorable manner. We will also obtain the CMS-64 and other statewide reports to ensure financial projections tie together. Leveraging the positive working relationships that Lewin has developed with key CMS contacts over the years, we will support the Bureau in working with CMS on any major program changes, such as modifications to eligibility groups, prior to submitting waiver renewals.

The Lewin Group will conduct analyses of access, quality of care, and cost-effectiveness as requested by the Bureau. Lewin will take into account the Bureau’s goals when developing strategies and protocols for these special, ad hoc analyses and, to the extent possible, special analyses will be conducted using existing tools for monitoring and collecting data to minimize additional burden. Lewin will prepare memos upon request. Studies of related issue areas from other states will be reviewed to facilitate the efficient development of strategies and protocols.

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The Bureau has stated publicly that it will conduct surveys or focus groups of SSI and TANF beneficiaries to identify any issues after expansion of the MHT program. As part of our efforts to monitor the federal waiver and assist with the program expansion, Lewin conduct up to four focus groups comprised of eight to twelve participants each year to assess beneficiary concerns and perceptions of the MHT program. As appropriate, the focus groups may include SSI and TANF beneficiaries, or adults who will be newly eligible for Medicaid in 2014. The focus groups will provide invaluable feedback on the program and demonstrate to stakeholders that beneficiaries have opportunities to provide input on the MHT program.

While it is not possible to predict the total number of special analyses that will be conducted during the upcoming contract period, for purposes of budgeting, Lewin has assumed based on previous experience with the Bureau a total of three special analyses will be conducted.

Lewin will prepare required reports to present findings from monitoring activities and submit drafts for the Bureau’s review. If necessary, Lewin will convene conference calls to discuss report findings or to answer any questions. Lewin will work with the Bureau to prepare reports and waiver applications that will be submitted to CMS in a timely fashion and will be available to discuss findings with or answer questions from CMS staff. The Lewin Group’s extensive repository of programmatic data will support swift and complete responses to any CMS inquiries.

Implementation The Lewin Group will submit results of monitoring activities related to the waiver to the Bureau 120 days before the expiration of the current waiver. Lewin will also conduct ad hoc monitoring activities within 60 days of request by the Bureau. The figure below summarizes the specific work steps required for 2012. This task will repeat for the 2014 waiver renewal process.

Figure 35. Task 3.2.4.2 Sample Work Plan and Timetable for 2012 Renewal

Prepare necessary waivers or state plan amendments for ongoing program and/or changes to the program (3.2.4.3)

The objective of this task is to support the Bureau in preparation of the necessary components of the 1915(b) renewal waiver application or any state plan amendments, including ongoing collaboration and communication with CMS to ensure effective completion.

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Deliverables: Task 3.2.4.3 Prepare Necessary Waivers of State Plan Amendments . Submit results of monitoring activities related to the waiver to the Bureau 120 days before current waiver expiration in 2012 and then again in 2014 . Conduct ad hoc monitoring activities within 60 days of request by the Bureau.

Overview of approach The Lewin Group will begin by reviewing other state approaches and best practices for securing federal authority for a program West Virginia currently uses a combination of the modification, such as inclusion of a specific 1915(b) waiver and the 1937 SPA to mandatorily eligibility category. Based on our review enroll Medicaid beneficiaries in managed care and Lewin’s extensive knowledge of programs. During the last waiver renewal, Lewin federal regulatory approaches, we will identified that West Virginia may also use the recommend the optimal federal authority 1932(a) SPA authority to mandatorily enroll most of the same populations currently enrolled in the for planned program changes. The Lewin PAAS and managed care program without the use Group will assist the Bureau for Medical of 1915(b) or 1115 waiver authority. Lewin Services with the preparation of the prepared a summary summarizing the various necessary renewal waiver application or regulatory authorities available for mandatory state plan amendment. The most recent enrollment of Medicaid beneficiaries. As a result, waiver renewal format requires the State to Lewin is conducting additional research to identify the optimal federal regulatory authority allowing provide a summary of all monitoring the State to preserve elements of personal activities and document results and responsibility for Medicaid beneficiaries, prepare findings. These waiver monitoring for increased program enrollment as a result of activities are described in greater detail in health reform legislation, and decrease the Subtask 3.2.4.2. As the first step in administrative resources required for securing preparing to develop the waiver renewal federal approval for the program. application, Lewin will gather relevant information on waiver monitoring activities, including information from the Bureau’s other subcontractors. We will ensure that the Bureau is able to document and demonstrate compliance with all the terms and conditions of the current waiver.

Lewin will then review any changes to the waiver application preprint and provide recommendations to the Bureau regarding appropriate responses to any substantive changes that may be required. Lewin will draft the waiver renewal application using the CMS preprint format and provide decision memoranda for Bureau staff where necessary. For example, Lewin prepared memoranda to the Bureau regarding the coverage of children with special health care needs and TANF caretaker relatives in the State’s 1915(b) waiver. Based on guidance from the Bureau, Lewin revised the waiver renewal application to ensure compliance with relevant federal regulations.

Following discussions with Bureau staff, we will submit a complete draft of the waiver renewal to the Bureau for review and comment. We would suggest that this draft be shared with CMS regional office staff at this point so that the Bureau and Lewin staff can incorporate CMS’s informal feedback before submitting the final waiver renewal application.

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One of the most important and onerous aspects of preparing a waiver application is the research and analysis associated with the cost-effectiveness portion of the waiver. The cost- effectiveness assessment required as part of the capitation rate-setting task (Subtask 3.2.1.1) will be structured in such a way as to make the final preparation of the cost-effectiveness portion of the waiver application a simple matter. It will entail including the final tables from the analysis stage as supporting documentation for the waiver application and drafting a description of the analytic approach. Lewin’s unique knowledge of the capitation rates developed for the Bureau will also enable a more efficient completion of the cost effectiveness section.

Upcoming MCO service area expansions will likely necessitate that the Bureau submit waiver amendments or state plan amendments, Lewin will prepare the necessary documentation and cost-effectiveness analysis and work with the Bureau to submit the amendment request to CMS, modify the request if necessary, and obtain approval of the change. The Lewin Group has assisted the Bureau in obtaining interim waiver amendments before and is familiar with the process of working with CMS to modify or add to existing waivers.

In our experience, a well-prepared waiver application that features clear and concise descriptions of the program, accompanied by documentation reflecting a thoughtful and comprehensive financial analysis of the program, will reduce the number of questions CMS will have for the Bureau. Nonetheless, there will undoubtedly be some questions and requests for clarifications from CMS staff. Lewin will assist the Bureau in any way necessary to respond quickly to requests from CMS regional and central offices and the Office of Management and Budget (OMB). Lewin will draft responses to CMS questions and participate in meetings or conference calls with the Bureau and federal officials as needed. The Lewin Group will perform any additional research or analysis that the Bureau needs to fully respond to CMS or OMB requests. Lewin has a long history of successfully working with CMS and OMB on behalf of states.

Implementation The Lewin Group will submit results of monitoring activities related to the waiver to the Bureau 120 days before the expiration of the current waiver. Waivers and/or state plan amendments will be submitted within 60 days of request by the Bureau. Lewin will also conduct ad hoc monitoring activities within 60 days of request by the Bureau. The figure below summarizes the specific work steps required for the 2012 renewal process. This task will repeat for the 2014 waiver renewal process.

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Figure 36. Task 3.2.4.3 Sample Work Plan and Timetable for 2012

Scope of Work: Additional Services (3.2.5)

As discussed in Section 4.1.7 of this proposal, The Lewin Group has expertise in a wide variety of areas related to health policy and the development and implementation of innovative strategies to manage public sector health programs. During the past 15 years, Lewin has assisted the Bureau with numerous tasks across the spectrum of health care issues.

Many of our engagements require in-depth policy analyses on all aspects of Medicaid programs. In addition to the variety of topic-specific Medicaid and CHIP policy projects described elsewhere, Lewin has conducted comprehensive reviews of several state Medicaid programs.

 For the State of Missouri, Lewin recently provided recommendations on how the State can achieve short-term Medicaid savings, conducting detailed assessments on achieving longer-term program savings, and evaluating options to improve the effectiveness and efficiency of the Medicaid program. Lewin is also developing supporting materials for the Medicaid agency to present to stakeholders and policy makers.  For the North Carolina General Assembly, Lewin completed an independent review of the process by which benefits are added to Medicaid; how well the benefits are managed; and how the benefit package and approach compare to other state Medicaid programs and to private insurers in North Carolina. Lewin also worked with its subcontractor, the West Virginia Medical Institute, to assess the utilization review procedures employed within the North Carolina Medicaid program to evaluate whether the benefits are authorized and approved according to the stated benefit menu and prevailing clinical standards.

In addition to our broad, comprehensive program assessments, we have conducted many in- depth policy analyses in a variety of areas. For example:

 In a project jointly funded by the Center for Healthcare Strategies and the Arizona Health Care Cost Containment System (AHCCCS), Lewin assisted the State of Arizona in making a policy decision regarding whether pharmacy should continue to be included in the MCO capitation program or carved out.  The Lewin Group recently assisted the Minnesota Department of Human Services Disability Services Division in developing recommendations for its Personal Care Assistant

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(PCA) Program. Recommendations were made on specific components of the PCA program such as service authorization, quality of care, health and safety, compensation, living arrangements, and improvements in program integrity.

 Lewin assisted the City of San Francisco in preparing for the implementation of a program to expand health services to the City's uninsured population, called Healthy San Francisco. We estimated impacts on enrollment, utilization, clinic capacity staffing needs, and financial implications.  Lewin is assisting CMS with an initiative that promotes value-driven health care and which aims to improve health care quality, information and cost-effectiveness for consumers. Specifically, Lewin is supporting efforts to develop and test a set of provider-based imaging efficiency measures and is also working with CMS to train providers on how to use imaging measures, which will be part of a pay-for-reporting initiative under the outpatient prospective payment system.

We will continue to be flexible in working with the Bureau in our approach and staffing to meet the evolving needs of the Bureau and State of West Virginia. The following is a high level Gantt chart outlining our work on each of the major subtasks associated with the providing the Bureau with additional services.

Figure 37. Task 3.2.5 Work Plan and Timetable for 2011-2015

Production of data and ad hoc requests for data analysis services to BMS (3.2.5.1)

Lewin realizes that administering a program as complex as Medicaid managed care gives rise to unexpected changes which can impact both program design and capitation rates, particularly in upcoming years with the passage of health reform under the ACA and the corresponding Medicaid expansion. These changes require quick response to ad hoc data analyses to estimate the impact to the managed care program. Lewin has the institutional knowledge of MHT and the depth and breadth of experience to respond to any request that BMS may need. We will work with BMS to identify value-added services based on the immense knowledge we have of West Virginia’s Medicaid program and associated data. For the capitation rate setting task, Lewin has produced detailed databases that link claims and eligibility data for all Medicaid beneficiaries and have created further databases that segment the managed care eligible

#523964 RFP #MED11010 Managed Care Administration population and services. Using these databases, Lewin can provide rapid but complete analyses of time-sensitive issues. In response to a GAO report citing The recent expansion of Medicaid under health reform that children in West Virginia were will bring a large proportion of the uninsured population not receiving necessary EPSDT into Medicaid. As the State lacks “Medicaid” experience services, the Bureau requested for this expansion population, BMS will need to utilize that Lewin conduct an analysis of other data sources in order to estimate the size and cost of EPSDT measures reported to CMS this expansion. Lewin is a nationally-recognized leader in and related HEDIS measures to determine whether children were health reform modeling and has developed national and receiving EPSDT services. Lewin state-level estimates regarding the size of the Medicaid compared performance of the MCO expansion population. Lewin will be able to leverage our and FFS programs on these simulation model and knowledge of health reform to measures and found that the MCOs provide BMS data support in regard to understanding the generally outperformed the FFS program on measures of EPSDT size and cost of the expansion population. participation. The MCOs have also demonstrated steady improvement During recent years, Lewin has worked with state on a number of measures related agencies in more than half of the nation’s states on tasks to children’s preventive services related to rate setting, actuarial analyses, Medicaid over the last several years. managed care, and program evaluation. Within these broad areas, we have assisted states in setting capitation rates, evaluating cost effectiveness, reviewing provider accessibility, evaluating federal compliance, and researching health care trends and best practices. In addition to working with states, our staff has experience working across different CMS offices, giving us a deep understanding of their policy objectives for transparency, accountability, and program integrity. We are closely following developments in federal policy that may impact Medicaid programs and can help states consider the impact these developments will have on their programs.

Our clients request and receive rapid but complete analyses of time-sensitive proposals. We are accustomed to developing research frameworks that include objectives, timelines, methodologies, and deliverables that meet clients’ needs and then conducting the research in a timely and thorough fashion.

Implementation The Lewin Group will support the Bureau in meeting all ad hoc data requests. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 38. Task 3.2.5.1 Sample Work Plan and Timetable for 2011 -2015

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Provide data analysis support on reimbursement issues and modeling upon request from BMS (3.2.5.2)

Support for reimbursement analyses will be provided at whatever level BMS desires. The services that can be provided include, but are not limited Lewin has performed periodic to, simulation models, reimbursement relativity analysis, analyses for the State regarding development of custom systems, evaluation of third party the inclusion of a pharmacy carve- solutions, and reimbursement system development in for the MHT program. With the research. Because of the existence of the claim and recent extension of Medicaid drug encounter databases from our rate setting work, impact rebates to Medicaid managed care estimates based upon program experience (as opposed to under ACA, West Virginia can now leverage the efficiencies of industry standard probability distributions and rate managed care without sacrificing manuals) can be developed quickly. These estimates will the substantial federal rebates it be more accurate because the models will reflect the currently receives. We project consumption of services (in terms of case-mix, utilization, that the improved management of risk prevalence, and unit cost) by the West Virginia the pharmacy benefit (e.g., higher generic fill rate, lower utilization) Medicaid population. under managed care could create savings up to $3 to $4 million in Lewin has analyzed and modeled a variety of State dollars. reimbursement issues for Medicaid programs. For the California Medicaid (Medi-Cal) program, Lewin compared Medi-Cal FFS outpatient provider fee schedule payment amounts with Medicare fee schedule payments amounts for 2009 and estimated the impact of setting minimum and maximum Medi-Cal fees based on a percentage of the comparable Medicare fees. We estimated the additional cost of increasing payment rates for each procedure to a minimum level of equivalent Medicare payment (80 and 100 percent) and the potential savings from reducing payment rates for higher priced procedures to a maximum level of equivalent Medicare payment (80 and 100 percent) for selected provider types. Additionally, we have estimated the impact of the changes in the Medicaid drug rebate provisions for numerous states, including the potential benefits and differences between a carve-in and carve-out model now that the drug rebates have been equalized. Our team includes experts who have implemented a variety of risk-sharing or diagnostic risk adjustment methodologies for several states, so we are fully versed in the advantages and disadvantages of each method should BMS want to introduce risk-adjusted payment rates for the managed care program.

Implementation The Lewin Group will provide data analysis support on reimbursement issues and modeling upon request by the Bureau. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

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Figure 39. Task 3.2.5.2 Sample Work Plan and Timetable for 2011 -2015

Provide data analysis support to assist with budgetary and legislative issues upon request from BMS (3.2.5.3) For the MHT annual report, Lewin The breadth of experience and expertise of The Lewin has calculated estimates of the Group in modeling and evaluating changes due to health cost savings from the managed reform, Medicaid eligibility and program expansion, care program. The cost savings are based on a review of per federal and state legislative mandates, and cost member, per month medical costs containment initiatives gives us a unique understanding in a select number of counties of Medicaid programs across states and the ability to before and after managed care analyze a wide variety of budgetary and legislative issues. implementation. Based on our As mentioned previously, Lewin has extensive experience analysis, we estimate that total costs under the managed care modeling the impacts of various health reform options program were over $5 million less and we can build upon our simulation models to help the that if the population had state understand the fiscal impacts of a variety of remained in FFS. provisions under the health reform legislation. Additionally, Lewin recently worked with the State of Missouri to conduct a substantive review of its Medicaid program and developed recommendations on how the State can achieve short- term Medicaid savings, conducted detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. Lewin developed a series of reports as well as supporting materials, and Lewin’s analyses were used by Missouri’s policymakers to craft the State Fiscal Year 2011 budget as well as guide decisions about future Medicaid program design and operations. We are prepared to assist BMS with budgetary and legislative assignments working in conjunction with BMS staff. Once our level of involvement is determined, we will work cooperatively with BMS (as well as entities that BMS designates) in completing the requested analyses.

Implementation The Lewin Group will provide data analysis support to assist with budgetary and legislative issues upon request by the Bureau. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

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Figure 40. Task 3.2.5.3 Sample Work Plan and Timetable for 2011 -2015

Create encounter data files as needed for other contracted Vendors working with the MHT, MHC, and PAAS programs (3.2.5.4)

Lewin will provide encounter data and FFS data extracts for other contracted Vendors working with the MHT, MHC, and PAAS programs as requested by BMS. As previously mentioned, we have already developed cooperative relationships with the existing vendors (e.g., participating MCOs, the fiscal intermediary, the EQRO) and can quickly engage the respective staff within each of these organizations to develop an appropriate data request and extract in a timely fashion.

Lewin’s vast experience with the MCO encounter data and FFS data through the rate setting process allows us to work with the other vendors to identify the minimum level of detail required for their data request and develop custom extracts that meet their analytic needs. For example, during the most recent SSI rate setting process, the MCOs requested detailed information regarding the SSI beneficiaries at the individual level. Lewin developed a de- identified individual-level file that summarized a person’s claims history at the diagnostic and procedural (CPT, revenue code, DRG) level. This de-identified summary file provided the MCOs with detailed information regarding the health condition and service utilization patterns of the SSI population without providing any information that would allow the MCOs to identify actual individuals or favorably select particular beneficiaries for enrollment. Data extracts can be constructed in a variety of electronic formats (i.e., delimited text, fixed text, SAS, SPSS, Oracle, SQLserver, Access, etc) to meet the vendor’s needs. Lewin will make technical assistance available to vendors on any issues regarding the provided data extracts through written and electronic communication, conference calls, and face-to-face meetings at the Bureau’s direction.

Implementation The Lewin Group will create encounter data files as needed for other contracted vendors and provide necessary technical assistance. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

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Figure 41. Task 3.2.5.4 Sample Work Plan and Timetable for 2011 -2015

Conduct research and recommend approaches in key areas (3.2.5.5)

The main objective of this task is to conduct research and recommend approaches in key areas of interest that will assist the Bureau in improving the efficiency, effectiveness, and quality of Medicaid services. Research areas, which will be determined by the Bureau or the legislature, may include, but are not limited to: chronic care/disease management, profiles of specific disease states, pharmacy, eligibility and coverage, quality improvement, improved rural health care delivery, and provider networks. Lewin will also continuously monitor best practices in the field so that we can provide innovative recommendations to the Bureau to stay ahead of the curve in lessons learned. Our research and work in this task area will enable the Bureau to draw from the work and experience of other states and other health care related organizations to improve overall program performance, enhance beneficiary access, and develop innovative approaches to maximize efficiency and increase quality.

Deliverables: Task 3.2.5.5 Conduct Research and Recommend Approaches in Key Areas . Respond to research requests within 30 days of request by the Bureau and provide implementation support as requested

Overview of Approach Lewin assisted the State of New York in collecting Upon request from the Bureau to and analyzing information on Medicaid primary care case management (PCCM) programs for consideration perform a research task, Lewin will in exploring a future PCCM program as an alternative convene a conference call with the to full-risk managed care in rural areas. State and Bureau and/or other staff, as Lewin staff identified five states, for which Lewin appropriate, to discuss the request in researched and reviewed state-specific information detail. During this call, participants will and conducted interviews to understand current discuss the research objectives, potential PCCM and MCO program; implementation strategies, including associated DM programs; PCCM program uses of research findings by the Bureau design strategies, including program administration or legislature, anticipated research and characteristics; comparisons of PCCM and MCO methods, and timeframes for completing program outcomes; and lessons learned. Based on the research. Lewin will then develop a this information, Lewin prepared a memo to draft work plan to accomplish the summarize key components of the five state programs, particularly around common PCCM research objective(s) with recommended program design strategies, with a focus on program research strategies and methods, outcomes, including DM and pay-for-performance including rationale for those approaches, (P4P) strategies, innovative features, and lessons clearly defined research products, learned regarding PCCM programs. concrete milestones for research

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#523964 RFP #MED11010 Managed Care Administration activities, and assigned Lewin staff with the most experience and expertise to complete the research request. Lewin will share and discuss the draft work plan with the Bureau and/or legislative staff, and will revise it as necessary.

Lewin has significant experience and expertise with several research strategies that would very effectively meet the diverse research needs of the Bureau and state legislature, including surveys, literature searches, stakeholder interviews, focus groups, and analysis of utilization, expenditure, and claims data. Research tools and protocols will be revised based on the requestors’ input. As a component of developing protocols and tools, Lewin will identify potential data sources, both maintained by the Bureau and from outside sources, and their validity. Lewin also has a vast library of resources and work products developed in projects for other states on various Medicaid topics as well as an extensive collection of data and knowledge staff, which Lewin may leverage to meet West Virginia’s needs with minimal cost to the Bureau.

Lewin will then conduct the research and will provide the Bureau and/or legislative staff periodic updates on the progress of research activities. Once completed, Lewin will prepare an informed, objective report, memo or written deliverable of research findings and submit it to the Bureau for review. Reports will provide an overview of the research activities, describe key findings, identify critical issues and key decisions, and Potential Dimensions for Data describe available alternatives. Lewin will provide a Analysis: complete assessment of advantages, disadvantages, and . Cost effectiveness possible consequences of all recommended program . Impact on access modifications or actions, as needed. If requested, Lewin . Impact on quality will review the report with Bureau and legislative staffs, . Operational challenges answer questions, and obtain feedback. The report will be . Appropriate federal authority revised as necessary. . Provider participation and Implementation satisfaction . MCO willingness The Lewin Group will respond to research requests . Internal capacity within 30 days. The Lewin Group will be ready to provide implementation support as requested by the Bureau. The figure below summarizes the specific work steps required for one research request. This task will repeat through the end of the contract as needed.

Figure 42. Task 3.2.5.5 Sample Work Plan and Timetable for One Research Request

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Provide policy impact analyses and support (3.2.5.6)

The objective of Task 3.2.5.6 is to assist the Bureau with ongoing intelligence regarding policy changes and the potential impact on West Virginia’s Medicaid services. Medicaid policy development involves numerous stakeholders with competing interests and points of view, and it is vital that the Bureau be well-informed of the potential For the Commonwealth Fund, impacts of policy changes including detailed information members of our team developed and analysis on all available policy options. Lewin is well estimates of the savings that could positioned to provide objective policy analysis for the be achieved by adopting several West Virginia Medicaid managed care program. changes to the health care financing and delivery system. Our project staff are health policy experts with many These included an analysis of changes in payment methodologies years of experience working with Medicaid managed care designed to create new provider plans in several states, bringing an extensive knowledge incentives to improve quality of other states’ Medicaid program best practices. Several while reducing costs and an Lewin project team members have over five years of analysis of public health experience working directly with the West Virginia initiatives, funding for health information technology, and Medicaid program, providing Lewin with a unique comparative effective research. understanding of the dynamics of the Bureau and MHT program and the feasibility of program changes. On several previous occasions, Lewin has worked with Medicaid stakeholders in West Virginia to implement large and controversial policy changes, such as the implementation of Mountain Health Choices. Lewin also has developed working relationships with other Bureau contractors that can be leveraged to obtain information and support for new policy initiatives.

Deliverables: Task 3.2.5.6 Provide policy impact analyses and support . On an as-needed basis, Lewin will submit materials, brief the Bureau staff, and develop memoranda or other documentation. . Lewin will respond to the Bureau requests for policy impact analysis within 45 days and is prepared to provide implementation support as requested.

Overview of approach Lewin will begin its analysis by identifying the operational data needed to develop and analyze the new policy initiative. Lewin will assess the impact of a policy initiative on the Medicaid budget and the parties impacted by the new policy. We will work with the Bureau and other contractors to develop implementation strategies and timelines and will draft the necessary documents to secure federal approval for the new policy initiative, if necessary. Lewin will deliver an extensive and well-researched policy analysis deliverable.

Depending on the scope of the policy change, Lewin can convene focus groups with affected stakeholders such as patient advocacy groups, provider associations, and other state agencies. To support the Bureau in publicizing policy changes, Lewin will develop an effective and comprehensive strategy to communicate the new policy initiative to stakeholders and the media including developing talking points or a public letter to providers or Medicaid beneficiaries.

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Lewin staff will conduct an initial review of any new or modified federal regulations and/or policy guidance and prepare a briefing memorandum for Bureau staff summarizing the regulations and/or guidance and key areas of interest to the Bureau and the MCOs. Lewin will make additional presentations of the briefing to Bureau staff, the MCOs, or others as needed, in conjunction with other on-site meetings or activities where possible (e.g., quarterly Task Force meetings). Lewin staff will then use input from the Bureau and others as appropriate to develop and analyze options for any required program modifications and recommendations for their adoption and implementation. Lewin will prepare necessary documentation for implementation, such as waivers, and prepare memoranda to assist the Bureau in designing implementing strategies.

The Lewin Group will prepare materials and analyses on an as-needed basis according to timeframes agreed upon by the Bureau.

Implementation While the details of each step may vary depending on the policy analysis required, the figure below summarizes the specific work steps required for one research request. This task will repeat through the end of the contract as needed. We are prepared to assist with a variety of implementation tasks, including developing contractor specifications, creating work plans, conducting detailed actuarial analyses, and monitoring implementation outcomes.

Figure 43. Task 3.2.5.6 Sample Work Plan and Timetable for 2012

Review, recommend, update, develop, and assist in the implementation of reimbursement schedules consistent with federal policies (3.2.5.7)

Lewin will review, recommend, update, develop, and assist in the implementation of reimbursement schedules as requested by BMS. As part of the rate setting task and larger policy support tasks, Lewin will monitor federal activity to identify the provisions within the ACA and other federal legislation and regulations that will affect Medicaid reimbursement policies, such as the mandate to pay primary care providers at 100 percent of Medicare rates for 2013 and 2014, or provide alternative payment structures that BMS may want to explore, such as bundled payments for episodes of care. To accomplish this, Lewin is prepared to develop necessary State Plan Amendments and respond to CMS requests. In addition, we will incorporate stakeholder input by surveying enrolled providers and present recommendations to relevant parties.

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Lewin has assisted numerous states in estimating the impacts of changes in reimbursement structure, including changes to existing payment systems and the introduction of new payment methods such as pay for performance and bundled payments. Lewin worked with the Kentucky Hospital Association to assess the Medicare-type DRG system recently implemented by the Medicaid Department and compare the adequacy Lewin has worked with the New of the Medicaid payment rates for Kentucky hospitals York State (NYS) Health Foundation relative to payment levels in neighboring states. We to develop a “roadmap to cost evaluated the equity of payment rates across hospitals in containment” for New York, with the state under the new Medicaid DRG system and practical approaches to reducing recommended modifications to the payment system to health care costs, including scenarios involving the promotion make the payment system more equitable across the of accountable care organizations states’ hospitals. (ACO) and medical homes, hospital pay-for-performance, bundled Implementation payments for episodes of care, and rebalancing of long-term care. The Lewin Group will review, recommend, update, develop, and assist in the implementation reimbursement schedules consistent with federal policies. The figure below summarizes the specific work steps required. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 44. Task 3.2.5.7 Sample Work Plan and Timetable for 2011 -2015

Provide additional services to comply with externally driven changes to BMS programs and requirements, including any state or federal laws, rules, and regulations (3.2.5.8)

Lewin has a dedicated staff person The objective of Task 3.2.5.8 is to support the Bureau in responsible for tracking and complying with externally driven changes to programs performing impact analysis on all and requirements, including any state or federal laws, federal regulations and grant rules, and regulations. On March 23, 2010, President opportunities surrounding the ACA. Obama signed comprehensive health reform, the Patient This staff person has access to a Protection and Affordable Care Act (ACA) into law. This wide range of federal resources that provide same-day health legislation will have important, longstanding reform updates and tracks this consequences for the Bureau, its Medicaid program, and information using an internal beneficiaries as components of the law are implemented Lewin database to assist staff in over the coming years. To that end, The Lewin Group will better understanding reform support the Bureau in strategically addressing the implications for our clients. potential impact of the ACA and other state or federal requirements as they may arise so that the MHT program

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#523964 RFP #MED11010 Managed Care Administration continues to be in full compliance with all regulations and requirements, while providing quality care to its beneficiaries.

To complete this task, Lewin will analyze and assess key health reform components that are likely to impact the Bureau and its stakeholders, track and evaluate several health-reform related funding opportunities, and provide analytic and modeling support for the Bureau. A number of the ACA provisions have implications for the Bureau’s planning, such as the development of state-based health benefit exchanges and eligibility screening for Medicaid and provider payment rate changes. Increased demand for services will also be a factor as the new law expands Medicaid eligibility to a national floor of 133% of poverty, which could lead to an estimated 26% increase in enrollment in the first year and a more than 40% estimated increase in enrollment by 2019 for West Virginia. This increased demand for services will have important implications for the Bureau’s planning for future procurement and MCO coverage. Lewin has many years of experience performing actuarial and micro-simulation analyses of the cost and coverage impacts of program expansion and health reform proposals and has recently developed national and state-level estimates regarding the number and demographic distribution of people in families who become covered by Medicaid. We will leverage Lewin’s considerable experience in modeling the impacts of health reform to develop estimates of the size and costs of the Medicaid expansion population that will need to be considered for the capitation rates in place for 2014. For example, Lewin’s data and modeling expertise can be leveraged to conduct a county-by-county assessment of the geographic distribution of newly covered lives to support West Virginia’s MHT planning activities.

As described in Section 4.1.7, Lewin has the depth and breadth of experience needed in addressing and planning for state and federal changes in law, rules, and regulations. For example, The Lewin Group recently completed a project with the NYS Health Foundation to address opportunities for containing health care costs throughout the New York State health care system. The goal of the engagement was to identify up to 10 specific cost containment scenarios that could be modeled by Lewin to determine the potential for future cost containment and health care system improvement. The project was modeled after the highly successful “Bending the Curve” national analysis conducted by Lewin and The Commonwealth Fund and was the first-of-its kind state-level endeavor.

To support the Bureau’s continued compliance with the evolving state and federal regulations, such as those related to the ACA, Lewin will provide additional services, including implementation support, as needed and identified by the Bureau. Services may include assistance with policy development impact analysis, requirements definition and testing activities, and support in developing proposals for health reform-related planning and implementation funding opportunities. Lewin will also continuously monitor best practices in the field so that we can provide innovative recommendations to the Bureau to stay ahead of the curve in lessons learned in managing externally driven changes such as the ACA. Lewin’s long history working with West Virginia provides an important benefit in our ability to highlight and prioritize key areas that will be of particular interest and importance to the Bureau and its stakeholders and enable us to make valuable and actionable recommendations that best meet West Virginia’s needs.

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Implementation The Lewin Group will provide additional services to comply with externally driven changes to BMS programs and requirements. This task will occur on an ongoing basis through the end of the contract, with tasks repeated as needed.

Figure 45. Task 3.2.5.8 Sample Work Plan and Timetable for 2011 -2015

The below high level Gantt chart illustrates the timelines for the activities required and planned milestones throughout the course of this project.

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Figure 46. Sample Project Work Plan and Timetable for 2011 -2015

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Vendor Staffing (4.1.9)

The Lewin Group has assembled a highly qualified project team to perform the tasks outlined in the Bureau’s “Managed Care Administration” RFP. The proposed project team brings extensive experience in Medicaid managed care, program management, and federal regulatory compliance, in combination with our in-depth knowledge of the West Virginia program. The Lewin Group has assisted West Virginia for 15 years and offers a consistent team for the new engagement. Team members have significant experience working with public and private sector clients to research and evaluate state Medicaid programs and policies and have expertise in the programmatic, regulatory, and service delivery issues associated with Medicaid and Medicaid managed care. The Lewin team that will serve the State of West Virginia brings superb qualifications to this assignment. Key aspects of this team’s credentials include:

 Clients in 46 states plus the District of Columbia have utilized The Lewin Group’s expertise in the development of their own managed care initiatives. This broad national experience has provided Lewin with a unique and highly comprehensive understanding of the Medicaid program, which in turn allows us to bring best practices and innovative solutions to the State of West Virginia.  The Lewin team has assisted the Bureau for Medical Services in the ongoing development, monitoring, and implementation of the Mountain Health Trust program. This experience has given Lewin a deep understanding of challenges unique to West Virginia and imperatives in reshaping its Medicaid progress. Our experts have intimate knowledge of the specific administrative practices employed by the Bureau and have established business relationships with key staff, which will allow the Lewin team to perform the required services efficiently.  The Lewin team has developed good working relationships with the Bureau’s stakeholders, including CMS, the MCOs serving the managed care population, and other vendors. We have a strong understanding of CMS’ concerns and priorities, and we will work with the Bureau to ensure that any inquiries from CMS regarding reports or waiver applications receive a prompt and comprehensive response. The Lewin team will also be able to leverage our relationships with the MCOs to achieve buy-in to new program initiatives.

Key Project Personnel

The Lewin team will provide the practical implementation experience, alongside policy expertise, needed to recommend workable solutions for the further development and expansion of the Mountain Health Trust program. Members of The Lewin Group team have both detailed understanding of the policy process and the technical understanding of managed care that this project demands. Talented support staff have been chosen to assist the senior consultants in their efforts.

As noted above, several team members proposed for this project have previously managed or supported consulting engagements for the State of West Virginia and throughout the development and implementation stages of the Mountain Health Trust program. Many of the proposed team members for this project have more recently been involved in numerous tasks

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#523964 RFP #MED11010 Managed Care Administration related to the ongoing management of the Mountain Health Trust program. Staff and subject matter experts new to the Bureau will be called upon to lend their specialized expertise in new areas of program growth as the Mountain Health Trust program expands and matures. In the past, The Lewin Group has made it a priority to provide the State of West Virginia with a consistent project team that can quickly and effectively identify and respond to the State’s needs. The Lewin Group will continue to ensure that top-notch, dedicated staff are available to meet the needs of the Bureau.

Project Staff Organization

We have included an organizational chart of the proposed team followed by a matrix indicating which tasks will be performed by team members on the next page. The Lewin Group has substantial experience with overall project management of large-scale state Medicaid managed care implementation projects and has successfully and efficiently executed the project management aspects of these large-scale projects. Individuals designated as core to this project have the breadth of experience necessary to complete and oversee task completion and have significant project and staff management experience. The organization chart below summarizes Lewin’s proposed staff for this engagement.

Figure 47. The Lewin Group Team

Lisa Chimento & Moira Forbes Co-Project Directors

Subject Matter Experts Pat Finnerty Anjali Jain, M.D. Kathryn Kuhmerker Joel Menges Ann Osborn John Sheils Jennifer Tracey Jeff Smith Project Manager

Operations Plan Team Program Management Program Evaluation & Federal Regulatory Co-Team Leads: & Improvement Team Improvement Team Compliance Team Chris Park & Team Lead: Team Lead: Team Lead: Jennifer Tracey Steve Johnson, Ph.D. Jessica Boehm Jessica Boehm Lead Actuary: Tom Carlson, F.S.A. Michael Madalena Roshni Arora Roshni Arora Chris Park Casey Langwith Samantha Flanzer Roshni Arora Michael Madalena Casey Langwith Casey Langwith Maik Schutze David Zhang

We will maintain our current strategy for senior leadership of the project, with Lisa Chimento and Moira Forbes acting as co-Project Directors. To appropriately address the four task areas included in the RFP, we have assembled four teams, each with a lead and support staff. Jennifer Tracey will be responsible for overall management of the teams, as well as serving as the co- team lead for the Operations Plan Team. For Task 3.2.5: Additional Services, we will assemble

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#523964 RFP #MED11010 Managed Care Administration the appropriate team for desired additional services. Ms. Chimento and Ms. Forbes will be responsible for oversight of these tasks and Ms. Tracey will be closely involved in the day to day management of each. As shown in the following figure, The Lewin Group will use a flexible staffing arrangement in which staff members with expertise directly related to the task at hand will be included on an as-needed basis, with overall coordination of all tasks being overseen by Ms. Forbes and Ms. Chimento. Ms. Forbes will directly answer to the Bureau. Lewin has also included a copy of either an existing contract or a signed letter of intent for our proposed subcontractors in the Appendix.

Figure 48: Summary of Key Staff and Advisor Qualifications

Task 1 Task 2 Task 3 Task 4 Task 5

Capitation rates Capitation & purchasing Contracting networks Provider management Program expansion Program Data analysis modification Program monitoring Program Quality assessment Waiver preparation & analysis Policy research Health reform Senior Leadership Lisa Chimento ● ● ● ● ● ● ● ● ● ● ● ● Moira Forbes ● ● ● ● ● ● ● ● ● ● Jennifer Tracey ● ● ● ● ● ● ● ● ● ● Team Leads Jessica Boehm ● ● ● ● ● ● ● ● ● Tom Carlson ● ● ● ● ● ● ● Steve Johnson ● ● ● ● ● ● ● ● ● Chris Park ● ● ● ● ● ● ● ● ● Project Staff Roshni Arora ● ● ● ● ● ● ● ● ● ● Samantha Flanzer ● ● ● ● ● Casey Langwith ● ● ● ● ● ● ● Michael Madalena ● ● ● ● ● ● ● ● ● Maik Schutze ● ● ● ● ● ● David Zhang ● ● ● ● ● Subject Matter Experts Pat Finnerty ● ● ● ● ● ● ● ● Anjali Jain ● ● ● ● ● Kathryn Kuhmerker ● ● ● ● ● ● ● ● ● Joel Menges ● ● ● ● ● ● ● ● ● ● ● Ann Osborn ● ● ● ● ● John Sheils ● ● ● ● Jeff Smith ● ● ● ● ● ● ● ● ● ●

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The Lewin Group offers a strong team of staff, each with significant time dedicated to the West Virginia project. The following provides the percentage of time for each staff person dedicated to the project team. In addition to Lewin staff members, Michael Madalena, our Encounter Data Subcontractor, will be working as a key member of our team.

Figure 49: Staff Percentage of Time

Staff Member Title Average Percent Time Senior Leadership Lisa Chimento Chief Executive Officer 10% Moira Forbes Managing Consultant 21% Jennifer Tracey Senior Consultant 36% Team Leads Jessica Boehm Senior Consultant 15% Tom Carlson Managing Director and Lead Actuary 13% Steve Johnson Managing Director 12% Chris Park Senior Consultant 36% Project Staff Roshni Arora Consultant 37% Samantha Flanzer Senior Research Analyst 16% Casey Langwith Senior Research Analyst 78% Maik Schutze Research Consultant 20% David Zhang Senior Programming Consultant 3%

Below, we provide synopses of the proposed project team members’ qualifications to perform the work outlined in this request. Complete resumes for each team member are included in Appendix B. All individuals in this proposal are currently part of Lewin’s staff. Whenever possible, we will notify the Bureau two weeks prior to replacing any key staff.

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Key Project Staff – Senior Leadership

Lisa Chimento Chief Executive Officer  Co-Project Director Ms. Chimento has been the Project Director for The Lewin Group’s work with the West Virginia Bureau for Medical  Leading Lewin’s work on Services since 1995. In this capacity, she assisted with the behalf of the State of West Mountain Health Trust program design, implementation, Virginia on all aspects of its regulatory compliance, and expansion. Specific tasks Medicaid managed care include waiver development and management, program program monitoring, capitation rate development, and vendor  Expert in directing multi- procurement and contracting. She has also directed Lewin’s year projects involving the work for the West Virginia Health Care Authority to development, increase health insurance coverage rates the State. implementation and evaluation of Medicaid Ms. Chimento has also been the Project Director for the managed care programs New York Department of Health’s multi-year contract with The Lewin Group to implement its mandatory Medicaid managed care waiver program. As Project Director, Ms. Chimento worked with the Department on a multitude of tasks, including: design of program features specific to the SSI population; conducting beneficiary surveys and focus groups; reviewing auto assignment and choice issues of relevance to the program; and assessing issues with provision of behavioral health services within the MCO program. Ms. Chimento has also led a series of foundation projects, including development of Managed Care Organization requirements for SSI enrollees in California & the readiness review and monitoring plan to support them, an assessment of California’s web-based Medicaid/CHIP enrollment system for the California Health Care Foundation, a series of Medicaid eligibility policy and cost impact studies, and a review of innovative ways that states are collecting and using data from various sources to monitor and improve their Medicaid managed care programs on behalf of the Center for Health Care Strategies. Currently, she is directing a large project with the Agency for Healthcare Research and Quality to focus on performance measurement and quality improvement, working closely with 13 states on their Medicaid disease management programs.

Ms. Chimento received her Master’s degree in Public and Private Management (M.B.A.) from Yale University and her B.A. in Economics from the University of Virginia.

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Key Project Staff – Senior Leadership

Moira Forbes Managing Consultant  Co-Project Director Ms. Forbes works with private, state, and federal clients on  Worked with the WV the development and implementation of Medicaid Bureau for Medical Services managed care programs and has assisted the Bureau for since 1995 and with the Medical Services with the implementation of the Mountain Public Employees Insurance Health Trust program since 1995. Her areas of professional Agency focus include managed care program development, implementation, and evaluation, program integrity,  Expert on state and federal eligibility policy, and federal and state regulation Medicaid and CHIP laws, compliance. Ms. Forbes has consulted with Medicaid and regulations, and policies CHIP programs in 11 states, including California, Connecticut, Indiana, New York, Maryland, Massachusetts, Montana, New Mexico, North Carolina, Oregon, and West Virginia. She has developed 1915(b) and 1115 waivers, drafted contracts and performance standards for SSI plans, participated in several procurements, created strategies to monitor managed care organization performance, surveyed Medicaid beneficiaries, and designed operational protocols for Medicaid managed care. Ms. Forbes has also worked with all state Medicaid and CHIP programs in the country on issues relating to program integrity, eligibility quality control, claims processing, and medical policy as manager of CMS’ multi-year Payment Error Rate Measurement initiative. Ms. Forbes has extensive familiarity with Medicaid laws and regulations and performs ongoing monitoring of the development of new federal policies for several public health programs. In addition, she has worked on several projects related to managed care programs for adults with disabilities and children with special health care needs. Ms. Forbes received her B.A. from Bryn Mawr College and an M.B.A. from the George Washington University.

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Key Project Staff – Senior Leadership

Jennifer Tracey Senior Consultant  Project Manager Ms. Tracey brings more than ten years of consulting  Currently managing the experience including assisting state, federal, managed care, day-to-day work of the and hospital and health system clients with operational and project including working systems improvements. She has also worked extensively closely with the Bureau with State Medicaid agencies and Medicaid MCOs on throughout the duration of program design and implementation, performance and the project monitoring, business requirements gathering and system design, and process improvement initiatives. In regard to  Extensive experience network development and review, Ms. Tracey has worked working with State closely with the states of Texas, Indiana, Pennsylvania, and Medicaid agencies, West Virginia to ensure adequate Medicaid managed care including West Virginia networks across a variety of state programs for beneficiaries. Ms. Tracey holds a Master of Health Administration from UNC at Chapel Hill (where she also earned her Bachelors) and has a Green Belt in Six Sigma.

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Key Project Staff – Team Leads

Jessica Boehm Senior Consultant  Federal Regulatory Ms. Boehm has provided extensive consulting services to Compliance and Project state Medicaid agencies and provides program Evaluation and development, management and oversight expertise. She has Improvement team lead worked on several tasks with the Bureau for Medical  Experience with the WV Services in support of its managed care program, including Mountain Health Trust revising health plan monitoring strategies, updating Program in several reporting requirements, expanding risk-based managed capacities, including care to rural counties, ensuring federal requirements were assistance with MHT and met, conducting the beneficiary satisfaction survey, and PAAS enrollee satisfaction updating the Quality Assurance and Performance and children with special Improvement (QAPI) plan. health care needs survey Ms. Boehm is currently working on a large knowledge  Worked with multiple transfer project for the Agency for Healthcare Research and states to provide Medicaid Quality on Medicaid disease management. AHRQ is and CHIP technical working with 13 Medicaid agencies to measure assistance performance and improve quality in their disease management programs and to share best practices across programs. This project includes individual and group technical assistance for each of the states on topics including childhood obesity, evaluation and measurement, telemedicine, and vendor contracting. Additional recent projects include two projects with the State of Ohio – one to model the impacts of a Medicaid Buy-In program on personal assistance services; the second to design and implement a resource website for people with disabilities and their caregivers to access services in Ohio.

Prior to joining The Lewin Group, Ms. Boehm worked at The Center for Health Care Strategies (CHCS). At CHCS, Ms. Boehm worked with Medicaid and CHIP agencies, through training and technical assistance opportunities. Ms. Boehm holds a Bachelor’s degree and a Masters in Public Policy, both from Georgetown University.

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Key Project Staff – Team Leads

Tom Carlson, F.S.A. Managing Director  Lead Actuary for the Mr. Carlson’s work focuses on rate setting, managed care Operations Plan team program development, evaluation, and policy implications.  Will serve as a subject As an actuary, his work is often financially oriented and matter expert for all rate- involves the estimation of risk and the calculation of the setting activities and appropriate payment for that risk. He has worked with utilization and cost data state Medicaid programs, Children’s Health Insurance analysis Programs, Medicare, and general assistance programs setting capitation rate levels and using appropriate risk  Currently calculating adjustment to account for risks that deviate from expected capitation rates for levels. Mr. Carlson is currently assisting in the calculation Mountain Health Trust of capitation rates for West Virginia’s mandatory Medicaid  Certified actuary with 16 managed care program, Mountain Health Trust. Tasks years of actuarial consulting include calculating the base per member, per month experience in a variety of (PMPM) costs, analyzing utilization data, calculating settings regional adjustment factors, and deriving trend factors to calculate capitation rates. Mr. Carlson has assisted the State of Colorado with the calculation of trends, Incurred but Not Reported (IBNR), Policy Changes, Fee Schedule Adjustments, and actuarial certification of the final rates used in the acute care, behavioral health care, and PACE Managed Medicaid programs for Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), and Foster Care populations. He also developed and certified fully capitated rates for the State of South Carolina’s Medicaid managed care program including TANF and SSI aid categories and special payment methodology for delivery and newborn cases. Mr. Carlson holds an M.A. in Economics from the University of California, Los Angeles and a B.S. in Economics from the University of Minnesota.

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Key Project Staff – Team Leads

Steve Johnson, Ph.D. Managing Director  Program Management and Dr. Johnson is a risk adjustment expert with over 36 years Improvement team lead of experience working with health care data, primarily  Expert in developing risk focusing on the analysis of Medicaid data. Dr. Johnson’s adjusted payment work has included the development of methodologies to methodologies for state conduct validation and reasonableness checks for data sets Medicaid programs received from outside vendors, and he has led efforts to develop programming logic to process claims data through  Over 36 years of experience risk adjustment algorithms in order to determine plan working with health care factors for risk-adjusted payment projects. He currently data supports projects that incorporate the utilization of risk adjustment systems to evaluate the health status of members enrolled in Medicaid managed care plans, profiles provider performance for the application of pay for performance methodologies on a risk-neutral basis, and manages data analysis projects evaluating the efficiency and utilization of Medicaid services.

Prior to joining Lewin, Dr. Johnson served as the Director of the Medicaid Risk Adjusted Rate Group at AmeriChoice Health Plan, focusing on the development of new products and processes to enhance the use of risk adjustment techniques to evaluate plan risk scores. Dr. Johnson has also served as a Senior Associate at Mercer Government Human Services Consulting, where he was responsible for the development of performance measures to evaluate managed care organizations in support of external quality review organization projects. Additionally, Dr. Johnson has supervised the Managed Care Rate Setting, Information Systems Unit, and Network Support Unit as the Director of Research and Program Development at the Center for Health Program Development and Management at the University of Maryland, Baltimore County campus. Dr. Johnson holds a Ph.D. in Economics from State University of New York College.

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Key Project Staff – Team Leads

Chris Park Senior Consultant  Operations Plan team lead Mr. Park has worked with state agencies to provide  Currently managing the quantitative and financial analyses, including Medicaid yearly actuarial derivation managed care capitation rate setting, the design, of capitation rates for implementation, and cost projections of Medicaid managed Mountain Health Trust care program expansions, and cost effectiveness analyses for waiver approval. He is currently managing the yearly  Expert in providing actuarial derivation of capitation rates for Mountain Health quantitative modeling and Trust, West Virginia’s mandatory Medicaid managed care financial analyses for program. Responsibilities include calculating the base per private and public sector member, per month (PMPM) costs using eligibility and clients claims data, analyzing regional variation in costs, analyzing the impact of price and programmatic changes, and developing unit price and utilization trends to calculate capitation rates. He has also been involved in the managed care cost effectiveness analysis for the 1915(b) waiver renewal process. For the state of Texas, Mr. Park assisted in the actuarial evaluation of the Texas Medicaid managed care program. He and his team created a financial model to evaluate the potential savings of various managed care models such as PCCM and HMO for both the TANF and SSI populations. Mr. Park also assisted the state of Delaware in their Medicaid managed care procurement process. Responsibilities included creating a detailed data book of the program’s cost and utilization experience which was distributed to potential bidders and evaluating the price proposals after bids were submitted. Mr. Park holds an MS in Health Policy and Management from the Harvard School of Public Health and a BS in Chemistry from the University of Virginia.

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Key Project Staff – Project Staff

Roshni Arora Consultant  Currently working as the key point of contact for the Ms. Arora works primarily on assisting state Medicaid Bureau on tasks related to managed care programs. Specifically, she is the key point of waiver and contract contact for the ongoing technical assistance contract with development, network the State of West Virginia Bureau for Medical Services on monitoring, and program tasks relating to network and contract administration. She expansion has analyzed plans’ readiness to begin enrollment of the SSI  Extensive experience in population into managed care and reviews MCO plan Medicaid, including performance regularly. Ms. Arora also recently completed managed care and disease an engagement working with 17 Medicaid care management programs management programs to measure performance, improve quality, and share best practices. Other Medicaid-related

work has included analysis of alternatives to reduce Medicaid spending through benefits limitations, market research and procurement strategies for multiple Medicaid health plans, and examination of the role of Medicaid health plans in reforms to cover the uninsured. Ms. Arora is also currently conducting a study of CMS’ current process for submitting and evaluating provider network tables submitted by Medicare Advantage applicants. Prior to joining Lewin, Ms. Arora worked at the Center for Health Care Strategies and the Children’s Defense Fund. Ms. Arora holds an M.P.H. from the Columbia Mailman School of Public Health and a Bachelor of Arts double majoring in Health & Societies and Political Science from the University of Pennsylvania.

Samantha Flanzer Senior Research Analyst  Will work with the Federal Regulatory Compliance Ms. Flanzer currently works on state Medicaid program team evaluations, identifying cost savings, operational  Experience with Medicaid improvements, and best state practices. Recent project work managed care in several has included an assessment of Minnesota’s Medicaid and states MinnesotaCare program requirements in support of State eligibility alignment efforts, claims data analysis for the CMS Payment Error Rate Measurement (PERM) project, and a comprehensive review of the Missouri Medicaid clinical services program. She has also assisted Medicaid health plans in the state procurement process and analyzed state Medicaid beneficiary satisfaction survey data. Ms. Flanzer is a graduate of the Johns Hopkins University where she received her Bachelors of Arts in public health.

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Key Project Staff – Project Staff

Casey Langwith Senior Research Analyst  Will provide support for all Ms. Langwith currently support projects with state clients, required project tasks including the West Virginia Bureau of Medical Services.  Currently assisting in the Her work with West Virginia has included monitoring monitoring of Mountain program outcomes and performing provider network Health Trust, including analysis related to the expansion of Medicaid managed care developing quarterly services. Prior to joining Lewin, Ms. Langwith worked as a dashboards and analyzing Research Assistant in the Department of Health Policy the CAHPS survey within The George Washington University’s School of Public Health and Health Services where she focused on obesity prevention and treatment, the economic costs of obesity, and state-level obesity initiatives. In addition, Ms. Langwith developed materials highlighting the public health and prevention provisions in the Patient Protection and Affordable Care Act. She graduated magna cum laude with a B.A. in Sociology and History from Rice University in 2009.

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Key Project Staff – Project Staff

Michael Madalena Consultant  Will perform data Mr. Madalena specializes in the development and processing and analysis application of analytic and operational processes to tasks maximize the value of health care information. He has  Thirteen years experience as extensive Medicaid experience, having worked with an independent consultant agencies in West Virginia, South Carolina, Texas, New Mexico, Oklahoma, Pennsylvania, Mississippi, Georgia,  Extensive Medicaid Missouri, Washington, and Kansas. He has been involved experience in many projects using data as the foundation of the work, including capitation rate development, fiscal impact analysis, program evaluation, waiver development, EPSDT program analysis, HEDIS reporting, prescription drug group purchasing initiatives, risk-adjustment methodologies, provider profiling, and shared savings methodology development.

Mr. Madalena has developed and maintained inpatient and outpatient hospital prospective payment systems and physician reimbursement systems (with and without site- of-service differentials). He has been involved with trend, underwriting, funding, contribution establishment, and actuarial analyses. He has also developed managed care surveys and associated analysis tools, wellness and disease management programs, application architecture analysis, health care simulation models, provider network implementation studies, and general decision support systems. In the area of decision support, Mr. Madalena has been involved in the development of many applications, from auto-associative heuristic learning models used for the measurement of disease and condition prevalence in populations based on traditional health insurance data (medical, eligibility, and prescription drugs) to simulations that predict the results of various managed care initiatives.

Mr. Madalena has served as a key member of a team responsible for the design, development, implementation, and ongoing evaluation of statewide provider networks in Texas, South Carolina, and Oklahoma. He served as a consultant for The Wyatt Company (an actuarial firm) from 1988 to 1993. He holds a B.A. from Clarion State College in Social Sciences and a M.S. from Carnegie Mellon University in Public Management and Policy Analysis with a Concentration in Information Systems.

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Key Project Staff – Project Staff

Maik Schutze Research Consultant  Will support rate-setting Mr. Schutze joined the State and Payer Practice of The and network analysis tasks Lewin Group in June 2007. His work has focused on  Experience with capitation program evaluation and health services research with a and monitoring in Medicaid particular focus on vulnerable populations and persons managed care with serious chronic conditions. Mr. Schutze has been closely involved in the development of capitation rates and utilization and cost impact analyses for an innovative New York Medicaid managed care program focused on beneficiaries infected with HIV. Mr. Schutze has also worked extensively with dual eligible Special Needs Plans (SNPs), preparing three annual reports on these organizations’ membership, case mix, and health care usage evolution. In addition, Mr. Schutze has experience performing provider network analysis for the Mountain Health Trust program in West Virginia. Prior to joining Lewin, he worked on behavioral health and health promotion programs at the Mayo Clinic in Rochester, Minnesota. He received his Bachelor of Science degree from Winona State University and the Master of Health Sciences degree in Health Policy from the Johns Hopkins University Bloomberg School of Public Health.

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Key Project Staff – Project Staff

David Zhang Senior Programming Consultant  Will work on capitation Mr. Zhang has extensive experience in computer program rate-setting and data development for Medicaid managed care analyses. Mr. analysis tasks Zhang has over 20 years of experience in software  Led programming engineering. He has done a variety of projects in numerical development to analyze the analysis, software product development, database design Medicaid managed care and application, systems administration and maintenance. program in West Virginia His expertise and demonstrated skills include computing and in five other states algorithm implementation, mathematical analysis, software systems development methodology, operating system and  Sixteen years of experience compiler design, database implementation and application, in software engineering, and computing systems architecture. He draws from a wide including proficiency in knowledge base in computer programming development programming languages for Medicaid managed care analysis. and a variety of other tools Mr. Zhang has participated in projects to develop capitation rates for the West Virginia Mountain Health Trust program, evaluated the cost-effectiveness of the waiver program, and compared utilization trends in the West Virginia Medicaid fee-for-service and managed care programs. Mr. Zhang has detailed knowledge of and experience with West Virginia’s claims, encounter, and eligibility data as well as the data sets available in several other Medicaid programs.

Mr. Zhang is responsible for the entire computer programming development of Medicaid managed care analyses for the States of Iowa, Connecticut, West Virginia, Delaware, Kansas, Arizona, Montana, New Mexico, and the District of Columbia. Basic programming work includes developing a series of algorithms to investigate and clean the raw claims and eligibility databases, checking the data for accuracy and completeness, analyzing the data and designing functional data structure, linking population data and claims data, choosing efficient programming tools, and implementing all logic and requirements in programming to meet each analysis. Mr. Zhang holds an M.S. in Computer Science from The George Washington University.

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Key Project Staff – Subject Matter Experts (SME)

Pat Finnerty Managing Director  Will serve as a subject Mr. Finnerty is a skilled and knowledgeable health care matter expert regarding consultant with thirty-two years of experience in public service delivery, strategic service. His work focuses on service delivery, benefits planning, and policy administration, strategic planning, educational programs, development and oral health access. As a former Medicaid Director in the  Three decades of experience state of Virginia, Mr. Finnerty led a successful redesign of in state government, the dental program, doubling the number of participating including serving as providers and significantly increasing utilization of dental Virginia Medicaid Director services. He also oversaw the expansion of the Medicaid managed care program in Virginia while developing effective relationships with legislators, providers, and key stakeholders. In addition, Mr. Finnerty served as a gubernatorial appointment to Virginia’s Health Information Technology Advisory Commission, which is charged with coordinating the state’s response to the Health Information Technology for Economic and Clinical Health (HITECH) Act. He holds a Master of Public Administration and a B.S. in Psychology from Virginia Commonwealth University.

Anjali Jain, M.D. Managing Consultant  Will serve as a clinical Dr. Jain is a practicing pediatrician and health services consultant for all program researcher, providing expertise in health care quality evaluation and measures. Her research, both federally and locally funded, improvement activities has combined the use of quantitative and qualitative  Extensive clinical and methods with a particular focus on parenting, feeding and policy expertise in child obesity prevention. Dr. Jain recently led efforts to improve health preventive health services among children insured by Medicaid in the District of Columbia in addition to both designing and directing research supporting advocacy efforts for an alliance of employers, insurers, patients, and providers to prevent and treat obesity. Dr. Jain is an Assistant Professor of Pediatrics and Health Policy at Children’s National Medical Center (CNMC) and George Washington University, where she continues to collaborate with colleagues in combining clinical and health services research. She earned her bachelor’s and medical degrees from the University of Virginia, completed a residency and Chief Residency in Pediatrics at the University of Chicago and a fellowship with the Robert Wood Johnson Clinical Scholars Program at Yale University.

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Key Project Staff – Subject Matter Experts (SME)

Kathryn Kuhmerker Managing Director  Will act as a subject matter Ms. Kuhmerker has extensive experience with Medicaid expert as called upon for program design, management and implementation, P4P tasks related to program and value-based purchasing, health care for the uninsured management, evaluation, and long-term care. She has served as Director of New York improvement and State’s $46 billion Medicaid program, responsible for expansion. managing the Medicaid program and its relationships with  Former Medicaid Director all levels of government and numerous advocacy and of New York State interest groups. During her tenure, Ms. Kuhmerker implemented New York State’s 1115 waiver which established the Family Health Plus program for low-income adults, led the Department of Health’s efforts to rebalance the State’s long-term care system, implemented the State’s replacement Medicaid Management Information System, reinvigorated the Medicaid program’s focus on identifying and eliminating fraud, waste, and abuse and directed the Medicaid program’s innovative response to the September 11 attack on the World Trade Center. Prior to becoming the Medicaid Director, she spent more than two decades working for the NYS Division of the Budget, which gave her broad knowledge of issues in the areas of Medicaid, health care, housing, mental retardation and developmental disabilities, transportation and state financing, including participating in developing several of the State’s most highly-rated bond programs. Ms. Kuhmerker has also operated her own consulting firm, The Kuhmerker Consulting Group, which allowed her to work with most state Medicaid programs. Prior to joining The Lewin Group, Ms. Kuhmerker served as a Vice President at Affiliated Computer Services (ACS) where she focused on improving state, local and federal health care programs with an emphasis on the appropriate use of information technology. Ms. Kuhmerker holds a Master’s degree in Health Systems Administration (MBA) from Union College and a BA in Anthropology from the State University of New York at Binghamton.

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Key Project Staff – Subject Matter Experts (SME)

Joel Menges Managing Director  Will act as a subject matter Mr. Menges is a nationally recognized leader in identifying expert for capitation rate- and promoting growth opportunities for the Medicaid setting and program managed care industry as a whole. He has led several evaluation studies in this arena, and is regularly invited to make key  Over 25 years of experience industry presentations at conferences and at meetings with in Medicaid managed care Administration and Congressional leadership staff. He has worked extensively designing, developing, strengthening  Thought leader in Medicaid and evaluating Medicare and Medicaid managed care managed care expansion initiatives. Mr. Menges has directed or co-directed engagements for dozens of health plans and for more than 30 state Medicaid agencies. He has conducted work in the Medicare and Medicaid managed care arenas throughout the past 25 years. His recent work has included an assessment of how to lower States’ Medicaid costs in the “least damaging” manner, evaluating Medicaid pharmacy policy options in the managed care arena, Medicaid capitation rate-setting and program evaluation support in New York, and assisting various health plans in assessing Medicaid expansion opportunities and preparing bids. Prior to joining The Lewin Group, Mr. Menges worked for AmeriChoice, developing the firm’s New York City health plan. He also worked for six years at a managed care consulting firm after beginning his career at the Department of Health and Human Services. He received his bachelor’s degree from Kalamazoo College and a Master of Public Administration from Syracuse University.

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Key Project Staff – Subject Matter Experts (SME)

Ann Osborn Associate Director  Will serve as a subject Ms. Osborn’s work is engaged in Medicaid and Medicare matter expert for managed care payer and program assessment and health procurement, network plan system operations. She has considerable experience adequacy and federal working with health plans and state governments on regulatory compliance provider network development and management including  Has worked extensively health care services pricing, provider reimbursement, with providers, health network adequacy measurement and access compliance, and plans, and state contracting. She is also proficient in coding and governments reimbursement methodology, cost and utilization analytics, and managing large and disparate claims, benefits, provider, and eligibility files. Before joining The Lewin Group, Ms. Osborn served as Vice President of Government Programs at UnitedHealth Networks, where she oversaw compliance of Medicaid activities related to provider access, sanctions, and patient management. She holds an M.B.A in Healthcare Administration from the University of Chicago.

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Key Project Staff – Subject Matter Experts (SME)

John Sheils Vice President  Will provide expertise on Mr. Sheils is a nationally recognized authority in health health reform system reform who has frequently written about the implementation financial impact of changes in eligibility and coverage  Expert in health system under Medicaid and the health care system as a whole. He reform and Medicaid directed the development of Medicaid cost projections expansion models and other models used to estimate the cost of expanding coverage under Medicaid at the state and national levels. Mr. Sheils directed several Lewin projects on approaches for expanding coverage under state planning grant projects funded by the Health Resources and Services Administration (HRSA), which included detailed analyses of health spending, provider capacity, and proposals to expand health insurance coverage at the state level. Mr. Sheils completed a comparative analysis of the Presidential candidate’s proposals to expand insurance coverage which was widely reported in the press. He has also testified before Congress and various state legislative committees on numerous occasions. As the architect of The Lewin Group’s Health Benefits Simulation Model (HBSM), he has developed comparative analyses of the cost impacts of alternative health reform proposals nationally and for many states. He has also worked with members of Congress to design and analyze tax credits for the purchase of insurance. Mr. Sheils specializes in performing analyses of major health reform legislation for individual states. He recently developed analyses of the cost and coverage impacts of alternative universal coverage proposals for Maryland, Massachusetts, and California. In recent years, he has performed similar analyses for Connecticut, North Carolina, Pennsylvania, New Mexico, and several other states. Mr. Sheils has an M.S. in Public Policy from Carnegie-Mellon University and a B.S. in Political Science from the State University of New York.

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Key Project Staff – Subject Matter Experts (SME)

Jeff Smith Vice President  Will act as a senior advisor Mr. Smith leads The Lewin Group’s States and Payers on the project, contributing Practice and is responsible for overseeing all client his expertise on specific relationships and ensuring that quality services are issues as called upon provided on time and within budget. He has extensive  Has worked with Medicaid experience in the design, implementation, and evaluation of managed care programs for managed care programs for Medicare and Medicaid over 25 years and has over populations; developing Medicaid program expansions, 30 years of experience in the including for special needs populations; and performing health care industry focused Medicaid cost analyses. Before joining Lewin, Mr. Smith served as Vice President in AmeriChoice’s Finance  Oversaw actuarial pricing department where he led the actuarial pricing, risk activities for all of adjustment, and encounter teams. In this role, he oversaw AmeriChoice’s 19 Medicaid actuarial pricing activities for all of AmeriChoice’s 19 managed care plans across Medicaid managed care plans across the country. Mr. Smith the country also implemented a unique provider profiling project to  Has worked with numerous identify providers who were under-reporting encounters states on a number of major based on the risk of the Medicaid population they served Medicaid managed care and implemented a provider outreach program to train initiatives those providers on proper encounter submission procedures. Prior to his work at AmeriChoice, he worked with Mercer Consulting as a principal in their Government Human Services Consulting group, where he led the actuarial and risk adjustment teams for Mercer’s GHSC and served as the client lead for a number of Mercer’s major Medicaid clients including Colorado, Georgia, Maryland, New Jersey, New Mexico, New York, North Carolina, Oklahoma, South Carolina, and Vermont. In this capacity, Mr. Smith worked with his clients on a number of major Medicaid managed care initiatives including the design and implementation of 1115 waivers, 1915(b) and (c) waivers, a 636 waiver, CHIP design and implementation, capitation rate development and health plan negotiations, and initial design and implementation of many of the risk adjusted models currently in use by state Medicaid programs. Mr. Smith holds a Bachelor of Science in Finance from Arizona State University.

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Subcontracting (4.1.10)

Michael A. Madalena, Consultant, will serve as a subcontractor to The Lewin Group. Mr. Madalena has operated as an independent consulting entity since 1993, specializing in the development and application of analytic and operational databases involving administrative systems such as claims and eligibility. Mr. Madalena has primarily worked with public sector clients, including Medicaid agencies in eleven states, public sector fiscal agents such as Affiliated Computer Services (ACS) and Unisys/Molina, and several Medicaid and commercial MCOs.

Additionally, Mr. Madalena’s organization has a long standing relationship with clients in the state of West Virginia. Mr. Madalena’s experience in West Virginia dates back to 1995 when his organization was engaged to study the impact that managed care would have on the traditional fee-for-service program offered by PEIA. Since that time, Mr. Madalena has provided analytic and reporting services to the Bureau for Medical Services (BMS) and the Health Care Authority in addition to PEIA.

Mr. Madalena will be the primary lead for tasks associated with gathering, processing, and validating the managed care encounter and claims data, providing technical assistance to the MCOs on data issues, and developing periodic EPSDT and provider profile reports (Tasks 3.2.2.2 through 3.2.2.10). In addition, Mr. Madalena will contribute to tasks requiring the analysis of managed care encounter data, including capitation rate setting (Task 3.2.1.1), analyzing baseline utilization and cost data and developing HEDIS measures (Task 3.2.3.2), and additional ad-hoc analyses (Tasks 3.2.5.1 through 3.2.5.7).

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Special Terms and Conditions (4.1.11)

The Lewin Group does not require any special terms and conditions to fulfill this contract.

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Signed Forms (4.1.12)

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RFP Requirements Checklist (4.1.13)

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ATTACHMENT II RFP REQUIREMENTS CHECKLIST

RFP Requirements Checklist: The RFP Requirements Checklist is a detailed listing of every general, technical, functional, staffing, and performance requirement.

- The Vendor is to crosswalk each RFP requirement (A) to the site where it is addressed in its proposal (Columns B and C).

A B C Proposal Proposal Managed Care RFP Requirements Section Page No. 3.1 Mandatory Requirements 3.1.1 Submit an Operations Plan that addresses compliance with 32 the following program requirements: Develop and maintain provider enrollment/MCO agreements, analyze and monitor contract performance, conduct readiness reviews, evaluate network adequacy and set capitation rates in accordance with all regulatory standards. 3.1.2 Submit a Managed Care Program Management and 78 Improvement Plan that addresses each activity presented in Section 3.2.2. and Section 3.2.3. 3.1.3 Identify and comply with all federal Medicaid laws, 86 regulations, and policies. 3.1.4 Gather, process, validate and analyze managed care 58 encounter and claims data for West Virginia’s Medicaid population, including carved out services and providing associated technical assistance to the MCOs on data issues. 3.1.5 Analyze Early Periodic Screening, Diagnosis and Treatment 67 Program (EPSDT) service provisions and prepare federal and state reports to improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. 3.1.6 Create provider profiles for the MHT, MHC, FFS and PAAS 68 programs or any future programs as needed. 3.1.7 Respond to ad-hoc data requests including, but not limited 54 to, comparisons of the managed care program with the fee for service program to improve the efficiency, effectiveness, and quality of Medicaid services in West Virginia. 3.1.8 Provide all data, program and regulatory analysis required 78 to respond to, but not limited to, Legislative, Federal, State, Budgetary, Provider Associations or Advocacy Groups requests. 3.1.9 Prepare and submit necessary waivers or State Plan 89 Amendments related to program and/or changes to programs to ensure federal regulatory compliance.

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. 3.1.10 Complete comprehensive quality assessment and 87 performance improvement strategy and implementation plan yearly. 3.2 Scope of Work 3.2.1 3.2.1 A yearly Operations Plan that addresses compliance with 3.2.1 33 all the following program requirements: designing and conducting review of provider enrollment/MCO agreements; developing and maintaining vendor contracts; analyzing and monitoring contract performance; and setting capitation rates that are actuarially sound and certified by an actuary who meets the qualification standards established by the American Academy of Actuaries. 3.2.1.1 Development of capitation rates yearly, effective July 1 of 3.2.1.1 34, 36 each year and in accordance with 42 CFR 438.6. This includes development of rates for TANF/SSI or any future populations by age and sex, preparation of the capitation rate setting methodology, presentations to and discussions with currently contracted and other interested MCOs, recalculation of the upper payment limit and cost effectiveness required by CMS under the state’s current waiver, and provision of a statement by a certified actuary attesting to the appropriateness and soundness of the methodology and capitation rates.

Deliverable: Complete rate development and submit methodology and CMS documents to the Bureau for Medical Services by March 1 of each year. 3.2.1.2 Development requirements for participation and 3.2.1.2 42, 43 agreement specifications, prepare necessary agreement materials, provide technical assistance to evaluation team(s) in reviewing proposals, conduct on-site reviews of provider’s capabilities, and conduct analyses of provider networks as appropriate.

Deliverable: Submit agreement materials within 30-days of request by the Bureau for Medical Services. Provide other agreement support (e.g., on-site reviews) as requested. 3.2.1.3 Development and maintenance of provider/MCO 3.2.1.3 45, 46 agreements. Develop agreements/contracts for other vendor types. Monitor federal contract requirements and develop necessary agreement modifications and addenda if new federal requirements are promulgated. Prepare agreements and assist in presenting agreements to providers, gaining CMS approval of agreements, and making any needed changes to agreements prior to execution.

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. Deliverable: Develop federally required information and agreements within 30-days of request by the Bureau for Medical Services. 3.2.1.4 Development of strategy for MCO contracting, including 3.2.1.4 48, 48 options for performance targets based on baseline data analyses and other reports, use of incentives and/or penalties, and modifications to program requirements.

Deliverable: Contracting strategy within 30-days of request by the Bureau for Medical Services. 3.2.1.5 Perform analyses and ongoing monitoring of MCO provider 3.2.1.5 51, 52 networks, conduct quarterly analyses of the MCOs’ networks against the waiver and program requirements and monitor the networks using MCO reports and provider directories. Develop MCO- specific and program-wide reports and maps showing providers, clinics, and hospitals by specialty and location. Conduct network analyses prior to MCO expansion into additional counties.

Deliverable: Submit network analyses to the Bureau for Medical Services within 45-days of the end of each quarter. Submit expansion county network analyses within 45-days of request by the Bureau for Medical Services. 3.2.2 Program Management and Improvement: 3.2.2 55

A Managed Care Program Management plan which should include the following activities and address how specified deliverables can be achieved including the timeframes associated with each. Plans should address coordination or relationship with other related programs such as PAAS or MHC. 3.2.2.1 Participate in ongoing program management activities 3.2.2.1 56 including but not limited to participation in MCO task force activities. 3.2.2.2 Capture encounter, claims and eligibility data from 3.2.2.2- 59 participating Managed Care Organizations (MCOs), the PAAS program and fiscal agent on a monthly basis. MCO data is consistent with UB92 and CMS1500 formats. 3.2.2.3 Review encounter data for completeness and/or 3.2.2.3- 61 inconsistencies. Conduct extensive validation of data using a variety of methods, including consistency with external sources of data from the Bureau and the MCOs. Consult with MCOs and the PAAS program to solve any data issues. 3.2.2.4 Produce monthly, quarterly, and annual encounter data 3.2.2.4- 62 reports for BMS that incorporates encounter data and FFS program data. Annual reports should include comparisons of MCO performance as well as MCO vs. PAAS performance.

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. Annual reports should also include comparisons with external and normative targets, including other West Virginia public payer experience. 3.2.2.5 Provide technical assistance to the MCOs on data issues. 3.2.2.5 67 3.2.2.6 Transmit monthly electronic reports to the MCOs on 3.2.2.6 68 pharmacy utilization experience of their enrolled members as long as pharmacy is carved out of the MCO’s capitation rate. 3.2.2.7 Conduct analysis of Medicaid EPSDT program (MCOs, PAAS, 3.2.2.7 68 fee-for-service) and create custom extracts to respond to state and federal requests for information on program performance, i.e. 416 Report. 3.2.2.8 Produce PAAS provider profiles on key services that are 3.2.2.8 69 health care cost drivers (e.g., emergency room, diagnostic lab and x-ray) and mail to providers and respond to providers’ questions related to the profile. 3.2.2.9 Produce annual report on PAAS provider performance. 3.2.2.9 70

3.2.2.10 Develop additional profile reports for inclusion in monthly 3.2.2.10 71 and annual reports.

Deliverable: Submit waiver renewal documents to the Bureau for Medical Services 90-days before expiration of the current waiver. Prepare interim waiver amendments or state plan amendments within 45-days of request by the Bureau for Medical Services. 3.2.2.11 Develop options for program expansion and assist in 3.2.2.11 72, 73 implementing program expansion. Prepare a document outlining the options for program expansion. Discussion of options should address the maturity and penetration of managed care across the state, other state programs, the Bureau’s goals, concerns of other state agencies, coordinated purchasing efforts, legal and regulatory constraints, and changing federal regulation. Additional areas to be reviewed should include populations and benefits, types of entities with which the Bureau might contract, region-specific variations that might be considered, and administrative and cost implications.

Deliverable: Submit proposals outlining options for program expansion for areas without managed care entities or as other populations are identified. 3.2.3 Program Evaluation and Improvement 3.2.3 76, 79

Vendor should propose a Managed Care Improvement Plan that identifies areas for program modification through the program performance assessments included in the waiver,

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. the findings of the External Quality Review Organization (EQRO), and other program monitoring activities. The types of modifications might include changes to the MCOs’ contract requirements, elements of the program design, the Bureau’s management of the program, and subsequent external reviews and evaluations. Where applicable, prepare cost estimates resulting from these changes. The improvement plan should include any deliverable listed.

Deliverable: Prepare memoranda and issue papers within 45-days of request by the Bureau for Medical Services. Annual summary reports of the MHT program within 45 days of the end of the year. 3.2.3.1 Recommend and develop processes that will improve the 3.2.3.1 79 efficiency, effectiveness, and quality of Medicaid services in West Virginia. 3.2.3.2 Analyze baseline utilization and cost data. Develop 3.2.3.2 85 baseline utilization and cost measures by age, sex, and eligibility category that can be used to evaluate the MCOs’ performance regarding provision of services against fee- for-service. To the extent possible, measures should conform to Health Plan Employer Data and Information Set (HEDIS) measures that methodologies and be comparable to the Bureau for Medical Services’ encounter data analyses.

Deliverable: On a quarterly basis, provide BMS with performance reports and strategies to improve the services. 3.2.4 Federal Regulatory Compliance 3.2.4 87

Vendor should prepare a narrative that demonstrates their understanding of relevant Medicaid Managed Care laws, regulations, and policies. Vendor’s response should specifically address their understanding of the following requirements and deliverables: 3.2.4.1 Develop a comprehensive quality assessment and 3.2.4.1 88 performance improvement strategy and implementation plan. Prepare a document outlining the options for a state performance improvement strategy that complies with new federal regulations. Review Quality Improvement Systems for Managed Care (QISMC), CMS standards, other quality review programs, and input from enrollees, advocates, managed care organizations, and other stakeholders to identify options and recommendations for monitoring and evaluating the quality and appropriateness of care and services to enrollees. Develop the corresponding implementation plan for the strategy selected by the

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. Bureau.

Deliverable: Complete comprehensive quality assessment and performance improvement strategy and implementation plan yearly and in accordance with all federal regulatory requirements. 3.2.4.2 Perform tasks necessary to monitor the federal waiver and 3.2.4.2 90 prepare required reports and waiver application. Develop appropriate data collection tools, such as beneficiary and provider surveys. Monitor periodic reports and data submitted by the MCOs. Conduct special analyses of access, quality of care, and cost-effectiveness. 3.2.4.3 Prepare necessary waivers or state plan amendments for 3.2.4.3 92 ongoing program and/or changes to the program. Provide support in maintaining the program and implementing program changes and/or expansions, including developing documentation that may be required by CMS, such as waiver applications or state plan amendments.

Deliverable: Submit results of monitoring activities related to the waiver to the Bureau for Medical Services 120-days before expiration of the current waiver. Conduct ad hoc monitoring activities within 60-days of request by the Bureau for Medical Services. 3.2.5 Additional Services 3.2.5 95 Additional services are desired within the scope of this contract. Vendor should demonstrate in their proposal experience and capacity to perform the following services: 3.2.5.1 Production of data and ad-hoc requests for data analysis 3.2.5.1 96 services to BMS. 3.2.5.2 Provide data analysis support on reimbursement issues and 3.2.5.2 98 modeling upon request from BMS. 3.2.5.3 Provide data analysis support to assist with budgetary and 3.2.5.3 99 legislative issues upon request from BMS. 3.2.5.4 Create encounter data files as needed for other contracted 3.2.5.4 100 Vendors working with the MHT, MHC and PAAS programs. Provide technical assistance as needed. 3.2.5.5 Conduct research and recommend approaches in key areas 3.2.5.5 101 of chronic care/disease management, pharmacy, eligibility and coverage, quality improvement, improved rural health delivery, provider networks, and others, as identified by the legislature or the Bureau. The scope of these services would include production of disease specific profiles.

Deliverable: Respond to requests within 30-days of request by the Bureau for Medical Services. Provide implementation support as requested.

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. 3.2.5.6 Provide policy impact analyses and support. Review and 3.2.5.6 103 analyze policy options, develop documents for review, analyze fiscal and programmatic impacts, conduct federal regulatory review, prepare additional waivers, make presentations to senior officials and interested parties, and assist with implementation of adopted strategies. Implementation tasks may include, but are not limited to, preparation of work plans, facilitation of stakeholder working groups, development of contractor specifications, detailed actuarial and related analyses, initial and ongoing program monitoring, and necessary evaluations for state or federal reporting.

Deliverable: Respond to requests for policy impact and analyses within 45-days of request by the Bureau for Medical Services. Provide implementation support as requested. 3.2.5.7 Review, recommend, update, develop and assistance in the 3.2.5.7 104 implementation reimbursement schedules consistent with federal policies. Tasks associated with this initiative include, but are not limited to, survey of enrolled providers, presentations, CMS correspondence, development of State Plan Amendment and discussions with relevant stakeholders. 3.2.5.8 Provide additional services to comply with externally 3.2.5.8 105 driven changes to BMS programs and requirements, including any state of federal laws, rules and regulations. Services provided by the vendor could include assistance with policy development impact analysis, requirements definition and testing activities that require substantial subject matter expertise derived from experience in other states, other health care organizations or participation in federal activities. Provide implementation support as requested. 3.3 Special Terms and Conditions 3.3.1 Bid and Performance Bonds: Non-applicable. N/A 3.3.2 The Vendor, as an independent contractor, is solely liable 4.1.5 7 for the acts and omissions of its employees and agents. Proof of insurance shall be provided by the Vendor at the time the contract is awarded. The Vendor shall maintain and furnish proof of coverage of liability insurance for loss, damage, or injury (including death) of third parties arising from acts and omissions on the part of the Vendor, its agents and employees in the following amounts: a) For bodily injury (including death): $500,000.00 per person, up to $1,000,000.00 per occurrence.

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. b) For property damage and professional liability: Up to $1,000,000.00 per occurrence. 3.3.3 License Requirements: Provide certification that Vendor is 4.1.5 7 registered with the Secretary of State’s Office to do business in West Virginia; provide evidence that Vendor is in good standing with the State Agency of Employment Programs as to Unemployment Compensation coverage and Worker’s Compensation coverage or exempt from such coverage. 3.3.4 Litigation Bond: Non-applicable. N/A 3.3.5 Debarment and Suspension: Vendor will not be considered 4.1.5 7 in proposal process if debarred or suspended. Vendor must certify that they are not debarred or suspended. Successful Vendor must certify that no entity, agency or person associated with the Vendor is debarred or suspended. 4.1 Technical Proposal Format 4.1.1 Title page. Should state the RFP Subject and number, the Title Page Title Page name of the Vendor, Vendor’s business address, telephone number, name of authorized contact person to speak on behalf of the Vendor, dated and signed by a person authorized to commit the vendor. Such authorization to commit will be included in writing, such as Board of Directors minutes, Delegation of Authority, etc. 4.1.2 Transmittal Letter. A transmittal letter signed in blue ink Transmittal Transmitta by an official authorized to bind the Vendor to proposal Letter l Letter provisions must accompany the proposal. The transmittal letter must be placed immediately behind the Title Page of the General Technical section. The letter must include a statement that the RFP terms are accepted. Vendors must also include a statement in the letter certifying that the price was arrived at without any conflict of interest. 4.1.3 Table of Contents. Clearly identify the material by section Table of Table of and page number. RFP responses should follow the same Contents Contents order as the RFP and use the same titles. 4.1.4 Executive Summary. Vendor should affirm their ability and 4.1.4 1 capability to provide experienced personnel to accomplish each mandatory requirement of Part 3.1.1 through 3.1.10. The Executive Summary should not exceed three pages. 4.1.5 Vendor’s Organization. The following items must be 4.1.5 4 included in a document titled “Business Organization” and must accompany the Transmittal Letter. 4.1.6 Location. Indicate the site or sites from with the Vendor 4.1.6 8 and subcontractors, if any, will perform the relevant tasks listed in the proposal. 4.1.7 Vendor Capacity, Qualifications and Relevant Experience. 4.1.7 9, 27 Proposals should provide a comprehensive profile of the

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. organization that includes a description of the management structure and ownership. Proposals should include at least three (3) business references that demonstrate the Vendor’s prior experience in administering managed care programs. Each reference should include the contact name, address, telephone number and email address of the client, organization, and the responsible project administrator familiar with the organizations performance, and brief description of services that are provided to the reference. 4.1.8 Project Approach and Solution. The vendor should provide 4.1.8 29 a "Statement of Understanding" (not to exceed 3 pages) that provides a high-level summary of the work requested by the Bureau for Medical Services in this RFP. Additionally, the vendor is expected to provide a detailed proposal for providing the services as described in Part 3 Procurement Specifications which discusses their understanding of the Scope of Work and the project objectives and timeline. The vendor should describe the approach and methodologies for completing the work. The purpose of this information is to provide the Bureau with a thorough understanding of the vendor's proposed plan and approach. The vendor is expected to identify how they are able to commence providing services upon award of contract and continue to provide those services over the anticipated duration of the contract. The vendor is to provide a timeline or Gantt chart for the activities required and planned milestones. The vendor is to complete Appendix A Requirements Checklist and submit with proposal to this RFP. 4.1.9 Vendor Staffing. The Vendor is responsible for providing all 4.1.9 109, 165 resources necessary to fulfill the requirements as specified in this RFP. Vendor is expected to provide a project staffing chart that demonstrates the vendor's ability and capability to provide knowledgeable, skilled and experienced personnel to accomplish the Scope of Work as described in Section 3. Key staff are to be identified and the percentage of time that each individual is to be dedicated to this project. Resumes are to be provided for the key staff members assigned to this project, including their licenses, credentials and experience in administration of a managed care program including rate setting components. 4.1.10 Subcontracting. Identify the required services that you 4.1.10 131 intend to subcontract, if any. 4.1.11 Special Terms and Conditions. Describe any special terms 4.1.11 132 and conditions required to fulfill this contract. The Bureau

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A B C Proposal Proposal Managed Care RFP Requirements Section Page No. must be informed of any terms, conditions, and/or limitations of the Vendor prior to entering into contract negotiations. 4.1.12 Signed Forms. Complete and sign all necessary forms, such 4.1.12 133 as the MED-96 and Purchasing Affidavit forms. The successful vendor shall be required to comply with the HIPAA Business Associate Addendum (BAA). If applicable, sign and submit a Resident Vendor Preference Certificate with the proposal. 4.1.13 RFP Requirements Checklist 4.1.13 134 4.1.14 Cost Summary 4.1.14 Bound and submitted separately 4.1.15 RFP Requirements Checklist 4.1.13 139

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Appendix A: Additional Corporate Qualifications

Summary of Lewin and Subcontractor Corporate Experience in Key Task Areas

Task 1 Task 2 Task 3 Task 4 Task 5

Capitation rates Capitation & purchasing Contracting networks Provider management Program expansion Program Data analysis modification Program monitoring Program Quality assessment Waiver preparation & analysis Policy research Health reform West Virginia Bureau for Medical ● ● ● ● ● ● ● ● ● ● ● ● Services State Medicaid Agencies/ Other State Agencies Alabama Department of Health ● ● ● California HITECH Strategy and ● ● ● ● ● ● Planning Colorado Department of Health Care ● ● ● Policy and Financing Colorado Health Networks ● ● ● ● ● ● Delaware Department of Health and ● ● ● ● ● ● Social Services Illinois Economic and Fiscal ● ● ● ● ● Commission Kentucky Hospital Association ● ● ● ● Minnesota Department of Human ● ● ● ● ● ● ● ● Services Missouri Department of Social Services ● ● ● ● ● ● ● New Mexico Medical Review ● ● ● ● ● ● ● Association New York State Department of Health ● ● ● ● ● ● ● ● ● New York AIDS Institute ● ● ● ● ● ● ● ● ● ● ● Rhode Island Department of Human ● ● ● ● Services Texas Department of Health and Health and Human Services ● ● ● ● ● ● ● ● Commission Other Related Engagements Agency for Healthcare Research and ● ● ● ● ● Quality California HealthCare ● ● ● ● Foundation/Medi-Cal Policy Institute The California Endowment ● ● ●

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Task 1 Task 2 Task 3 Task 4 Task 5

Capitation rates Capitation & purchasing Contracting networks Provider management Program expansion Program Data analysis modification Program monitoring Program Quality assessment Waiver preparation & analysis Policy research Health reform Colorado Blue Ribbon Commission for ● ● ● Health Care Reform Commonwealth Fund ● ● ● DHHS, Assistant Secretary for Planning ● ● ● ● ● and Evaluation (ASPE) DHHS, Centers for Medicaid & Medicare ● ● ● ● ● ● ● Services Governing Board of the County Medical ● ● ● ● ● ● ● Services Program in California Pennsylvania Coalition of Medical ● ● ● Assistance Managed Care Organizations New York State Health Foundation ● ● ● ●

Project Qualifications

West Virginia Lewin developed the initial capitation rate-setting methodology, Bureau for Medical extracted and analyzed claims and eligibility data, and calculated Services managed care rates for participating plans for the initial program year as well as the subsequent rate periods for the past 15 years. Lewin develops capitation rates in compliance with final Medicaid managed care regulations on an annual basis. Lewin has presented the capitation rates to the MCOs each year and assisted the Bureau working with the CMS to secure federal approval. In past years, Lewin also conducted preliminary analyses analyzing per capita costs for a potential PACE program, and examined per member per month costs relating to pharmacy and behavioral health services.

Lewin has developed RFPs and evaluated proposals for MCOs, the enrollment broker, and the external quality review organization (EQRO). Lewin staff researched state best practices, developed review protocols and scoring methodologies, and provided technical assistance to Bureau staff in evaluating proposals.

Lewin developed the initial contract between the MCO and the State, assisted the Bureau in negotiations with MCOs, and has prepared annual updates to the contract to comply with program and regulatory changes, particularly those required after the passage of the Balanced Budget Act

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in 1997 (BBA). In 2001, Lewin developed a comprehensive revision to the contract to clarify program requirements and improve its effectiveness as a program management tool, and made significant revisions in 2002 to bring it into compliance with the final Medicaid managed care regulation. Lewin identified additional changes to the MCO contract bringing it into compliance with CMS requirements. In more recent years, Lewin has modified the contract based on findings from MIG audits and to ensure compliance with relevant federal regulations. Lewin also assisted in drafting the PCCM contract, and assisted with efforts to bring the PAAS program into compliance.

Lewin developed the original Network Adequacy Methodology that was used to evaluate MCO readiness to serve specific counties within the Mountain Health Trust service area. The methodology identified minimum provider ratios in key primary and specialty care areas based on an analysis of FFS. Lewin has assessed network capacity on an ongoing basis as the programs have expanded to additional counties and as MCOs have expanded their service areas. Lewin has monitored the extent to which MCOs are complying with program access requirements, including both access to specific provider specialties and distance and travel time standards. Lewin conducted special analyses of provider capacity for the retrospective waiver analysis and has conducted ad hoc reviews when potential access problems are identified. Lewin has also created provider network standards for evaluating MCO networks for the provision of behavioral health and children’s dental services, and the enrollment of SSI beneficiaries.

Lewin also prepared a waiver amendment to allow the State to mandate enrollment in counties with only one MCO and also prepared an amendment to implement the single-plan rural option allowed under the final Medicaid managed care regulation, which was approved by CMS.

Lewin has assisted BMS with all aspects of the design and implementation of Mountain Health Trust since its development in early 1995. Lewin’s tasks include participating in ongoing MCO task force activities, attending meetings and coordinating with other State contractors, providing technical assistance to MCOs and other vendors, assisting with coordination of the PAAS program, developing mechanisms to evaluate performance across programs, writing annual reports, and developing SSI-specific materials. Lewin has also prepared materials describing specific aspects of the program for new administrations, State legislators, and federal agencies.

Consultants to Lewin, in co-operation with BMS and the participating entities, designed, implemented, tested and put into production a database of claims/encounters from participating MCOs, along with carved-out benefits and eligibility from the State’s fiscal intermediary. The combined MHT, PAAS, and FFS database was used to support BMS initiatives and measure the effectiveness of the participating plans by

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producing HEDIS® measures annually. The database was also used to supply data to external entities. Examples of this function included providing electronic prescription drug utilization data reports to the participating plans for their enrollees, EPSDT data for federal reporting, and provider profiles for feedback to PAAS physician on their patients’ use of emergency room services, and PAAS provider performance reports. The database was used to develop additional profile reports for inclusion on monthly and annual reports. Lewin consultants reviewed and validated data for the Bureau, and have produced annual encounter data reports for the Bureau. Consultants to Lewin have also provided technical assistance to MCOs on data issues.

Lewin has assisted the Bureau with the management and expansion of the MHT program since its inception in 1995. Because managed care penetration in West Virginia was relatively low, Lewin staff worked very closely with providers, insurers, and MCOs in the development of the program to ensure that its design would meet the State’s goals and be attractive to potential contractors. Lewin helped develop the “Options” plan to allow continued geographic expansion of the program at a time when most parts of the state were served by only one MCO, and later assisted the Bureau in the implementation of the single plan rural option authorized by the BBA. Lewin has assisted the Bureau in recruiting additional MCOs to participate in the program, and has worked with all the MCOs in the expansion of their service areas. As a result, the program is available in all areas of the State.

Lewin is working with the Bureau and the MCOs to begin the phase-in of the SSI population and inclusion of behavioral health and children’s dental services, which is anticipated to begin during 2011, and has already completed preparations such as waiver authorization and negotiations with CMS. In addition, as part of efforts to assist BMS prepare for the program expansion, Lewin developed a detailed implementation strategy, drafted stakeholder presentations and a fact sheet, modified MCO reporting requirements to comply with the Waiver Conditions of Approval, and conducted network and operational reviews of each MCO’s readiness to enroll SSI beneficiaries and provide behavioral health and children’s dental services.

Lewin designed many of the quality assurance and performance improvement standards used in MHT, including the standards for quality assurance for MCOs, EQRO scope of work, quarterly reporting requirements, and retrospective evaluations. Lewin worked with program stakeholders in the development of these program standards and updates these standards annually. Lewin has prepared many documents for CMS, including waiver applications describing how the MHT program complies with federal quality assurance standards. Lewin also developed implementation plans for monitoring and ensuring quality for CSHCN and adults with disabilities.

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Lewin assisted the Bureau in designing its Medicaid managed care program, including populations, benefits, and geographic areas to be included, types of risk arrangements, delivery system and administrative requirements, outreach and enrollment plans, and quality assurance approach. Lewin has prepared program modifications in many of these areas to account for the continued expansion and maturity of the program, as well as the changing regulatory environment. Lewin has assisted the Bureau in designing and implementing approaches to strengthen program performance in areas identified through a variety of monitoring activities.

Lewin developed the most recent 1915(b) waiver renewal application, including descriptions of all activities the State will take to monitor compliance with the waiver during the current two-year approval period. Lewin conducted retrospective assessments of quality, access, and cost- effectiveness for the previous four waiver renewals. Lewin monitors the MHT program on a continual basis through the review of MCO quarterly reports and other monthly reports, and has conducted many review activities, including surveys of beneficiaries in the MHT and PAAS programs (including special surveys of CSHCN) and high-volume primary care providers, analyses of provider network capacity and access, and audits of compliance with program rules such as after-hours access. As part of this process, Lewin also updated the State’s QAPI to reflect revised reporting requirements, MCO contract requirements, and federal regulations.

Lewin prepared the initial 1915(b) waiver application, discussed key program features with CMS officials, and assisted Bureau staff in responding to written questions from CMS. Lewin has subsequently prepared six successful waiver renewal applications with CMS’ revised 1915(b) application preprint. Lewin prepared prospective and retrospective cost-effectiveness analyses for each waiver application and negotiated with CMS to use a single capitation rate on a statewide basis. Lewin has prepared responses to questions from CMS, OMB, and other federal agencies. Lewin prepared waiver amendments to allow the State to mandate enrollment in counties with only one MCO (the “Options” program) and has prepared an amendment to implement the single-plan rural option allowed under the final Medicaid managed care regulation, which was approved. In the most recent waiver renewal, Lewin worked closely with the Bureau and CMS to ensure compliance with newly issued federal regulations affecting the mandatory enrollment of parents and caretakers.

Lewin conducted multiple analyses of baseline utilization and cost data as part of annual rate-setting efforts, as part of a study comparing MHT performance to fee-for-service, and for ongoing program monitoring and improvement purposes. In preparation for enrollment of SSI beneficiaries, Lewin developed baseline fee-for-service utilization

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measures and indicators to be used in evaluating the MCOs’ performance in serving this population. Lewin conducted additional analyses of FFS and MCO data to identify potential areas for State-specified quality improvement projects and financial incentives. Consultants to Lewin are able to provide technical assistance and create encounter data files for other contracted vendors working with the MHT and PAAS programs.

Lewin conducted numerous ad hoc research projects for the Bureau and developed policy recommendations in key areas of interest. These included: providing pharmacy coverage to low-income elderly persons in the State through Medicaid, estimating the cost of expanding Medicaid eligibility to cover children through age 18 who are between 100 and 200% of FPL, and researching innovative state approaches regarding seamless CHIP and Medicaid systems for children. Lewin also researched EQRO regulation requirements and has previously updated the scope of work and contract for the reprocurement. Lewin also updated the State’s QAPI to reflect updates in the EQRO regulations.

Lewin prepared numerous policy analyses and developed specific recommendations, implementation plans, working documents, and other materials necessary for the Bureau to implement the policy changes. In the past, Lewin drafted the State’s comments, which were signed by the Governor, on the draft Medicaid managed care regulation. Several of these recommendations were adopted by CMS and included in the final regulation. Lewin reviewed the economic stimulus packages proposed in Congress and the President’s budget and prepared an analysis of the possible budget implications for West Virginia. More recently, Lewin has been actively engaged by the Bureau to design a detailed implementation strategy for the upcoming expansion of the MHT program to include SSI beneficiaries, behavioral health services, and children’s dental services. Lewin has also assisted the Bureau in responding to numerous letters of concern from provider groups, advocacy groups, State legislators, and federal agencies.

State Medicaid Agencies/ Other State Agencies

Alabama For the Alabama Children’s Health Insurance Program, The Lewin Group Department of designed eight options for expanding insurance coverage in the state Health including Medicaid eligibility expansion for parents, employer based initiatives such as the “Healthy New York” model, and a Medicaid Buy- in program. This project included actuarial analysis of program benefits costs and simulation of enrollment and stakeholder impacts using the Health Benefits Simulation Model. Lewin also performed an analysis of tax credits for small employers of low-wage workers.

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California HITECH The Lewin Group led a team to develop a strategy and implementation Strategy and plan for Medicaid electronic health record (EHR) incentive program Planning payments to providers in the State of California. Lewin conducted an environmental scan of Medi-Cal providers, a provider and vendor analysis on the current penetration of EHR use, and interviews with a sample of providers. We developed a proposed staffing structure and job descriptions for DHCS oversight of the program as well as a detailed strategic plan for the Incentive Program with discrete performance targets. The team also developed a Campaign Plan to reach providers who will implement EHRs and Medi-Cal beneficiaries and defined key components of an operational implementation plan with recommendations on technical assistance to facilitate provider adoption.

Colorado The Lewin Group is currently providing actuarial and budget modeling Department of services to the Colorado Department of Health Care Policy and Financing Health Care Policy for the development of capitation rates for the Health Maintenance and Financing Organizations and Program of All-Inclusive Care for the Elderly, Behavioral Health Organizations, and Child Health Plan Plus programs. Lewin will also be providing health policy analyses and guidance as requested on an ad hoc basis by the State.

Prior to our current project, The Lewin Group assisted Colorado with its rate setting for Medicaid managed care programs. In conjunction with the Department of Health Care Policy and Financing, Lewin has conducted the following activities: reviewed programming logic for data collection and summarization, calculated and established trend rates, reviewed calculation of risk adjustment which was used for trend calculation and rate adjustment, modeled the rate setting process in compliance with CMS rate setting guidelines, discussed assumptions and results with participating HMOs and established capitation rates and actuarial certification for the program. Lewin initially conducted this rate setting exercise for rates in the Denver region and later assisted the State with an expansion of the program into nearby Weld County.

Colorado Health Lewin provided an analysis of the impact of mental health interventions Networks on physical health costs in Colorado for the Colorado Health Networks (CHN). As a capitated waiver program, CHN provides behavioral health services to Medicaid recipients within CHN’s contracted service area. The project included three parts: conducting a comprehensive literature review of mental health interventions that result in physical health cost savings; conducting a qualitative analysis of key mental health interventions that CHN can implement in order to impact cost savings for the state; and modeling the impact of CHN care management and treatment interventions based on literature review and using the HBSM to estimate the potential impact that these mental health interventions could have on Medicaid health spending in Colorado.

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Delaware Lewin developed upper payment limits and risk-sharing methodologies Department of for two Medicaid managed care programs designed to serve special Health and Social needs populations (physically disabled and elderly persons, including Services Medicare and Medicaid dual-eligibles, and persons with mental illness and substance abuse dependency disorder). Lewin analyzed cost and eligibility data, developed risk-adjusted capitation rates for both populations, and performed budget neutrality calculations for the waiver application. Lewin has set the capitation rates for Delaware since 1999. Lewin assisted with the development of two Medicaid managed care programs designed to serve special needs populations (physically disabled and elderly persons, including Medicare and Medicaid dual- eligibles, and persons with mental illness and substance abuse dependency disorder). The Lewin Group developed capitation rates for Delaware’s acute care managed care program, Diamond State Health Plan (DSHP). The rate setting process included individual stop-loss options. DSHP operates through a competitive bid process. To assist the state, The Lewin Group created data books both on the historical fee-for-service (FFS) experience alone and recent health plan encounter data blended with the FFS experience to distribute to prospective bidders. The Lewin Group also provided assistance in evaluating the cost proposals of the bidding health plans. In addition, The Lewin Group studied many of the financial and design issues related to DSHP and worked closely with state officials to make strategic recommendations for the future structure of the program. Previously, The Lewin Group developed financial payment model options for Delaware’s Medicaid managed long term care initiative. The Lewin Group worked with DHSS staff to develop viable payment options with appropriate incentives to create more cost effective alternatives to nursing home care. The Lewin Group also prepared the necessary waiver cost effectiveness analyses and documentation to CMS for waiver approval, tabulated family planning and institutions for mental disease costs for federal match reporting, and performed other ad hoc tasks as requested throughout the contract. Illinois Economic During the first half of 2005, Lewin conducted a comprehensive and Fiscal assessment of Medicaid managed care expansion options for the State of Commission Illinois. Models assessed included a range of DM and case management initiatives, as well as capitated MCO models. Lewin’s recommendations involved implementing DM in conjunction with primary care case management as soon as possible throughout all the rural regions of the State (where the capitated model was not deemed viable).

Kentucky Hospital The Lewin Group was commissioned by the Kentucky Hospital Association Association to assess the level of Medicaid payment rates for Kentucky hospitals and to assess the Medicare-type diagnosis related group (DRG) system recently implemented by the Medicaid Department. Using claims data, hospitals cost report data, and other data supplied by

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Kentucky hospitals, The Lewin Group assessed the adequacy of the Medicaid payment rates for Kentucky hospitals relative to payment levels in neighboring state Medicaid programs. The Lewin Group evaluated the equity of payment rates across hospitals in the state under the new Medicaid DRG system. Working with the Kentucky Hospital Association, some of our recommended modifications were adopted by the state Medicaid agency in order to make the payment system more equitable across the state’s hospitals.

Minnesota Lewin is currently under contract with the Minnesota Department of Department of Human Services to design and assist in the implementation of an Human Services evaluation of the Demonstration to Maintain Independence and Employment (DMIE) program, called “Stay Well, Stay Working” (SWSW), funded by the Centers for Medicare and Medicaid Services. By enhancing access to and utilization of needed health care, behavioral health, and employment support services, the program aims to improve the economic self-sufficiency and reduce public welfare program dependency of employed individuals with serious mental illness. Minnesota has developed an integrated, consumer-directed intervention that provides health, mental health, and employment supports to enrollees through a coordinated provider network. Lewin is designing an evaluation that includes both process and impact evaluation components. The process evaluation examines the nature of the enrolled population, including an assessment of “work motivation,” the current organizational and service delivery context, and the facilitators of and barriers to outreach and enrollment. The impact evaluation employs a randomized control design to assess program impact on employment, income and health stability outcomes. Lewin is developing the data evaluation’s infrastructure, which combines multiple data sources, including: Minnesota Medicaid Information System claims, Unemployment Insurance, supplemental DMIE encounter data, chart reviews, annual assessment and survey data, and qualitative data collected through focus groups and interviews with DHS program staff, members of the service provider network, and demonstration participants. Lewin developed a comprehensive Medicaid managed care incentive program. Lewin reviewed efforts in other states and national best practices, conducted interviews with health plans and State staff, evaluated the completeness of encounter data, recommended specific performance areas and incentive strategies, and used encounter data to test the feasibility of selected performance measures.

Lewin developed a comprehensive Medicaid managed care incentive program. Lewin analyzed MCO encounter data to obtain an accurate baseline of each health plan’s performance to determine the reasonableness of the performance targets and to reveal potential problems in data collection or measurement methodologies.

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For the Plan To Align Eligibility Requirements and Administrative Processes project, Lewin provided DHS with analysis and options to align eligibility standards and administrative processes for children and adults who receive (or could receive) health care coverage through the Medical Assistance and MinnesotaCare programs, in order to reduce client confusion, administrative barriers, and administrative costs. Lewin prepared reports on current eligibility and enrollment practices, to provide recommendations for this study and inform future policy questions. Lewin then evaluated and reported on eight alignment areas and present specific options and supporting analysis for each to support prioritization and decision-making. Finally, Lewin created alternative overall strategies for alignment and develop a final report for submission to the Legislature.

Missouri For the State of Missouri, Lewin conducted a comprehensive review of Department of the Medicaid program with recommendations on how the State can Social Services achieve short-term Medicaid savings, providing detailed assessments on achieving longer-term program savings, and evaluated options to improve the effectiveness and efficiency of the Medicaid program. Lewin developed a series of reports as well as supporting materials, and Lewin’s analyses were used by State policymakers to craft the state fiscal year 2011 budget as well as guide decisions about future Medicaid program design and operations. Specific areas of analysis included short-term cost containment opportunities, long-term care, pharmacy, care management, non-emergency medical transportation, and overall program financing and operations. Our final report provided a series of recommendations regarding the structure and operation of the program, performance metrics to guide program management, and proposed approaches and priorities for enhancing the quality and efficiency of care to advance value-based purchasing and care coordination.

New Mexico The Lewin Group conducted an assessment of New Mexico’s managed Medical Review care program, Salud!, and behavioral health managed care program and Association developed reports to fulfill the CMS requirement for an independent assessment of the state’s 1915(b) waiver programs. The reports assessed three dimensions of health care: access, quality, and cost-effectiveness. Lewin reviewed state contractual requirements, provider networks, satisfaction surveys, national performance standards, HEDIS results, CAHPS scores, and various financial reports as part of this assessment.

New York State Since 1999, Lewin has worked with the State of New York to implement Department of its statewide mandatory Medicaid managed care program, The Health Partnership Plan. Lewin’s work covers a range of issues from dental and behavioral health access to SSI program design to assessing the outreach and enrollment process to a series of provider and beneficiary surveys. In addition, Lewin assisted the Legislature’s Medicaid Managed Care Advisory Review Panel on special projects and provided technical

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assistance to MCOs. The following are several tasks that Lewin has perform for the project:

Lewin reviewed financial incentive systems used by several state Medicaid managed care programs and wrote a white paper summarizing potential approaches for New York’s mandatory Medicaid managed care program.

Lewin assisted the Department in designing program modifications to support the enrollment of the SSI population, including the development of quality assurance standards for MCOs and a program monitoring plan for the State. Lewin facilitated a statewide task force to consider various design issues, including those related to quality assurance and performance improvement, and investigated the experiences of other states that have enrolled SSI adults and children.

Lewin also established network requirements for SSI enrollees in several counties and reviewed plan networks against the criteria, as well as developed detailed network evaluation criteria for TANF and SSI evaluation plan networks against criteria.

Lewin assisted with monitoring the Medicaid managed care programs, including conducting English and foreign language beneficiary focus groups to identify successful mechanisms for outreach and enrollment, and surveying beneficiaries on their experiences with managed care. Lewin worked with the State to develop and administer a survey of auto-assigned enrollees, using CAHPS as a model, and conducted a survey of beneficiaries regarding access to dental services.

As a complement to the Department’s MCO quality oversight program, Lewin conducted a study of MCO relationships with contracted behavioral health organizations (BHOs). The study examined how the MCO and BHO coordinated services, as well as overall BHO operations.

For the NYS 1115 Waiver program, The Lewin Group collected and analyzed information on Medicaid primary care case management (PCCM) programs, including associated disease management (DM) and care management components, for New York's consideration in exploring a future PCCM program as an alternative to full-risk managed care in rural areas. State and Lewin staff identified five states (Illinois, Maine, Massachusetts, North Carolina, and Pennsylvania) with PCCM programs. We researched and reviewed state-specific information and conducted interviews to understand current PCCM and managed care organizations (MCO) programs; implementation strategies, including associated DM programs; PCCM program design strategies, including program administration and characteristics; comparisons of PCCM and MCO program outcomes; and lessons learned. Based on this information, Lewin prepared a memo to summarize key components of

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the five state programs, particularly around common PCCM program design strategies, with a focus on program outcomes, including DM and pay-for-performance (P4P) strategies, innovative features, and lessons learned regarding PCCM programs.

As a part of the NYS Early Intervention Program Utilization Review project, Lewin evaluated service utilization NY's Early Intervention Program (EIP), developed benchmarks and provided recommendations for the program. Lewin activities included data analysis, focus groups, literature research, provider surveys and stakeholder interviews. Lewin activities informed an interim and comprehensive final report.

New York AIDS Throughout the past 15 years, Lewin has assisted New York’s Institute Department of Health in developing, operating, and strengthening its Medicaid managed care program targeted exclusively for HIV-infected beneficiaries. Lewin has assisted in designing the program, including the financial and rate-setting aspects; writing segments of the RFA; developing criteria and a scoring methodology for evaluation and selection of special need plan (SNP) contracts; and directly assisting in the procurement process. Lewin also prepared a suggested monitoring approach to help assure that the SNP initiative is closely overseen during its initial implementation and beyond and is assisting in those efforts, and has evaluated the solvency of the SNPs, conducting a detailed assessment of the smallest entity during early 2006.

Lewin assisted in the design and implementation of SNPs to serve Medicaid-eligible individuals with HIV/AIDS. Lewin conducted the following activities: writing segments of the RFA; developing criteria and a scoring methodology for evaluation and selection of SNP contracts; assisting in the procurement process; assisting in the development of the readiness review process; participating in on-site readiness reviews; and assisting in the development of the HIV SNP model contract.

For the New York HIV/AIDS SNP program, Lewin assisted the State in developing and implementing a contracting strategy that ensured participation of key providers and geographic diversity in the SNPs’ service areas.

Lewin established network requirements for HIV SNPs in the following areas: standard ratios of HIV specialist primary care providers; inclusion of “co-located” service providers offering HIV care and services to women, persons with mental health and drug use disorders; designation of clinical and social case managers; and, establishment of SNP linkages with important community-based organizations serving the HIV infected population.

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Lewin assisted the Institute in developing quality standards and monitoring approaches for the special needs plans for individuals living with HIV/AIDS. Lewin staff developed on-site audit tools for Department of Health staff to use in their oversight of this innovative, cross-agency program.

Lewin has also assisted the AIDS Institute and Division of HIV Health Care, Bureau of Community Support Services staff in developing reimbursement rates for supportive services for the period April 2008- March 2009 and April 2009- March 2010. Supportive service include: case management, transportation, translation, health education; treatment adherence; and other allowable supportive services.

Lewin has established annual capitation rates for the program each year, from 2003 through 2011. Lewin has also conducted a detailed analysis of the program’s impacts on medical costs and usage, publishing these findings during 2003.

Rhode Island The Lewin Group analyzed historical Rhode Island Medicaid per Department of member per month data and financial projections under the current Human Services program design and under the proposed Global Consumer Choice 1115 waiver application (which sought to transform RI Medicaid to a block grant program). Lewin then assisted the State in identifying and defending financial terms and conditions in the negotiations with CMS to protect the state in the event of significant differences between the anticipated environment and actual experience

Texas Department Lewin helped the State prepare for and conduct readiness reviews of of Health and Medicaid MCOs selected through a competitive bidding process. Lewin Health and Human conducted a two-day training session, produced the review protocols Services for use, and performed on-site reviews of each MCO in conjunction with Commission State and CMS staff. Lewin also assisted in the procurement of the MMIS vendor, the enrollment broker, and a quality monitoring organization. Lewin assisted in the development of a hospital selective contracting initiative. Lewin developed an RFP and contract, met with industry officials to explain the initiative, conducted bidder’s workshops, evaluated hospital proposals, conducted market analyses, and assisted the State in negotiating with the selected hospitals.

Lewin created the actuarial framework for tabulating program savings in the nation’s largest Medicaid DM initiative. Lewin provided extensive actuarial support, reviewing the price bids of the finalist vendors, participating in contract negotiations with the selected vendor (on the State’s behalf), developing the specific coding requirements to establish baseline costs and program savings, and preparing a detailed reconciliation document that defined exactly how cost savings would be tabulated.

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Lewin assisted in designing and implementing a Medicaid selective contracting initiative and in the procurement of MCOs. Lewin developed the RFPs that served as the basis for the contracts, and assisted the State in negotiations with successful bidders.

Lewin prepared a report on the cost savings potential of various Medicaid managed care models by eligibility group and geographic region. Lewin also prepared a report shaping policies around payments for MCO services rendered on an out-of-network basis.

West Virginia For the West Virginia Hospital association, Lewin performed an (Various Agencies) assessment of hospital costs and margins for all hospitals in the State of West Virginia. The report evaluated the cost shift and compare hospital efficiency in WV to other US state averages.

For the West Virginia Center for Healthcare Policy and Research, Lewin developed a series of policy options for expanding coverage, some of which were variations on a HIFA waiver. Lewin examined reconfiguring the Medicaid and SCHIP eligibility levels in a way that would permit an expansion in eligibility without an increase in state expenditures. Lewin developed analyses of the cost of establishing a high-risk pool in the state using the grant monies made available under the Trade Adjustment Assistance Reform Act. In addition, we estimated the impact of several other types of public and private models for expanding insurance coverage.

Other Related Engagements

Agency for The Lewin Group assisted AHRQ in leading a learning network of 17 Healthcare Research State Medicaid disease management and care management programs. and Quality Through the learning network, Lewin compiled State experiences with Medicaid care coordination (encompassing disease management and other care management initiatives), provided technical assistance (TA), and worked with the States to improve and evaluate their programs. Lewin provided the TA through several venues and support services, including site visits, Web conferences, teleconferences, and large group workshops. Lewin also provided individualized TA to individual States on all aspects of designing, implementing, and evaluating their care management programs. A primary focus area of technical assistance provided by Lewin was developing performance measures and designing program evaluations.

Lewin is working on the AHRQ CER Horizon Scan project. The purpose of this project is to meet an immediate need at AHRQ to establish a horizon scanning system. Through this procurement, AHRQ seeks to quickly and efficiently implement a horizon framework and infrastructure to immediately generate information that will inform comparative effectiveness research investments through the Effective

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Health Care (EHC) Program. It is expected that a majority of the effort necessary to accomplish the required tasks below will be dedicated to the implementation of a horizon scanning system and to the actual conduct of horizon scanning.

As part of the Health Information Technology Research Center (HITRC) funded by the Office of the National Coordinator for Health Information Technology (ONC), Lewin is supporting the Regional Extension Centers (RECs) in their outreach and marketing of the adoption of electronic health records (EHR) by primary health care practitioners (PHCPs). With an extensive portfolio of support services, RECs are designed to accommodate the needs of providers in diverse settings and at different stages of EHR readiness. The RECs will be evaluated based on their success in assisting primary health care practitioners in becoming meaningful users of certified EHRs. Each REC has a goal of providing at least 1,000 PHCPs with technical assistance in the first two years. Over the course of this four year contract, The Lewin Team will support the RECs in reaching this goal by: (1) assessing the marketing and communications needs of the RECs and determine the most effective strategies and approaches; (2) branding the collaborative effort of the non-profit REC organizations to enhance the unified impact; (3) arming the RECs with the expertise and leading-edge tools they need to reach their various constituencies and advance EHR adoption; (4) synthesizing data from the RECs collected through HITRC’s Customer Relations Management (Salesforce).

For the Agency for Healthcare Research and Quality (AHRQ)’s Evaluation of National Guideline Clearinghouse project, Lewin is assisting AYFA, Inc, to conduct a comprehensive evaluation of AHRQ’s National Guideline Clearinghouse™ (NGC) website. The mission of the NGC is to provide a variety of stakeholders an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use. To inform our research questions and evaluation design, Lewin conducted a comprehensive analysis of NGC project data and assisted AFYA in gathering input from a group of individual experts in guideline development, evaluation, dissemination, and implementation who formed the evaluation's Participant Evaluation Team (PET). The evaluation will use three methods to obtain data to answer our research questions, including: a web-based survey, 11 focus groups, and 30 key informant interviews. Lewin led the development of the interview and focus group guides and had a large supportive role in the creation of the survey instrument as well. Lewin will also be leading a portion of the focus groups and interviews. Given the extensive effort to collect primary data for this evaluation, Lewin also assisted AFYA in creating an OMB clearance package. Lewin assisted with the analysis of the data resulting from the three data collection methods. The results will be summarized

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California Lewin conducted a comprehensive assessment of the Medi-Cal HealthCare California Working Disabled Program, a Medicaid buy-in program. Foundation/Medi- Specific activities included modeling enrollment and cost impacts of Cal Policy Institute program expansion options using Census Bureau and State data; designing, administering, and analyzing results from an enrollee survey, which yielded a 26% response rate; interviewing county eligibility workers; and facilitating focus-group like discussions with non- enrollees.

Lewin prepared a detailed cost estimate for providing continuous Medi- Cal (Medicaid) eligibility to children in California. The project involved working with the State’s eligibility and claims files for over 250,000 Medi-Cal eligibles, to develop a simulation model. Lewin also prepared cost estimates for allowing children to be deemed presumptively eligible for Medi-Cal.

Lewin conducted a study comparing Medi-Cal physician fee-for-service rates to rates paid by other Medicaid programs nationally. Lewin collected data from every state’s Medicaid agency on fees for 50 CPT codes, and compiled Medicare average allowed charge information for each of these procedures. Lewin ranked the 50 states’ Medicaid physician payments on a variety of statistics.

The California The Lewin Group evaluated the Frequent Users of Health Services Endowment Initiative, which is jointly funded by The California Endowment (TCE) and the California HealthCare Foundation (CHCF). The Initiative funds grantee programs to find and serve people who are frequent and high cost users of health services. These individuals most often have chronic physical and mental illnesses, which are compounded for low income, minority and immigrant populations which traditionally have less access to services. The evaluation was being conducted in two phases, design and implementation. Throughout the design phase, Lewin worked closely with TCE, CHCF, and grantees to assess “implementation readiness” and ensure the feasibility, relevance, and success of the project. The implementation phase involved providing hands-on technical assistance to grantees, interviews of key informants, and site visits to assess preliminary evaluation design and data capacity/infrastructure, creation of a data baseline on organizational/program characteristics, and coordination with the grantees regarding their role relative to the external evaluation in producing data for the uniform data system. This evaluation provided key stakeholders with critical decision-making information of use in responding to environmental changes affecting the state and national health care systems, ranging from looming state budget deficits to escalating health care costs.

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Colorado Blue Lewin analyzed several proposals to achieve universal coverage Ribbon including a single payer program. The study included a detailed Commission for analysis of the impact of the single payer program on health services Health Care Reform utilization, insurer and program administrative costs, provider administrative costs, bulk purchasing savings and long-term projections of program costs and the adequacy of the proposed financing mechanisms. The study also included analyses of the distributional impacts of alternative mechanisms for funding the program.

Commonwealth The Lewin Group developed analyses of the cost and coverage impacts Fund of several pieces of legislation that would expand health insurance coverage in the U.S. These include a proposal to cover all Americans under Medicare, and an analysis of a modernized benefits package for Medicare including alternative reimbursement methodologies. The results of these analyses were presented on Capitol Hill and in Congressional testimony. More specifically, The Lewin Group investigated the impact of instituting a bundled payment for inpatient and outpatient services based on an episode of care. Using the Episode Treatment Grouper (ETG), we calculated the average cost of an episode for 13 disease conditions. The risk adjusted episodes for the 13 conditions accounted for approximately 20 percent of Medicare expenditures. We used the average cost per episode by condition as a basis for calculating a geographically adjusted episode payment. We used this rate to estimate the savings to the Medicare program from implementing a bundled payment for these conditions. DHHS, Assistant Lewin was hired by the U.S. Department of Health and Human Services Secretary for (DHHS), Office of the Assistant Secretary for Planning and Evaluation Planning and (ASPE) to conduct several national and state-level impact analyses of Evaluation (ASPE) various health care reform proposals, including President Bush’s health proposal. The President’s proposal would replace the current tax exclusion for employer provided health benefits with a flat tax credit combined with a state-based grant funding component. For the U.S. and each state, Lewin developed a baseline database of health spending and utilization in 2009, provided an analysis of the cost and coverage impact of the proposal, and provided 10-year projections of the proposal’s impact. Other proposals investigated included Medicaid expansions, premium subsidies for private health insurance, auto-enrollment provisions, mandatory enrollment provisions, as well as provisions expanding coverage to immigrants and the use of section 125 plans. The analyses focused on cost and coverage impacts associated with each alternative, as well as potential crowd-out effects.

The analyses were conducted with The Lewin Group Health Benefits Simulation Model (HBSM). HBSM is a micro-simulation model of the U.S. health care system. HBSM is a fully integrated platform for simulating policies ranging from narrowly defined Medicaid coverage expansions to broad-based reforms such as changes in the tax treatment

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of health benefits. The model uses data from several sources including the Medical Expenditure Panel Survey, the Current Population Survey, and the Kaiser/Health Research and Educational Trust survey of employers.

DHHS, Centers for The Lewin Group was contracted in 2009 to perform this large, multi- Medicare and faceted project in order to develop concise and defensible criteria for Medicaid Services adequate provider networks that ensure access for Medicare Advantage (CMS) (MA) beneficiaries to their health care benefits, and create the business requirements and process for CMS to automate the submission and review of the Health Services Delivery (HSD) tables that are the vehicle for MA applicants to describe their contracted networks. After completing comprehensive formative research on the standards and practices in place throughout the commercial and Medicaid industries, the higher level clinical needs of the varying populations, and their historic utilization patterns, Lewin mapped the availability of providers, by specialty type, against the location of beneficiaries, and developed the requirements for maximum travel time, maximum travel distance, and the minimum number of providers for a network. Criteria varied by specialty and by geography. Our preparatory work for the development of the process for automation included interviews with key stakeholders from the CMS Divisions of Medicare Advantage Operations (Central and Regional staff), Plan Data, Policy, Analysis and Planning, and Special Programs; MA plans, Medicaid agencies, and clinical experts.

Since 2001, The Lewin Group has assisted CMS in the development, implementation, and refinement of the Payment Error Rate Measurement (PERM) program for Medicaid and CHIP. From 2001 to 2005, Lewin worked CMS and 34 pilot states to develop, test, and refine a methodology to measure the accuracy of claims payments and eligibility determinations in Medicaid and CHIP. From 2005 to 2009, Lewin served as the Statistical Contractor for the PERM program, performing all statistical, sampling and error rate calculation functions. Lewin was responsible for obtaining claim-level data in a variety of formats for Medicaid FFS, Medicaid managed care, CHIP FFS, and CHIP managed care programs. Lewin analyzed each dataset for compliance with PERM requirements, applied the necessary data scrubbing to establish data conformance with program requirements, and ran the cleaned data through a proprietary statistical sampling program. The sampled claims were sent to other contractors for review. Lewin also worked with states on the measurement of eligibility errors, reviewed state-developed eligibility sampling plans, and assisted states in extracting stratified monthly universes of all Medicaid and CHIP beneficiaries from a variety of eligibility systems. Lewin developed a secure website for states to submit monthly eligibility quality control reports and a calculator for states to use to estimate state-level eligibility error rates. Information on claims and eligibility errors and their dollar

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values were sent to Lewin, which compiled the information and calculated state level error rates and standard errors, and projected a national error rate and its standard error. All stages of the data development and analysis were methodically tracked and documented for the purposes of establishing the integrity of the audit and resulting error rates. Lewin also assisted CMS in a variety of pilot projects and special analyses designed to further improve and streamline the PERM process. These included a pilot test of a standardized state data submission process that would better align with the existing CMS MSIS data initiative, and a methodology for measuring error rates in non- claims-based Medicaid and CHIP payments.

Governing Board of For the County Medical Services Program (CMSP) The Lewin Group the County Medical estimated the cost/savings of expanding coverage under the state’s Services Program in Medicaid 1115 waiver, which parallels the early Medicaid expansion California option under the Federal Patient Protection and Affordable Care Act (ACA). Under ACA, states will be required to expand Medicaid coverage to all adult legal residents starting January 1, 2014 and receive 100 percent federal matching funds for the expansion population during the first three years, which will be phased down to 90 percent in 2020. ACA also provides states with the option to expand Medicaid coverage to low-income adults below 138 percent of the federal poverty level (FPL) before January 1, 2014 through a State Plan Amendment and receive federal matching funds for the costs. The Lewin Group estimated the cost to CMSP of meeting the eligibility requirements under the Act and the impact of receiving federal matching funds. The analysis indicated that the CMSP program could realize savings depending on how far the eligibility level is extended and when the expansion is implemented due to the influx of federal funding.

For California County Medical Services Program’s (CMSP’s) Local Health Connections Pilot, The Lewin Group was contracted to provide technical assistance services. The Local Health Connections Pilot Project will test the effectiveness of providing community-level services and support to CMSP enrollees with complex medical and/or social conditions. CMSP's goal for the project is to promote timely delivery of necessary care, facilitate targeted enrollees' linkages to other resources and support services, and improve the cost effectiveness of CMSP services for the pilot program's enrolled population as compared to nonenrolled CMSP members with similar characteristics. Lewin will review grant proposals, conduct needs surveys, provide web-based training, develop and conduct program conferences, and extend direct on-site technical assistance to grantees.

The Lewin Group has designed and implemented an evaluation plan for the CMSP Governing Board's Mental Health and Substance Abuse Pilot Project, involving the provision of grants to up to 21 provider organizations to coordinate primary care and MH/SA services for

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CMSP beneficiaries. CMSP is a consortium of 34 California counties which collectively administer services to the adult general assistance population. Lewin assisted in the specifications of grantee requirements, particularly with regard to data collection and operational requirements related to the evaluation, and in the evaluation of proposals to ensure the selected organizations demonstrate the necessary capabilities to conform to the evaluation parameters. The evaluation of grantee performance will occur over a three-year period, with a final report to be delivered to the Governing Board in the spring of 2011.

New York State The Lewin Group contracted with the New York State Health Health Foundation Foundation to develop a three-phased roadmap to cost containment for New York with practical approaches to reducing health care costs. A key element of our overall approach was the establishment of a technical advisory panel (TAP) of industry and health policy experts in New York to assist in selecting and evaluating cost containment options for the State. In Phase I, Lewin worked with the Foundation and the TAP to identify specific areas of potential savings in the existing health system and identify policy options designed to realize these savings. In Phase II, Lewin conducted detailed data analyses of New York claims data and other data sources to develop realistic estimates of what these options would save. In Phase III, Lewin worked with key stakeholders to prioritize a subset of the options studied above, develop high-level implementation plans for these prioritized options, and assist the Foundation in disseminating results.

Pennsylvania Lewin prepared a comprehensive assessment of one of the nation’s Coalition of largest and longest-standing capitated Medicaid initiatives. To conduct Medical Assistance this evaluation, Lewin met with each of the seven MCOs participating in Managed Care HealthChoices to fully understand their programs and reviewed Organizations relevant data from both the FFS and HealthChoices programs as well as from other state Medicaid programs. Lewin collected a vast array of written information on the program and prepared four reports. The first assessed the program’s cost-effectiveness, finding that HealthChoices has achieved large-scale savings and that the program is in exceptional financial balance. Almost 90% of the capitation payments are used to pay for health care services, with the MCOs implementing a wide array of outreach and education initiatives within their administrative spending (which comprises less than 10% of revenue). The MCOs have achieved a modest positive operating margin and the program has stable, experienced MCOs. Lewin also assessed the program’s impacts on access, quality, and the performance in serving special needs subgroups. In each of these areas, the program was found to be highly successful.

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Appendix B: Staff Resumes

LISA M. CHIMENTO CHIEF EXECUTIVE OFFICER

EDUCATION

Masters in public and private management (M.B.A.), Yale University B.A., economics, University of Virginia

EXPERIENCE

Ms. Chimento is Chief Executive Officer of The Lewin Group. Her own consulting work focuses on state and local health reform initiatives. She has worked on behalf of more than 30 state and local governments and is a nationally-recognized expert on Medicaid. Prior to joining Lewin in 1994, Ms. Chimento conducted research and analysis of issues in the organization and delivery of health care services at the National Academy of Sciences, Institute of Medicine (IOM) where she served as Project Officer. She also served as a policy analyst at the federal Office of Management and Budget (OMB). Following is a summary of her health care and management experience: Medicaid Managed Care

 Managing a multi-year project for the State of West Virginia involving the design, implementation, and administration of a mandatory physical health managed care program for its TANF and adult SSI Medicaid populations, including development of a special initiative to encourage health plans to contract with local health departments, school-based health clinics, and other publicly-supported providers. Work involves designing the benefit structure and the administrative processes associated with the program; assisting with program expansion and monitoring activities; surveying Medicaid enrollees and providers; conducting evaluations of the waiver; and performing ongoing program administration.

 Led two large, multi-year projects for the State of New York Department of Health to assist with implementation of The Partnership Plan, the State’s statewide mandatory 1115 waiver program. Primary tasks included: assisting with the Department’s stakeholder task group to review program design features for SSI beneficiaries; review of other states’ experiences with managed care for disabled individuals; development of criteria to determine readiness to mandate enrollment of disabled individuals into The Partnership Plan; design of beneficiary surveys; assistance with implementation of mandatory SSI pilot program; study of behavioral health organizations; presenting results of tasks to the State’s legislative oversight body; conducting beneficiary focus groups; and improving county office outreach and education approaches.

 Assisted the State of Connecticut in the implementation of a mandatory, statewide Medicaid managed care program, including development of a competitive procurement for enrollment of beneficiaries who did not select a health plan. Program design and health plan evaluation efforts targeted the integration of physical and behavioral health services,

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building incentives for plans to include historic providers in their networks, requiring plans to contract with school-based health centers, and ensuring systematic outreach efforts for wellness and EPSDT services. Work included: development of an overall program design; actuarial analyses; submission of CMS waiver; the redesign of information systems; preparation of a plan for state management and administrative structure; development of baseline health status and utilization statistics; Medicaid enrollee and provider satisfaction surveys; and initial program monitoring.

 Advised a national health care system on the design of a Medicaid managed care program in Louisiana, including analysis of the state’s Medicaid program, assessment of the public hospital system, development of feasible options, preparation of the federal waiver, and recommendations for short- and long-term implementation strategies. State and Federal Policy and Legislation

 Leading a project on behalf of the California HealthCare Foundation to develop recommendations to support the mandatory enrollment of disabled persons into managed care. Lewin is working with an advisory group of stakeholders to develop health plan contract performance standards and measures which will foster improvements in quality of care for people with disabilities and chronic illness; strategies to address cross-agency issues that affect quality of care for people with disabilities and chronic illness; and strategies to monitor health plan contract compliance on an ongoing basis.

 Assisting the California HealthCare Foundation in providing analytic and technical support to the California Department of Health Services Medi-Cal redesign efforts. Project deliverables included analysis of the financial and programmatic impact of potential Medi- Cal benefits changes, development of a model to assess impact of a “tiered benefits package,” and examine operational issues, and assessment of possible Medi-Cal managed care expansions and eligibility changes.

 Directed a project to study Indiana’s Medicaid program and identify possible options for increasing the program’s long-term sustainability in the face of mounting demand for services and dwindling State dollars on behalf of The Central Indiana Corporate Partnership. The major deliverable was a summary report designed to present several options that could potentially lead to savings in the State’s Medicaid program, based on Indiana-specific research and analysis, and other state experiences.

 On behalf of the Center for Health Care Strategies, co-directed a study of how leading states are using data (e.g., encounter data, MCO reports, beneficiary surveys, HEDIS) to manage and oversee their Medicaid managed care programs. Special emphasis was placed on how this data can be most effectively used for public reporting, accountability, and performance improvement. Operations and Performance Reviews

 Co-directed a large, multi-year project for the Agency for Healthcare Research and Quality on Medicaid care management and performance improvement. Lewin convened a learning network of 17 Medicaid agencies to help them assess their disease management or care management programs. Specific tasks included technical assistance to states on program

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management, clinical and operational quality improvement activities, data analysis, and performance measurement.

 Led annual site visits and assessments of six managed care contractors on behalf of the West Virginia Public Employees Insurance Agency (PEIA). All aspects of managed care operations were reviewed, including health services delivery, utilization review and management, quality assurance, financial solvency, medical loss ratios, member services, and data reporting.

 Assisted the United Hospital Fund (UHF) in identifying ways the Medicaid enrollment process in NYC could be improved through an automated system by documenting the timeframes of the current process. Lewin conducted site visits of eligibility determination sites and analyzed data from these organizations' various tracking systems to develop quantitative and qualitative measures of performance in key areas (e.g. timeliness, user satisfaction). The application process will be analyzed to determine the potential effects of automation and areas where improvements might be realized, and results were presented to UHF staff for use in planning for an automated system. Procurement-related Experience

 Led a project to conduct a thorough review and evaluate managed care organizations wishing to serve Medicaid recipients in Maryland’s new 1115 waiver program, HealthChoice. Specific tasks included: development of criteria for written and on-site evaluation; review of proposals; ongoing technical assistance to plans particularly in the special populations area; site visits to applicants; and final recommendations for contracting. Applicants included non-HMOs, such as provider- and FQHC-sponsored entities. SELECTED PUBLICATIONS AND PRESENTATIONS

“Rate Setting and Actuarial Soundness in Medicaid Managed Care,” (co-authored with Grady Catterall), prepared for the Association for Community Affiliated Plans and the Medicaid Health Plans of America, January 2006. “Electronic Applications Present Opportunities to Improve Enrollment into New York’s Public Health Insurance Programs,” (co-authored with Anna Theisen-Olson and Maya Bhat), prepared for the United Hospital Fund, November 2004. “Opportunities and Observations for Indiana Medicaid,” (co-authored with Michael Cheek, Jessica Boehm, and Melissa Rowan), prepared for the Indiana Government Efficiency Commission, September 2004.

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MOIRA FORBES MANAGING CONSULTANT

EDUCATION

M.B.A., Financial Management, George Washington University B.A., Political Science and Russian, Bryn Mawr College

EXPERIENCE

Ms. Forbes is a Managing Consultant at The Lewin Group with sixteen years of experience working with private, state, and federal clients on Medicaid and CHIP policy. Ms. Forbes’ career has focused on Medicaid managed care program development, implementation, and evaluation, demonstration design and development, federal and state policy analysis, and quality assurance. She has also worked on several projects related to managed care programs for adults with disabilities and children with special health care needs. Since 2001, she has worked with every state Medicaid and CHIP program on issues relating to program integrity and eligibility quality control. Ms. Forbes has extensive familiarity with Medicaid laws and regulations. She has also worked with a number of Medicaid managed care plans on a variety of strategic, procurements, and operational issues. Her experience at The Lewin Group includes: Medicaid Managed Care

 Managing a project for the State of West Virginia to operate, monitor, and strengthen the state’s Medicaid managed care program, Mountain Health Trust. Ms. Forbes helped the state address policy changes necessitated by the Balanced Budget Act of 1997 (BBA), and recently developed a revised contract between the State and participating managed care organizations to comply with the new BBA regulation. Ms. Forbes was involved in monitoring managed care organization performance and refining quality oversight approaches. Ms. Forbes contributed to the development of first and second 1915(b) renewal waiver applications and independent program assessments. She was also involved in the initial procurement of managed care organizations and the external quality review organization and has performed various other research and policy analysis tasks for this client since 1996.

 Managing a project for the California HealthCare Foundation to update the Medi-Cal (California Medicaid) Facts and Figures Databook and prepare three issue briefs on policy issues relating to the Medi-Cal program, including one on high-cost Medi-Cal populations and one on chronic conditions. Through a related engagement, Ms. Forbes is serving as a Technical Expert for the Medi-Cal 1115 Waiver Advisory Committee (Seniors and Persons with Disabilities Technical Workgroup). She has developed background materials and analyses to support workgroup decision-making, presented at workgroup meetings in Sacramento, and participated in follow-up meetings.

 Managed a project for the California HealthCare Foundation to develop recommendations for California’s Medicaid agency to support the mandatory enrollment of disabled persons into managed care. Ms. Forbes worked with an Advisory Group of California stakeholders

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to develop health plan contract performance standards and measures which will foster improvements in quality of care for people with disabilities and chronic illness; strategies to address cross-agency issues that affect quality of care for people with disabilities and chronic illness; and strategies to monitor health plan contract compliance on an ongoing basis. Previously, Ms. Forbes worked with a group of stakeholders to test the feasibility of developing and implementing performance standards and measures for California’s Medicaid program) that are specific to the needs of beneficiaries with disabilities. She also wrote an Issue Brief synthesizing current research on policy considerations regarding expanding enrollment of persons with disabilities in managed care.

 Managed a project for the State of Texas Health and Human Services Commission to evaluate the readiness of 17 health plans to participate in Texas’ Medicaid and SCHIP managed care programs (STAR and CHIP), and of 4 health plans to participate in the Medicaid integrated long term care/managed care program (STAR+PLUS). Ms. Forbes led a risk assessment for each plan to identify the operational, systems, and provider network areas to be reviewed for each plan. Ms. Forbes oversaw the development of review criteria in each of these areas and coordinated the review of all 17 STAR/CHIP plans and 4 STAR+PLUS plans. She developed the onsite review criteria for the 8 plans deemed at high risk and led 7 site visits. Ms. Forbes prepared final recommendations for the state and is now monitoring the plans for continued progress.

 Assessed expansion opportunities for a public sector managed care plan, identifying specific market opportunities and contributing a growth strategy for Medicaid behavioral health, integrated Medicaid managed care, and Medicare Advantage product lines. State and Federal Policy and Legislation

 Assisting the California Department of Health Care Services in expanding meaningful use of electronic health records (EHR) to Medicaid providers. Ms. Forbes contributed to efforts to identify appropriate program integrity strategies for EHR incentive payments processed by the State and ensure that these strategies meet federal rules, and contributed to an implementation plan for the deployment of federal Health Information Technology for Economic and Clinical Health (HITECH) funds to support meaningful use of EHRs.

 Managing a project for the Kansas Health Policy Authority, assisting the State of Kansas in responding to the requirements of the federal Payment Error Rate Measurement (PERM) Project for FFY2009, including assistance with eligibility sampling plan development, claims universe preparation, sample claim details population, and development of a corrective action plan.

 measure payment accuracy in Medicaid and CHIP fee-for-service and managed care, and development of a new methodology to assess the accuracy of Medicaid and CHIP eligibility determinations.

 Assisted the North Carolina General Assembly in conducting a comprehensive analysis of the scope, amount, and duration of Medicaid benefits.

 Assisted the Center for Health Care Strategies, a Robert Wood Johnson Foundation-funded Medicaid think tank, in analyzing the administrative impacts and costs for managed care

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organizations and states as a result of the passage of the Balanced Budget Act and related regulation.

 Contributed to a project for the Medi-Cal Policy Institute, estimating the costs for continuous and presumptive eligibility for children in California.

 Assisted the District of Columbia in revising its State Plan for Medicaid to bring it into compliance with DC and Federal law.

 Contributed to the Indiana Governor’s Advisory Panel on Children’s Health Insurance blueprint for the State’s Title XXI (CHIP) program. Operations and Performance Reviews

 Leading a project for the Centers for Medicare and Medicaid Services (CMS) to conduct a comprehensive study to evaluate the impact of four proposed Medicaid regulations on each of the 50 states and the District of Columbia. Ms. Forbes managed the state data collection effort, coordinated the analysis, and contributed to the final Report to Congress, including developing recommended actions for the federal government and the states to improve the accuracy and documentation of claims associated with these regulations.

 Assisted a provider-sponsored Medicaid health plan with identifying opportunities for performance improvement, developing operational strategies to implement selected improvements, and preparing a successful proposal.

 Assisted the Medi-Cal Policy Institute in analyzing three potential eligibility simplification options for Medi-Cal (California's Medicaid program). Ms. Forbes reviewed the experience of other states, evaluated the policy implications of each option, and developed a final report encompassing the quantitative and qualitative analyses. Ms. Forbes also contributed to the development of a mathematical model to predict the cost implications and enrollment impacts of each of the three options individually and in combination with each other.

 Participated in a thorough review and evaluation of managed care organizations applying to serve Medicaid recipients in Maryland’s new 1115 waiver program, HealthChoice. SELECTED PUBLICATIONS AND PRESENTATIONS

“PERM Systemic Vulnerabilities: Limitations on the PERM Review,” (co-authored with Mary Pohl and Allison Haley), prepared for the Centers for Medicare and Medicaid Services, March 2010. “Care Management and Coordination of Carve-out Services,” presented to the California 1115 Waiver Stakeholder Advisory Committee Seniors and Persons with Disabilities Technical Workgroup, February 2010. “PERM Systemic Vulnerabilities: State Hazards,” (co-authored with Terry Savela, Mary Pohl, and Allison Haley), prepared for the Centers for Medicare and Medicaid Services, October 2009. “Report to Congress on Four Medicaid Regulations,” (multiple co-authors), prepared for the Centers for Medicare and Medicaid Services, September 2009.

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JENNIFER TRACEY SENIOR CONSULTANT

EDUCATION

M.H.A., Managed Care Concentration, Department of Health Policy and Administration, The University of North Carolina at Chapel Hill B.S.P.H, Health Policy and Administration Concentration, Department of Health Policy and Administration, The University of North Carolina at Chapel Hill Professional Certification, Academy for Health Care Management Green Belt Six Sigma Certification

EXPERIENCE

Ms. Tracey joined The Lewin Group in 2006 and has over ten years of experience in health care consulting. She has experience in various aspects of operations, strategy and policy including: business process re-design, workforce transformation, program evaluation for various state government clients, Medicaid program design, and performance and quality audit reviews. She also has experience working with financial ratio analysis, industry best practices, trend and data analysis, certificate of need applications, quality-driven information system implementation, focus group facilitation, and long-term care Veterans’ health issues.

In addition to her consulting experience at The Lewin Group, she has held positions with IBM’s Business Consulting Provider Clinical Transformation Practice and with Tucker Alan Inc. (now Navigant Consulting). Selected examples of Ms. Tracey’s experience follow:

Medicaid Managed Care Program Design, Implementation, and Evaluation

 Managing ongoing technical assistance contract with the State of West Virginia Bureau for Medical Services. Key tasks include managing daily contact with client, bi-annual member satisfaction survey, yearly MCO contract updates, readiness reviews, contract monitoring, network evaluation and standards development, and program design/implementation.  Managed an engagement to assist a large national health plan with creating a proposal in response to a State Request for Proposals to expand mandatory Medicaid managed care across two new geographic zones of the State. Key tasks included conducting overall operational reviews and assessments, working with key plan staff to draft cohesive and complete responses for the proposal, managing daily project activities, and preparing the final proposal response for production.  Provided consulting and operational assistance to a large Medicaid plan in New York State facing an Article 44 license audit. Worked with the COO and executive management of the plan to identify operational deficiencies, recommended and evaluated fixes, and provide guidance on successfully responding to the audit demands by the State Department of Health.

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 Conducted a study for the Association for Community Affiliated Plans (ACAP) to evaluate the financial pros and cons of using a “carve-in” versus a “carve-out” approach for pharmacy benefits within capitated Medicaid managed care programs. Key tasks included data analyses using recent cost and usage information from both the carve-in and carve-out settings and evaluation of the financial dynamics of a policy option that would combine federal Medicaid rebates with the benefits management that occur when pharmacy is handled through capitated managed care organizations (MCOs).  Assisted with the development of Medicaid managed care program design features for the Commonwealth of Pennsylvania. Gathered information from various states on Medicaid managed care programs and analyzed each model’s strengths and weaknesses as they related to the Pennsylvania market, in addition to creating recommendations for managed care implementation based on examination of utilization patterns, managed care market penetration and Medicaid enrollment trends.  Assisted in conducting research for a grant awarded by the Center for Health Care Strategies and the Robert Wood Johnson Foundation, which involved identifying states’ best practices in transitioning Medicaid clients from exiting managed care organizations. Contacted approximately 30 states to determine their exit strategies, examined each state’s Medicaid State Plan to determine best practices, and prepared a resource binder to distribute to other state Medicaid agencies. Special Needs Populations  Conducted an operational review for Health Services for Children with Special Needs, a Medicaid health plan serving children with special needs in the District of Columbia. Tasks involved interviewing key executives and personnel within the organization to determine potential areas for improvement, researching best practices for serving special needs populations, and drafting a report to the health plan’s leadership outlining potential areas for improvement. Report focus areas included care management, disease management, outreach, improved technology, and cost containment.  Assisted the State of Texas with conducting readiness reviews for managed care organizations to determine their readiness for enrolling members in STAR+PLUS, the state’s Medicaid managed care program for the Aged, Blind and Disabled. Tasks included leading desk and site reviews for two new managed care organizations to the program including development of review criteria, conducting analysis of submitted documentation, participating in site visits, and reporting findings to the state.  Assisted the Commonwealth of Pennsylvania in the development of a special needs population reporting package to be used monthly by Medicaid physical health managed care organizations. The package collects monitoring and performance data regarding services provided to special needs populations in the following areas: access to care, disease and case management, and training, education and outreach activities. Designed data collection templates, researched special needs performance measurements, and facilitated meetings between Commonwealth staff and Medicaid physical health organizations to determine feasibility of collecting specific performance measurements.

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Operations and Performance Reviews  Led a team to assist L.A. Care with six independent reviews of its MCLA member assignment and selection process to ensure consistency with internal policies, procedures, and contractual agreements. The reviews focused on member enrollment, e.g., auto assignments, member transfers, auto assignment algorithms, and overall Call Center activities. At the conclusion of each review, Lewin prepared three detailed reports summarizing our findings and recommendations and presented findings to key health plan executives.  Worked with Health New England health plan to explore development of a Medicaid line of business and to objectively and accurately assess whether serving Medicaid is a good fit for the organization. Tasks included conducting an operational assessment through staff interviews to determine existing capabilities to serve the population, defining resource commitments and administrative steps, and developing a set of financial projections depicting various Medicaid enrollment, state capitation rates, and medical cost scenarios, to assist the plan with assessing the financial dynamics of entering the Medicaid arena.  Led a team in conducting a readiness review of the State of Indiana’s enrollment broker. Involved analyzing the enrollment broker’s policies and procedures, educational and training materials, and daily operations through desk and on-site reviews. A final report was delivered to the State detailing findings from the review.  Assisted the State of Indiana in preparing an Annual External Quality Review report of its Medicaid managed care program. Analyzed results from member and provider satisfaction survey data, quality improvement activities, and required quarterly report data received from managed care entities to summarize the program’s effectiveness in delivering care to Medicaid recipients. At the conclusion of the review, recommendations for improving the types of data collected from managed care entities were developed. SELECTED PUBLICATIONS AND PRESENTATIONS

“Des Peres Hospital – Clinical Systems Conversation Administrative Team Overview,” – Des Peres Hospital, Saint Louis, Missouri, March 27, 2006. “Change Management Orientation,” – Tenet Health Care, March 20, 2006. “IMPACT Change Management Strategy,” – Tenet Health Care, January 31, 2006. “IMPACT Change Management Project Governance,” – Tenet Health Care, January 31, 2006. “Emergency Department Process Flow,” – Massachusetts General Hospital, August 26, 2005. “Clinical Process Analysis Project – Safe and Lean Hospital Final Deliverable,” – Massachusetts General Hospital, June 17, 2005. “MedStar Health Positive Patient Identification: Medication Management System and Specimen Labeling,” – Washington Hospital Center, April 20, 2005.

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JESSICA BOEHM SENIOR CONSULTANT

EDUCATION

M.P.P., Georgetown University, Public Policy Institute B.A., Sociology, Georgetown University EXPERIENCE

Jessica Boehm, Senior Consultant, joined The Lewin Group in 2002. Prior to joining Lewin, Ms. Boehm worked at The Center for Health Care Strategies (CHCS) in Princeton, NJ. At CHCS, Ms. Boehm worked with state Medicaid and SCHIP agencies, through training and technical assistance opportunities, on topics including quality monitoring, performance incentives, primary care case management, and strategic planning. Ms. Boehm also worked at the District of Columbia Office of Early Childhood Development as a legislative analyst. Medicaid Managed Care

 Worked with the State of West Virginia on ongoing tasks to support its Medicaid managed care program. Specifically, Ms. Boehm worked on revising the health plan monitoring strategies and updating reporting requirements. In addition, Ms. Boehm worked with the State to expand its risk-based managed care program to rural counties and to ensure that federal requirements are met. Other tasks in West Virginia included updating the Medicaid Quality Assessment and Performance Improvement Program, procuring an External Quality Review Organization, and a beneficiary satisfaction survey.  Worked with the State of Minnesota Department of Human Services to provide recommendations for a sustained, comprehensive Medicaid managed care incentive program. In addition to conducting a literature review, Ms. Boehm interviewed other state Medicaid agencies and select private payers who are utilizing performance incentive strategies to learn what practices are successful. Ms. Boehm also conducted interviews with the Medicaid health plans and with Minnesota State staff to fully understand the unique needs of Minnesota.  Assisted in a comprehensive assessment of Pennsylvania’s HealthChoices program, a capitated Medicaid managed care initiative.  Assisted in analyzing out of network payments in the Texas Medicaid MCO program and developing an appropriate payment methodology. State and Federal Policy and Legislation

 For the Blue Cross Blue Shield Foundation of Massachusetts, assisted in a project to improve knowledge regarding the nature and capacity of the licensed professional workforce in the children’s mental health service delivery system in Massachusetts. The goals of the project were to: (1) develop an estimate of need for children’s mental health services in Massachusetts; (2) assess child and family mental health service delivery capacity among licensed providers; (3) identify variation in capacity to meet the mental health needs of children and families, including capacity by geography, linguistic ability,

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and cultural competence; and (4) document challenges to meeting current demand for services, such as provider retention, reimbursement, and barriers to entry. Project tasks included the facilitation of a project Advisory Group, the development, implementation, and analysis of random sample survey of Massachusetts mental health providers, provider and stakeholder interviews, and a review of relevant literature.  Ms. Boehm was the project manager on an engagement to assist the federal Agency for Healthcare Research and Quality (AHRQ) in facilitating a learning network of 13 state Medicaid disease management and care management programs. Through the learning network, Lewin is continually compiling state experiences in the Medicaid care coordination arena (encompassing DM and other care management initiatives), providing technical assistance, and working with the states to improve and evaluate their programs. Lewin uses its own expertise as well as the expertise of external subject matter experts to provide technical assistance. Lewin has provided technical assistance to states on topics including procurement and measurement and evaluation. Lewin has helped states develop and refine their disease management RFPs, create RFP evaluation tools, and score their RFPs. In addition, Lewin has helped several states design and perfect their program evaluations and measures. Lewin and its contracted experts have provided advice on the appropriateness of measures, the structure of evaluations, and evaluation results. Through the technical assistance and time spent with the states, Lewin has compiled extensive information from the participating Medicaid agencies under this engagement. Technical Assistance and Training

 Through a multi-year contract with the Agency for Healthcare Research and Quality (AHRQ), provided individual and group technical assistance to 17 state Medicaid agencies on Medicaid care management. As part of this engagement, Ms. Boehm led the development of 9 workshops on topics such as program design, procurement, measurement, evaluation, communications, and continuous quality improvement. To supplement the in-person workshops, Ms. Boehm facilitated bi-monthly webconferences. In addition to these workshops and webconferences, Ms. Boehm provided on-site technical assistance to each of the 17 states on selected areas of interest. As the culmination of this project, Ms. Boehm led the development of a toolkit: “Designing and Implementing Medicaid Disease and Care Management Programs: A User’s Guide.” Operations and Performance Reviews

 For a disease management organization, developed state marketing plans for the organization’s public sector products focused on care management.  For the Indiana Medicaid program, reviewed current cost containment strategies and analyzed new opportunities for savings. New opportunities focused on long-term care, Medicaid managed care, pharmacy, and program administration. Ms. Boehm was responsible for reviewing cost containment initiatives in other states to assist in the recommendations for Indiana.  For the Washington State Medicaid program, Ms. Boehm worked on a project team to conduct three major analyses with respect to Medical Assistance Administration’s (MAA) current cost containment efforts: 1) Inventory current cost containment efforts already underway; 2) Independently evaluate the cost savings estimates already produced by

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MAA; and 3) Recommend future cost containment strategies Washington could consider, based on Lewin’s experience and expertise in Medicaid cost containment. Procurement-Related Experience

 Assisted a prominent health plan with a bid protest involving a contract to serve enrollees in a State Medicaid program. Tasks involved reviewing scoring sheets and proposals for all bidders, comparing select bidder responses to determine the adequacy of responses, and documenting potential scoring errors. The protest resulted in the discovery of a scoring error due to the oversight of a required document which led to the health plan winning the protest and the opportunity to serve Medicaid recipients.  Assisted a Medicaid managed care organization in responding to a state Request for Proposals to participate in a mandatory managed care program for Medicaid and SCHIP beneficiaries. Reviewed health plan policies and procedures, interviewed health plan staff and executives, and drafted key sections of the proposal.  For the State of West Virginia, assisted with Medicaid managed care expansion. Specific tasks included: development of criteria for written and on-site evaluation, review of proposals, site visits to applicants, and final recommendations for contracting.

SELECTED PUBLICATIONS AND PRESENTATIONS

“California Medi-Cal EHR Incentive Program: Landscape Assessment, prepared for the California Department of Health Care Services, March 2010. “Accessing Children’s Mental Health Services in Massachusetts: Workforce Capacity Assessment,” prepared for the Blue Cross Blue Shield of Massachusetts Foundation, October 2009. “Designing and Implementing Medicaid Disease and Care Management Programs: A User’s Guide,” (co-authored with Roshni Arora, Lisa Chimento, Lauren Moldwater, and Catherine Tsien), prepared for The Agency for Healthcare Research and Quality, February 2008. “Opportunities and Observations for Indiana Medicaid,” (co-authored with Michael Cheek, Lisa Chimento, and Melissa Rowan), prepared for the Indiana Government Efficiency Commission, Subcommittee on Medicaid and Human Services, September 2004. “Medicaid Cost Containment: Reports No. 3,” (co-authored with Charles Milligan and Anna Theisen), prepared for The Washington State Legislature, January 2003. “Medicaid Cost Containment: Reports No. 2,” (co-authored with Charles Milligan and Anna Theisen), prepared for The Washington State Legislature, December 2002.

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THOMAS P. CARLSON MANAGING DIRECTOR

EDUCATION

Masters of Arts in Economics, UCLA Bachelors of Science in Economics, University of Minnesota

PROFESSIONAL ASSOCIATIONS

Fellow in The Society Of Actuaries Member of The American Academy of Actuaries

EXPERIENCE

Thomas Carlson is a Managing Director at The Lewin Group. Mr. Carlson’s has 16 years of actuarial consulting experience in a variety of settings. Recent work has centered on the provision of actuarial services and Medicaid program operations and policy. He has extensive experience analyzing state and federal health policy, evaluating Medicaid initiatives, and providing technical assistance for capitating commercial and government health care programs. Recent experience includes the following projects:

Rate Setting, Risk Adjustment and Payment Methods

 Assisting in the calculation of capitation rates for West Virginia’s mandatory Medicaid managed care program, Mountain Health Trust. Tasks include calculating the base per member, per month (PMPM) costs, analyzing utilization data, calculating regional adjustment factors, and deriving trend factors to calculate capitation rates. Other tasks include assessing the impact of changes in payment rates on participating HMOs and the impact of recent case mix changes on the capitation rate. Finally negotiations and discussions with the State, CMS and the participating health plans regarding the rate setting processes and possible modifications to the process in the face of the changing environment.  Developed and certified fully capitated rates for the State of South Carolina’s Medicaid managed care program including Temporary Assistance for Needy Families (TANF) and Supplemental Security Income (SSI) aid categories and special payment methodology for delivery and newborn cases. Rates are risk adjusted for plan experience vis-à-vis fee-for- service experience. Calculated rates using raw claims data received on 3490 tapes and imported into databases for summary and analysis. Adjustments applied include Incurred but Not Reported (IBNR), managed care eligibility calculations, large claims analysis, and newborn reinsurance carve-out. This experience is directly applicable to the proposed project in Delaware. 2002 – 2006.  Calculated and certified capitated rates for an expansion of the STAR+PLUS program in Texas. STAR+PLUS covers the ABD population with the expansion increasing coverage from Harris County to other large urban areas of the State. The expansion carved out

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inpatient hospital services, however the contract for the program included incentives and penalties based on the management of inpatient services. This work is directly applicable to the project in Delaware. 2005 – 2006.  Worked with multiple Blue Cross Blue Shield plans to determine an optimal range of surplus for the plans to ensure financial viability and ongoing vitality. Surplus ranges were determined based on financial projections as well as historical precedents of similar Blue plans, and project work included expert testimony to insurance regulators.  Assisted the State of Colorado with the calculation of trend, Incurred but Not Reported (IBNR), Policy Changes, Fee Schedule Adjustments, and actuarial certification of the final rates used in the acute care, behavioral health care, and PACE Managed Medicaid programs. These programs cover Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI) and Foster Care populations.  Assisting the State of Texas recalibrating relative DRG weights and base rates (Standard Dollar Amount). Updated hospital-specific DRG Standard Dollar Amounts with 2004 Medicare cost report data, and adjusted for administration and capital levels in Medicare cost reports. Calculated regional relative weights using Medicare values when credible samples were not available.  Worked with South Carolina on developing actuarially sound rate ranges, allowing State procurement of services based on geographical areas.  Worked with South Carolina’s Medically Fragile Children program to develop actuarially sound rate ranges, as required by CMS for this capitated program. Medicaid Managed Care

 Assisting the Detroit Wayne County Community Mental Health Agency in implementing a Medicaid managed care program for persons with developmental disabilities, severe mental illness, or severe emotional disability to comply with Michigan’s 1915 (b)(c) waiver. Mr. Carlson helped the Agency work with the newly formed networks which would serve the recipients in the program, created a prepaid model for the reimbursement including reinsurance for the new networks. Federal and State Policy and Legislation

 Delivered pricing scenarios for the State of Illinois health care expansion, including costs by various eligibility cohort, variations in benefit design, implementation timeline and employer health care assessment modeling. We worked with a team from multiple state agencies including the Governor’s office, the Department of Insurance, the Department of Revenue and Medicaid to coordinate state functions.  Calculated rates and waiver costs for implementing a consumer directed health program for South Carolina’s proposed 1115 waiver. Mr. Carlson assisted the State with the calculation of rates, benefit designs, assumptions used to calculate the benefits and projections involving the carry-forward of account balances.  Worked with Texas and South Carolina on acute care and transportation waivers’ cost effectiveness. This work entailed filling out the appropriate form, Appendix D, as required by CMS.

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 Calculating and certifying the daily psychiatric rehabilitation treatment facility (PRTF) rate for the State of Colorado in their program. The rate accounts for more stringent requirements with respect to the clinical component of care.  Delivered an issue paper for the State of Texas explaining the problems with uncompensated care reporting. The paper estimates the cost of uncompensated care in Texas by considering the reported charges, converting charges to estimated costs, and then removing revenue streams which pay for uncompensated care. Procurement-related Experience

 Delivered disease management procurement services to South Carolina’s Medicaid program. This included running selection criteria, answering bidders’ questions, and developing the reconciliation process. Other Relevant Experience

Analyzed financial projections for numerous M & A engagements. Typically examining multi- year reserving calculations to determine if they were being done consistently to give a true estimate of current earnings before interest, taxes, depreciation, and amortization.

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STEVEN JOHNSON MANAGING DIRECTOR

EDUCATION

Ph.D., Economics, State University of New York College M.A., Economics, State University of New York College B.S., Applied Mathematical Economics, State University of New York College

EXPERIENCE Dr. Johnson, Managing Director at The Lewin Group, is a risk adjustment expert with over 36 years of experience working with health care data, primarily focusing on the analysis of Medicaid data. Dr. Johnson’s work has included the development of methodologies to conduct validation and reasonableness checks for data sets received from outside vendors, and he has led efforts to develop programming logic to process claims data through risk adjustment algorithms in order to determine plan factors for risk adjusted payment projects. Additionally, Dr. Johnson has supervised the Managed Care Rate Setting, Information Systems Unit, and Network Support Unit as the Director of Research and Program Development at the Center for Health Program Development and Management at the University of Maryland, Baltimore County campus. Recent projects include: Medicaid Managed Care  In his previous position as a Senior Associate at Mercer Government Human Services Consulting, he was responsible for the development of performance measures to evaluate managed care organizations in support of external quality review organization projects.  Developed interactive decision support tool that states can use to evaluate the completeness of the encounter data they receive from their managed care organizations (MCOs)  Designed and implemented algorithms to evaluate the health care history of members to identify members with under reported diagnoses.  Developed interactive tool that incorporates measures of health care utilization and a members health status that can be used to evaluate the efficiency of MCOs in providing services to their members Rate Setting, Risk Adjustment and Payment Methods  Prior to joining Lewin, Dr. Johnson served as the Director of the Medicaid Risk Adjusted Rate Group at Americhoice Health Plan, focusing on the development of new products and processes to enhance the use of risk adjustment techniques to evaluate plan risk scores.  Analysis of internal encounter data, to identify encounters that have not been submitted to state Medicaid programs, determine which of these encounters will impact member risk scores, and identify encounters that can be submitted to the state with a high probability of state acceptance.

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 Developed processes that utilize the Adjusted Clinical Groups (ACGs), Chronic Disability Payment System (CDPS) and Medicaid Rx risk adjustment system to measure the acuity of members enrolled in MCOs.  Designed pay for performance programs including the selection of measures, processes to measure the performance of participating providers on a risk neutral basis, and development of a scoring algorithm to determine a provider’s portion of shared savings  Developed of risk adjusted payment methodologies for state Medicaid programs  Utilization of risk adjustment systems to identify members with chronic conditions, quantify their health status and identify members for disease management interventions  Served as Project Director of “Making Risk Adjustment Work for State Medicaid Directors,” an effort to provide technical assistance on health-based, risk-adjusted payment methodologies to state Medicaid agencies—this project involves surveying nine states, conducting two forums, holding a briefing with state Medicaid directors, and developing a detailed guidance manual

TEACHING APPOINTMENTS

 University of Maryland, Baltimore County, 2000-2004: Offered a course in Principles of SAS Programming, Data Analysis using SAS Software, and Microeconomics  State University of New York, Albany NY, 1979-1999: Instructor in Economics, offering coursework in Principles of Macroeconomics, Principles of Microeconomics, Money and Banking, Public Finance, Health Economics, and Health Care Financing  Union College, Albany NY, 1986-1989: Conducted a course in Quantitative Methods, instructing students in the use of Econometrics Analysis and the use of several computerized statistical packages to estimate regression models  Sienna College, Loudenville, NY, 1978-1984: Assistant Professor of Economics, offering coursework in Principles and Macroeconomics, Principles of Microeconomic, Money and Banking, Econometrics, Intermediate Macroeconomics, and Honors Seminar in Economics

SELECTED PUBLICATIONS AND PRESENTATIONS

Data Completeness in Maryland Medicaid. Presented to the Johns Hopkins ACG Risk Adjustment Conference, November 2003. Implementing a Risk-Adjusted Payment System – The Medicaid Experience. Presented to the Institute for International Research, July 2003. “Overcoming Technical and Administrative Challenges: Learning from State Medicaid Programs’ Implementation Experiences.” Institute for International Research, October 2002. “Medicaid Eligibility Status as a Predictor of Medicare Costs,” Gerontological Society of America, November 2000. Moving from Fee-For-Service to Encounter Data within the Maryland Medicaid Program. Presented to the Johns Hopkins International ACG Risk Adjustment Conference, September 2000.

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CHRISTOPHER PARK SENIOR CONSULTANT EDUCATION

M.S., Health Policy and Management, Harvard School of Public Health B.S. with distinction, Chemistry with Biochemistry Specialization, University of Virginia

EXPERIENCE

Mr. Park is a Senior Consultant with eight years of experience primarily working with private and state clients on Medicaid policy. Mr. Park has worked with state agencies to provide quantitative and financial analyses, including Medicaid managed care capitation rate setting, the design, implementation, and cost projections of Medicaid managed care program expansions, and cost effectiveness analyses for waiver approval. Mr. Park has also been involved in Medicare Part D benefit analyses and is experienced in pharmaceutical data analysis. Mr. Park has worked on the following projects since he joined The Lewin Group: Medicaid Managed Care  Involved in the managed care cost effectiveness analysis for the 1915(b) waiver renewal process for Mountain Health Trust, West Virginia’s mandatory Medicaid managed care program.  Assisted in the evaluation of the potential carve-out of pharmacy benefits from Arizona’s Medicaid managed care program. Responsibilities included interviewing key stakeholders such as PBMs, health plans, and state Medicaid officials, detailed analysis of pharmaceutical data, and creating a comprehensive data book of the state’s pharmaceutical costs.  Assisted the Medi-Cal Policy Institute in their assessment of Medicaid managed care eligibility options provided by the BBA, specifically guaranteed eligibility and lock-in. Activities included researching the federal regulations, interviewing other states about their experiences with guaranteed eligibility and lock-in, and creating cost analyses for the possible implementation of both options for the state’s Medicaid managed care population.  Assisted in the actuarial evaluation of the Texas Medicaid managed care program. Created a financial model to evaluate the potential savings of various managed care models such as PCCM and HMO for both the TANF and SSI populations. Rate Setting, Risk Adjustment, and Payment Methods  Assisted in the research of states’ Medicaid risk adjustment methodologies. Tasks include interviewing state representatives and gathering publicly available documentation to understand the risk model used, populations risk adjusted, frequency of risk score calculation, and other aspects of the various methodologies the states’ use to risk adjust the capitation rates for their Medicaid managed care programs.  Managing the yearly actuarial derivation of capitation rates for Mountain Health Trust,. Responsibilities include calculating the base per member, per month (PMPM) costs using eligibility and claims data, analyzing regional variation in costs, analyzing the impact of

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price and programmatic changes, and developing unit price and utilization trends to calculate capitation rates. Other tasks include conducting revenue analyses to assess the impact of changes in payment rates on participating HMOs and the impact of recent case mix changes on the capitation rate. Also has been  Assisted the Medi-Cal Policy Institute in assessing the Medicaid physician fee schedule. Responsibilities included picking high volume, high cost CPT-4 codes to be used in the survey instrument, collecting survey responses and fee schedules from all 50 states and the District of Columbia, determining the Medicaid fees as a percent of the Medicare physician fee, weighting the physician fees on a geographic basis, and ranking the states in terms of flat fee, weighted fee, and percent of Medicare.  Assisted in the derivation of Medicaid Managed Care capitation rates for the District of Columbia by creating a fee-for-service data book that was provided to HMOs involved in the bidding process. Tasks included the creation of IBNR completion factors, adjusting Medicaid claims data to account for different program options, and calculating costs on a per member per month basis. Program Design and Operations

 Assisted the state of Missouri in identifying cost savings opportunities in the Medicaid program. Evaluated numerous aspects of the pharmacy program for cost savings opportunities, including pharmacy reimbursement and dispensing fees, brand/generic mix, formulary design, and high users. Also assisted in identifying cost drivers and potential savings opportunities for inpatient hospital, ER, hospice, and other clinical areas.  Assisted in a feasibility study to assess options and develop a business plan for a pharmaceutical purchasing model that will increase value for a diverse group of safety net providers, including providers participating in the federal 340B program, county and community clinics, and hospitals in a large state. Responsibilities included detailed pharmaceutical data analyses, modeling the impact of price discounts due to group purchasing, modeling drug volume switching due to implementation of a preferred drug list, and estimating savings due to increased generic utilization.  Evaluated an electronic application system (One-e-App) that allows applicants to apply to several public programs, including Medi-Cal, Healthy Families, and other local and state health and social services programs, through a single application. Developed a variety of process and operational measures to assess the process flow of applications for these various county and Medicaid programs using the electronic system and estimated any potential efficiency gained by switching from a series of paper applications to a single electronic application. Federal and State Policy and Legislation

 Developed an web-based calculator to help states and other key stakeholders estimate potential Medicaid bonus payments made available through the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA). Used the calculation laid out in the CHIPRA legislation and existing MSIS data to calculate the average cost for children and project the baseline child enrollment thresholds for the bonus tiers.

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 Assisted in developing a report to Congress regarding the impact of Medicaid regulations on cost limits, rehabilitation services, school-based services, and graduate medical education on the Medicaid programs in all fifty states and the District of Columbia. Developed a standardized method to analyze data from all fifty one Medicaid programs to assess the financial impact of each regulation on the respective Medicaid program.  Estimating the impact of the health reform legislation, the Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act (HCERA), on Medicaid drug rebates in several states. Estimating the increase in Medicaid drug rebates for states with pharmacy carve-ins, the impact of the offset in non-Federal share on existing rebate amounts, and the net impact on State share under both the ARRA- enhanced FMAP and regular FMAP rates.  Assisted in the analysis of the Medicare Part D benefit. Responsibilities include estimating the number of Medicare beneficiaries with comprehensive drug coverage by type of coverage, by state, before and after Part D implementation in 2006, analyzing annual changes in premium, deductible, and benefit design for Part D plans, analyzing formulary coverage of Part D plans, researching the VA’s experience in negotiating prices, and analyzing the coverage of the VA national formulary as compared Part D plan formularies.  Assisted the states of Washington and Indiana to evaluate cost containment activities. Responsibilities included estimating the savings due to the implementation of maximum allowable fees, coordination of benefits with alternative payers, and several pharmaceutical initiatives such as a preferred drug list, consultation services, mail order pharmacy service, and additional price discounts off of AWP.  Assisted the state of New Mexico in the initial development of a new 1115 waiver to cover uninsured adults under 200% of poverty using a unique public/private partnership to extend coverage to those employed but uninsured. Responsibilities included research into other states’ expansion programs to cover uninsured adults and experiences with crowd- out, estimating the eligible population, determining the take-up rate of this program, and developing initial cost projections. Procurement-related Experience

 Assisted the state of Delaware in their Medicaid managed care procurement process. Responsibilities included creating a detailed data book of the program’s cost and utilization experience that was distributed to potential bidders and evaluating the price proposals after bids were submitted.

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ROSHNI SHAH ARORA CONSULTANT

EDUCATION

M.P.H, Health Policy & Management, Columbia Mailman School of Public Health B.A., Health & Societies and Political Science, University of Pennsylvania

EXPERIENCE

Roshni Arora, Consultant, joined The Lewin Group in 2006. Prior to joining Lewin, Ms. Arora worked at The Center for Health Care Strategies (CHCS) in Princeton, NJ and the Children’s Defense Fund in Washington, DC. At CHCS, Ms. Arora worked on Medicaid managed care issues, including health disparities and care management. Medicaid Managed Care  For the State of West Virginia, serving as the key point of contact for ongoing technical assistance contract with the State of West Virginia Bureau for Medical Services. Key tasks include managing daily contact with client, ongoing evaluation of MCO performance, assessment of network adequacy for provider networks, annual MCO contract updates, readiness reviews, contract monitoring, and development, coordination with CMS, and program design/implementation.  Conducted a study for the Association of Community-Affiliated Health Plans (ACAP) to identify the benefits and challenges associated with utilizing and leveraging Medicaid and safety net health plans for health reform efforts.  For the Arizona Health Care Cost Containment System (AHCCCS), identified areas for cost savings that would minimize adverse impacts on the health status of AHCCCS beneficiaries. Ms. Arora led efforts to coordinate with the managed care organizations and for each measure identified, estimated the projected cost savings, advantages, potential adverse effects on the target population, exacerbation of related chronic conditions, cost shifting to other covered services, and delayed access to care.  For the State of New York, assisted in the collection and analysis of information on Medicaid primary care case management (PCCM) programs, including associated disease management (DM) and care management components, for New York's consideration in exploring a future PCCM program as an alternative to full-risk managed care in rural areas.  For the State of New York, assisted in the evaluation of beneficiary access to primary care and specialist providers through focus groups.  For the Connecticut Association of Health Plans, assisted in assessing the performance of Connecticut's HUSKY Program, a capitated Medicaid initiative operated through contracts with four health plans, to provide objective information about the HUSKY Program and to compare the policy alternatives of retaining HUSKY versus adopting a “managed fee-for- service” model of coverage.  Assisted in developing an independent assessment of New Mexico’s managed care program, Salud!, and behavioral health managed care program. The reports assessed three

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dimensions of health care: access, quality, and cost-effectiveness. Ms. Arora reviewed state contractual requirements, provider networks, satisfaction surveys, national performance standards, HEDIS results, CAHPS scores, and various financial reports.

Medicare Advantage  For the Centers for Medicare and Medicaid Services, assisted an effort to document the detailed business requirements for automating the review and evaluation of Health Service Delivery, as well as communication process. This project also focused on developing establishing access criteria and appropriate exceptions.  For the Centers for Medicare and Medicaid Services, led an effort to review the network adequacy of Regional Preferred Provider Organization (RPPO) networks.

Care Management

 Through a multi-year contract with the Agency for Healthcare Research and Quality (AHRQ), provided individual and group technical assistance to 17 state Medicaid agencies on Medicaid care management. As part of this engagement, Ms. Arora assisted in the development of workshops on topics such as program design, procurement, measurement, evaluation, communications, and continuous quality improvement. To supplement the in- person workshops, Ms. Arora organized bi-monthly webconferences. In addition to these workshops and webconferences, Ms. Arora provided on-site technical assistance to each of the 17 states on selected areas of interest. As the culmination of this project, Ms. Arora developed a toolkit: “Designing and Implementing Medicaid Disease and Care Management Programs: A User’s Guide.”  Assisted a national care management company in developing a marketing plan for the public sector.

Other Relevant Experience

 Assisted multiple Medicaid managed care organizations in responding to state Request for Proposals to participate in a mandatory managed care program for Medicaid beneficiaries. Reviewed health plan policies and procedures, interviewed health plan staff and executives, and drafted key sections of the proposal.  For the Centers for Medicare and Medicaid Services (CMS), assisted in efforts to conduct a comprehensive study to evaluate the impact of four proposed Medicaid regulations on each of the 50 states and the District of Columbia.

SELECTED PUBLICATIONS AND PRESENTATIONS

“Designing and Implementing Medicaid Disease and Care Management Programs: A User’s Guide,” (co-authored with Jessica Boehm, Lisa Chimento, Lauren Moldwater, and Catherine Tsien), prepared for The Agency for Healthcare Research and Quality, February 2008.

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“Medicaid Health Plans: A Turnkey Solution for Expanding Health Insurance Coverage: Case Studies of California and Massachusetts,” (co-authored with Lisa Chimento, Roshni Arora) prepared for the Association of Community Affiliated Plans, July 2007. “Independent Assessment of New Mexico’s Medicaid Managed Care Program – Salud!” (co- authored with Tara Bubniak, Joel Menges, Andrea Park), prepared for New Mexico Medical Review Association, March 2007. “Independent Assessment of New Mexico’s Behavioral Health Program” (co-authored with Joel Menges), prepared for New Mexico Medical Review Association, March 2007. “Assessment of HUSKY, Connecticut’s Medicaid Managed Care Program,” prepared for the Connecticut Association of Health Plans, January 2007.

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SAMANTHA FLANZER SENIOR RESEARCH ANALYST

EDUCATION

BA, Public Health, Johns Hopkins University

EXPERIENCE

Ms. Flanzer joined The Lewin Group in September 2009. Working with both state and private clients, she has experience in qualitative data analysis, quantitative data analysis, and Medicaid program evaluation. Prior to joining Lewin Ms. Flanzer served as a Healthcare Staff Consultant at McBee Associates where she gained extensive knowledge of Medicare billing operations. Examples of current and prior project work at Lewin include:

Medicaid Managed Care

 Ms. Flanzer evaluated results of a 2009 survey of adults and children in the West Virginia Medicaid managed care organizations (MCOs) and primary care case management (PCCM) programs, to determine respondents’ contentment with their Medicaid plan. She was also responsible for entering survey data, and developing Microsoft Access queries in support of the survey analysis.  Ms. Flanzer evaluated results of a 2009 survey of adults and children in the West Virginia Medicaid managed care organizations (MCOs) and primary care case management (PCCM) programs, to determine respondents’ contentment with their Medicaid plan. She was also responsible for entering survey data, and developing Microsoft Access queries in support of the survey analysis. Program Evaluation and Improvement

 Ms. Flanzer is a member of the team evaluating the Missouri Medicaid program. Ms. Flanzer is responsible for researching best state practices for clinical services programs such as non-emergency medical transportation (NEMT), durable medical equipment, and hospice in order to identify both short and long term cost containment opportunities. She has also done research on current Medicaid oversight and reform committees’ efforts, section 1115 waivers, and long term care initiatives. Procurement-Related Experience

 Ms. Flanzer assisted a Rhode Island Medicaid health plan in the state procurement process. Tasks included on-site interviews of key health plan staff, background research, and drafting and editing support.  For Americhoice Medicaid health plans, Ms. Flanzer worked to identify state enrollment data in support of Americhoice market research efforts. Focusing on states where Americhoice currently lacks market penetration, Ms. Flanzer identified and organized enrollment data for state Medicaid MCOs, PCCMs, and fee-for service (FFS) plans.

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PRIOR PROFESSIONAL EXPERIENCE

McBee Associates (July 2008 – September 2009)  Staff consultant, conducting financial and Medicare billing audits on behalf of home health agencies and hospitals

Office of the Maryland Attorney General, Health Advocacy and Education Unit (September 2007 – May 2008)  Consumer advocate, analyzing and medicating health care consumer complaints submitted to the Consumer Protection Division

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CASEY LANGWITH SENIOR RESEARCH ANALYST

EDUCATION

B.A., magna cum laude, History and Sociology, Rice University

EXPERIENCE

Ms. Langwith joined The Lewin Group in September 2010. Currently, she supports projects with state clients, such as the West Virginia Bureau of Medical Services. Her work with West Virginia has included tasks related to monitoring program outcomes and the expansion of Medicaid managed care services. Prior to joining Lewin, Ms. Langwith served as a Research Assistant in The George Washington University Department of Health Policy. She worked primarily for the STOP Obesity Alliance, focusing on obesity prevention and treatment, the economic costs of obesity, and state-level obesity initiatives, including coverage issues. Examples of her recent work include:

Medicaid Managed Care

 Assisting with readiness review for the Mountain Health Choices program in West Virginia. Specifically, performed analysis of provider networks for contracted Managed Care Organizations.

 Assessed Request for Proposals related to External Quality Reviews for 11 states to determine scope and range of quality review activities.

 Prepared quarterly reports summarizing utilization trends and expenditures for Managed Care Organizations.

REPORTS AND PUBLICATIONS

Dor, A., Ferguson, C., Langwith, C., & Tan, E. (2010). The George Washington University Department of Health Policy A Heavy Burden: The Individual Costs of Being Overweight and Obese in the United States. Washington, DC: The George Washington University Department of Health Policy.

Ferguson, C., Langwith, C., Muldoon, A., & Leonard, J. (2010). Improving Obesity Management in Adult Primary Care. Washington, DC: STOP Obesity Alliance.

PRIOR PROFESSIONAL EXPERIENCE

The George Washington University Department of Health Policy (June 2009 – September 2010)

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MICHAEL MADALENA CONSULTANT

EDUCATION

M.S., Public Management and Policy Analysis, Carnegie Mellon University B.A., Social Sciences, Clarion State College

EXPERIENCE

Mr. Madalena has 18 years experience working as a health care consultant. He works with governmental clients analyzing health care data to improve public programs such as Medicaid, state employee benefit programs, and retirement systems. He also has experience with private employer, insurance carrier markets, and operational systems (e.g., claims processing, utilization management, and eligibility). He is skilled in the processing and analysis of health care data, and has developed several databases and applications. These applications range from quality and financial reporting to simulation models that predict selection bias. His consulting experience includes:

Medicaid Managed Care

 From 1996-2004, for the West Virginia Bureau for Medical Services (BMS), designed, implemented, tested, and put into production an encounter data system that gathered claim and encounter data from all participating managed care organizations (MCOs). In addition to integrating data from four MCOs (Carelink, The Healthplan of the Upper Ohio Valley, MAMSI, and Unicare), the system also integrated data from the State’s Primary Care Case Management (PCCM) program, PAAS, the program-wide eligibility file maintained by the State, and the carved-out benefits processed by the fiscal intermediary. The consolidated database is used to provide HEDIS® reporting, utilization analysis, EPSDT reporting, provider profiles (emergency room and radiology/laboratory services), financial analysis, prescription drug reporting to participating MCO, and benchmarking.

Program Monitoring and Data Analysis

 Developed and maintain (1995-present) an integrated database for the West Virginia Public Employees Insurance Agency (PEIA). The system stores claim and encounter data of all insurance options for PEIA enrollees (Acordia National, Carelink, The Healthplan of the Upper Ohio Valley, Advantage Health, MAMSI, PrimeONE, and Mountain State Blue Cross and Blue Shield), enrollment history, and prescription drug claims. The database, which is updated monthly, is used extensively for applications, including monthly management reporting, comprehensive annual reports, HEDIS® reporting, plan design change modeling, fiscal note preparation, selection bias analysis, hospital (inpatient and outpatient) rate setting, physician reimbursement analysis, disease management initiatives, and audit and actuarial support. In addition to supporting written reports, the database is also accessible to PEIA management and professional staff in a web-based application that includes on-line analytic processing (OLAP) tools, ad-hoc query, and production reporting tools.

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 For the West Virginia Healthcare Authority (HCA), designed, implemented, tested, and put into production the Agency’s public payer database (1997-present). The database stores all claim and encounter data for PEIA, Medicaid, CHIP, and Worker’s Compensation. Data includes integrated medical, pharmacy, and eligibility data to assist HCA in its health policy mission. Support the database, provide technical assistance, and provide analytic assistance on several topics, including breast cancer mortality and morbidity rates, cardiac disease burden, diabetic incidence rates, and crossover analysis among West Virginia’s public health insurance payers.  Provide analytical services to West Virginia Children’s Health Insurance Program (CHIP). Designed, implemented, affirmed, and put an analytic database into production that stores all medical, dental, and prescription drug claims. The database has been used to support the program in several ways, including annual HEDIS® reporting, fiscal note preparation, audit and actuarial support, and reimbursement analysis. In addition to supporting written reports, the database is also accessible to CHIP management and professional staff in a web-based application that includes OLAP tools, ad-hoc query, and production reporting tools.  Assisted with a variety of projects for the South Carolina Department of Health and Human Services (SCDHHS) (1999-present). Projects often include database development, and have been used to complete analyses in areas, including budget projections, responses to legislative and executive requests, reimbursement analysis (institutional and professional), financial modeling, disease management, and general program support. Assisting with the development of the State’s 1115 demonstration waiver for Medicaid reform, and contributing to the waiver approval process and the analysis of the impact of the Deficit Reduction Act on key provisions of the demonstration project.  Working with the South Carolina Employee Insurance Program (SCEIP) (1990-present). The engagement’s initial focus was the re-design of the employee health insurance program. Constructed a database that supported benefit modeling activities and monitored plan performance. Constructed a preferred provider organization that served State employees in 1990 and still in use and supported. Developed and maintained a system to support rate entities that optionally join the SCEIP. Also assist with: establishing HMO plan design and contribution rates; supporting State procurements (e.g., pharmacy benefit management services, behavioral health vendors, ASO vendors); court cases; annually updating the inpatient, outpatient, ambulatory surgical center and physician networks; and budget, legislative, and audit support. The SCEIP database is also accessible to management, professional, and audit staff in a web-based application that includes OLAP tools, ad-hoc query, and production reporting tools.  Assisted with the design, implementation, testing, and production of a database that integrated information from Texas’ medical claims/encounters, prescription drugs, and eligibility data. In addition to the benefit modeling and reporting roles, the database was used to develop a statewide, direct contract provider network, and to provide budget and legislative support, audit support, and actuarial analysis.  For the New Mexico Retiree Health Care Authority (NMRHCA), constructed an analytic database to support the consolidated purchasing agreement it had entered into with the New Mexico Public Schools Insurance Agency, Albuquerque Public Schools, and the State

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Division of Risk Management. Integrated medical claims from six managed care options, a prescription benefits manager, and three eligibility systems into one database. The primary purpose of the database is to provide measurement tools that compare health plan performance. Developed a series of analyses based on HEDIS® definitions that examined and compared health plan performance from financial, utilization, and quality perspectives. The system is also used to monitor overall system performance with respect to unit cost, utilization, and case mix. NMRCA staff use the web-based OLAP, query, and production reporting tools to support the budgetary process, audit functions, and the plan’s independent actuary. SELECTED PUBLICATIONS AND PRESENTATIONS

“Actuarial Review of the State Health Plan”, (co-authored with William Hickman and Jeanna Bonneau), prepared for the Executive Director of the South Carolina Budget and Control Board, annually from 1998 to present. “Institutional Reimbursement Equity Analysis”, prepared for the South Carolina Department of Health and Human Services, 2005. “Cost Implications of Mandatory Preventative Benefits”, prepared for the South Carolina Employee Insurance Program, 2004. “Adverse Selection Potential in the Implementation of a Statewide Teachers Health Insurance Program”, (co-authored with William Hickman and Jeanna Bonneau), prepared for the Teacher Retirement System of Texas, 2001. “Mountain Health Trust Performance Report”, (co-authored with Jeanna Bonneau and Janet Scouten), prepared for the West Virginia Bureau for Medical Services, annually from 1998 to 2003. “Longitudinal Health Insurance Cost and Disease State Predictive Model”, (co-authored with William Hickman), prepared for the South Carolina Employee Insurance Program, 1996. “Construction of a Preferred Provider Organization Network for State Employees Feasibility Analysis”, (co-authored with William Hickman and Jorge Font), prepared for the South Carolina Budget and Control Board, 1991. “Evaluating County Performance in Providing Mental Health Services”, (co-authored with Gordon Lewis and Cindy Bryce), Research published by Carnegie Mellon University (Working paper 88-8), 1988.

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MAIK H. SCHUTZE RESEARCH CONSULTANT

EDUCATION

M.H.S., Health Policy, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland

B.S. with honors, Health Promotion, Winona State University, Winona, Minnesota

EXPERIENCE

Mr. Schutze joined the State and Payer Practice of The Lewin Group in June 2007. His work has focused on policy analysis, program evaluation and health services research with a particular focus on vulnerable populations and persons with serious chronic conditions. Mr. Schutze is also involved in extensive policy and data analysis to build evidence for integrated delivery systems for frail, sick and disabled adults and other persons with serious chronic conditions for the SNP Alliance of the National Health Policy Group. Mr. Schutze work at Lewin includes:

Rate Setting, Risk Adjustment, and Payment Methods

 Involved in the development of capitation rates, risk adjustment, and a delivery model impact analysis of the Medicaid Special Needs Plan (SNP) for individual with HIV/AIDS in the State of New York.

 Cost saving estimates of capitation contracting for dual eligibles in Florida including public policy analysis of pathways for legislative actions

Medicaid Managed Care

 Extensive qualitative and quantitative analyses of managed and coordinated care initiatives with a particular focus on dual eligible populations

Program Evaluation and Improvement

 Evaluating the Minnesota Demonstration to Maintain Independence and Employment, a research and health care initiative funded by the Centers for Medicare and Medicaid Services.

 Review of policies and procedures for a public health plan in Los Angeles County

 Currently contributes to the evaluation of the CMSP Behavioral Health Pilot Project in California, an initiative to assess the financing and implementation of integrated medical and behavioral health care services for indigent adults in rural community health centers.

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Federal and State Policy and Legislation

 Comprehensive review of the mandate for state-run Health Insurance Exchanges in the Patient Protection and Affordable Care Act (ACA)

PRIOR EXPERIENCE

Prior to joining Lewin, Mr. Schutze worked on behavioral health and health promotion programs at the Mayo Clinic in Rochester, Minnesota. He was actively engaged in personal and community health promotion initiatives, chaired the America on the Move Olmstead County Steering Committee, and was a member of Mayo Clinic Action on Obesity taskforce. Mr. Schutze has also been involved in advocating the integration of health promotion concepts into national health policy.

Mr. Schutze prepared and presented a comprehensive report for the Emergency Medical Treatment and Labor Act (EMTALA) Technical Advisory Group. The white-paper discusses disparities in the quality of health care experienced by racial and ethnic minorities as well as other vulnerable groups and is part of a larger report informing the Secretary of the Department of Health and Human Services of the law’s impact on the U.S health care system.

SELECTED PUBLICATIONS & REPORTS

“2009 SNP Alliance Profile and Advanced Practice Report”. Prepared in Collaboration with the National Health Policy Group and the Special Needs Plan Alliance. Rich Bringewatt, Valerie Wilbur, Joel Menges, Maik Schutze. December 2009.

“Evaluation of New York’s HIV Special Needs Plan Program: Cost and Usage Impacts”. Prepared in collaboration with the AIDS Institute, New York State Department of Health. Franklin Laufer, Joel Menges, Maik Schutze and David Zhang. November 2009.

Schutze, Maik. “Role of Exercise in Cancer.” Together. Mayo Clinic Cancer Center. Volume 6. Number 2. Spring 2006.

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DAVID G. ZHANG SR. PROGRAMMING CONSULTANT

EDUCATION

M.S., Computer Science, George Washington University, Washington, DC B.S., Computer Science, the Northeastern University of Technology EXPERIENCE

David Zhang is a Senior Programming Consultant in the Falls Church office of The Lewin Group. Prior to joining Lewin in 1993, David was Software Engineer at ICF-InfoTech as IBM internal software product developer for IBM mainframe platform. David has more than twenty years of experience in software engineering. His expertise and demonstrated skills include computing algorithm implementation, mathematical analysis, software systems development methodology, operating system and compiler design, database implementation and application, and computing systems architecture. David has focused on providing high quality computer programming support for a variety of practice areas of health care. David has developed numerous computer software systems for analytical projects. David has extensive experience on manipulating, programming and analyzing on large-scale data files across different platforms, worked remotely on Medicare SAF data since 1992 using the CMS mainframe. He has also built up his extensive experience and expertise on Medicaid claim files and Medicaid eligibility systems by developing Medicaid Managed care capitation rates for 15 different states. David is proficient in a variety of programming languages and tools.

Some of David’s programming engagements include the following: Rate Setting, Risk Adjustment, and Payment Methods

 Providing computer programming support in the derivation of multiple year capitation rates for Mountain Health Trust, West Virginia’s mandatory Medicaid managed care program. Tasks include generating benchmarks, IBNR reports, analyzing claims data and implementing logic to define necessary rate setting element, developing simulation model to identify retrospective eligible months or non-retrospective eligible months and generating the capitation rates.  Worked on CMS’s PERM project to implement a methodology to measure payment error rates in state Medicaid programs. Studied thoroughly on 17 states’ Medicaid claim data. Investigated, analyzed and evaluated the raw data for benchmark checking, developed and implemented the sampling algorithm to pull the required samples for further review. Also, provided necessary technical support for trouble-shooting the PERM data residing on network and on mainframe whenever needed. Medicaid Managed Care

 Computer programming development for Medicaid managed care analyses. Mr. Zhang is the person responsible for the entire computer programming development of Medicaid managed care rate settings for the state of West Virginia , Iowa, Connecticut, Montana, New Mexico, Kansas, Delaware, and District of Columbia. The basic programming work

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includes developing a series of algorithms to investigate and clean up the raw claims database and eligibility database, checking the data for accuracy and completeness, analyzing the data and designing functional data structure, linking population data and claims data, choosing efficient programming tools, and implementing all logic and requirements in programming to meet each analysis. Other Relevant Data Analysis Experience

 Analyzed the cost impact of Medicaid Beneficiaries who convert to coverage under a Medicaid Buy-in (MBI) for workers with disabilities in states of Iowa and Indiana. Assessed the changes in service utilization and Medicaid expenditures between the time periods before and after MBI enrollment.  Worked on a number of analytical projects by providing computer programming support for numerical analysis, model design and algorithm implementation based on CMS claims data (both Part A and Part B), CPS, CACI, ARF and CHAMPUS data bases.  Served as a principal programming developer to implement all the programming logic and algorithms for Outpatient Imaging Efficiency Measures using the CMS mainframe system. Developed total eight imaging efficient measures derived from CMS 100% Medicare SAF data.  Completed a project for the NACHC to develop a county-level data base for the "at-risk" and "medically underserved" populations and physician shortage areas, by analyzing and integrating the existing data files, such as the Current Population Survey, a CACI geographic data file, the Area Resource File, Community Service Area File, and data on unemployment.  Developed a series of computer algorithms to perform statistical analysis of DRG cost, compared the different costs of surgical, medical and cancer DRGs between cancer hospitals and others.  Developed a series of computer program models to perform various statistical analyses for CHAMPUS Mental Health project using CHAMPUS hospital discharge claims data.  Developed all computer algorithms to estimate the average plan cost of medically appropriate infertility treatments for Cost Infertility Treatment (CIT) model.  Generated all necessary programming algorithms for a study under contract to the Alcohol, Drug Abuse, and Mental Health Administration aimed at determining costs of Alcohol and Drug Abuse and Mental Illnesses.  Implemented a programming model to analyze the need for drug abuse treatment in the United States utilizing data from the NIDA funded Treatment Outcome Prospective Survey. PRIOR EXPERIENCE

 1988 - 1992: IMB mainframe internal product development. Co-developer of PLSORT/VSE, a utility package for efficient data sorting and aggregations. Implemented the capability to allow multiple input files to be read. Developed the internal supports for all standard user exits including the interface with VSAM input/output files. Produced programming codes

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to enhance I/O performance, and implemented an algorithm to support the use of SORTWORK with maximum of 16 work files.  1987 - 1988: Systems Programmers/Analyst for Jerry Thompson & Associates, Inc.: Designed and implemented the Air Traffic Control Automation Systems. Undertook systems design, software top-level design, low-level design, programming and testing. Developed the simulated radar target display subsystem, and the program to compensate for aircraft climb, descent and level flight speed changes. Provided assistance in the completion of the ATC controller message input subsystem.  1982 - 1985: Software Engineer for the Hydroelectric Power Ministry of China: Software product development. Developed the Cross Systems Assembler and the FORTRAN Cross Systems Compiler under IBM 370 and VAX 780 families for Hitachi Corporation. Involved in research and studies of operating systems for parallel programming.

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PATRICK W. FINNERTY CONSULTING DIRECTOR, PWF CONSULTING

EDUCATION

Master of Public Administration, Virginia Commonwealth University B.S., Psychology, Virginia Commonwealth University

EXPERIENCE

As the Sole Proprietor of PWF Consulting, Mr. Finnerty is a skilled and knowledgeable health care consultant who gained considerable experience through thirty-two years of public service: serving as Virginia’s Medicaid Director for eight years; managing the Virginia state employee health benefits program; and directing a legislative health policy commission. Mr. Finnery is a highly effective health care professional and leader with a proven record of success working at the highest levels of state government and the private sector. Following is a summary of his health care and management experience: Medicaid Experience  Provides health care consulting regarding service delivery, benefits administration, strategic planning, management, policy development and analysis, educational programs, and philanthropic activities to state and national health care-related organizations  Appointed by Governor Mark R. Warner in 2002 and reappointed by Governor Timothy M. Kaine in 2006 to direct the Commonwealth’s largest health care financing program (Medicaid). Served as CEO of the Department and its 400+ employees. Provided executive leadership for the Virginia Medicaid program and Children’s Health Insurance Program (CHIP) which account for a combined annual budget of nearly $6.5 billion and provide health benefits to more than 800,000 enrollees through partnerships with more than 55,000 health care providers. Achieved numerous successes including: o Re-engineering the CHIP program in Virginia, which earned national honors for enrolling an additional 200,000 children o Implementing a completely redesigned and highly successful dental program that: doubled the number of participating providers; increased utilization of dental services by 60%; and became a national model for Medicaid/CHIP o Modernizing the pharmacy benefit program to reduce costs and improve quality o Expanding the Department’s managed care program; and - Creating a nationally recognized Program Integrity unit that doubled prior year program recoveries o Restoring the integrity and credibility of the Department and developed highly effective personal/professional relationships with legislators, state and national health care organizations, providers and key interest groups.

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Federal and State Policy and Legislation

 Provides consulting expertise on various health care issues with a specific focus on matters involving Medicaid, the Children’s Health Insurance Program (CHIP), oral health access, and other state/local health programs.  As Executive Director of the Joint Commission on Health Care in Virginia, directed the staff and all activities of this legislative health policy Commission; represented the Commission at national and state health policy conferences; and conducted critical health policy analyses o Guided the Joint Commission’s legislative recommendations through the General Assembly by working effectively with key members of the legislature and the Governor’s Office; coordinating with legislative staff; and testifying in legislative committee meetings  Conducted complex policy analyses on a wide range of health policy issues including Medicaid, CHIP, health insurance, managed care, health workforce, health care regulation, and many others  Drafted legislation and budget amendments, and presented them to legislative committees; advocated for approval of Commission legislation

Other Relevant Experience

 Serves as expert faculty/speaker at various health care training programs, symposia, and conferences.  Has served on many advisory groups and Commissions related to Medicaid/CHIP.  As Director of State and Local Health Benefits Programs for the Virginia Department of Human Resource Management, directed the procurement, design, pricing and administration of the state’s health benefits program for approximately 100,000 employees and 20,000 retirees o Supervised a staff of 16; managed a $200 million employee health insurance fund; managed office budget and ensured compliance with all state procurement, accounting, and financial regulations

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ANJALI JAIN, MD-FAAP MANAGING CONSULTANT

EDUCATION

Fellow, Robert Wood Johnson Clinical Scholars Program, Yale University, New Haven, CT Chief Resident, University of Chicago, Chicago, IL Pediatric Resident, University of Chicago, Chicago, IL M.D., University of Virginia School of Medicine, Charlottesville, VA B.S., Chemical Engineering with Honors, University of Virginia, Charlottesville, VA

EXPERIENCE Dr. Jain is a Managing Consultant at Lewin is a practicing pediatrician and health services researcher with both general and specific knowledge in the care of children, with an emphasis on children from underserved communities. At Lewin, Dr. Jain leads research projects in the areas of child health, obesity, health services research, health policy and clinical practice. Provides consulting services to public and private organizations and provides ongoing clinical and scientific expertise. Her research, both federally and locally funded, has combined the use of quantitative and qualitative methods with a particular focus on parenting, feeding and obesity prevention. She is an Assistant Professor of Pediatrics and Health Policy at Children’s National Medical Center (CNMC) and George Washington University, where she continues to collaborate with colleagues in combining clinical and health services research.

Medicaid Experience  As Assistant Professor of Pediatrics and Health Policy at Children’s National Medical Center & George Washington University, acted as Co-Investigator of a project to improve the receipt of preventive health services among children insured by Medicaid in the District of Columbia. Led the systematic review of the literature (manuscript in preparation) and developed policy recommendations based upon literature and stakeholder engagement.

LEADERSHIP EXPERIENCE Chair of Healthcare Subcommittee, Childhood Obesity Committee, 2008-Present State of Maryland Narrative Column for Academic Pediatrics 2006-Present Early Women in Medicine Leadership Conference, AAMC 2008 Research Director, STOP Obesity Alliance 2007 Clinical Evidence for Diagnosis 2004-2005 Obesity White Paper 2003-2004 Family Activity and Nutrition Clinic 1999-2000

PREVIOUS PROFESSIONAL EXPERIENCE  Assistant Professor of Pediatrics and Health Policy at Children’s National Medical Center & George Washington University (2006-2010). Combined clinical care of general pediatric patients, teaching of medical students, residents, and fellows and a research program

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focused on obesity prevention and policy. Also taught courses in medical narrative writing at the GWU School of Public Health  Academic Pediatrics, Associate Editor (2006-Present). Founding co-editor of narrative section of journal “In the Moment” and general associate editor for the journal in general and for obesity research, health services research and policy, and qualitative research.  BMJ Publishing Group, Physician Editor (2005-2006). Directed projects focused on the dissemination of evidence-based clinical practice and public health policies. o What works for obesity? Director and author of comprehensive white paper on obesity interventions which was printed as a monograph and sent to 500,000 primary care physicians in the US, and about 5,000 employer groups o Clinical Evidence for Diagnosis: Director of project to create and launch an evidence- based e-journal for the diagnosing of common adult and childhood conditions using clinical rules and diagnostic tests. Role included consulting with experts in diagnostic research, creating a prototype website, directing market research and testing of the prototype on potential users and customers, writing the business case and business plan for the British Medical Journal Publishing Group.  University College London, Clinical Research Fellow (2003). Awarded a six-month research fellowship to collaborate with Dr. Jane Wardle on research projects centered on parenting and obesity prevention among diverse populations. Mentored graduate students in psychology and public health.  Investigator and Research Director (2007). Led investigative efforts for a project funded by Sanofi to form and support an Alliance of health leaders relevant to obesity to achieve consensus for obesity policy recommendations and conduct research supportive to those goals. Members of the Alliance include the AAP, the American Heart Association, the American Diabetes Association, the Obesity Society, CDC, Trust for America’s Health, American Health Insurance Plans, American Medical Group Association, National Business Group on Health, Service Employees International Union, the Disease Management Association and the NQF and the National Center for Quality Assessment.

PUBLICATIONS Original Scientific Research Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don’t low- income mothers worry about their preschoolers being overweight? Pediatrics. 2001;107:1138- 46. Baughcum AE, Powers SW, Johnson SB, Chamberlin LA, Deeks CM, Jain A, Whitaker RC. The relationship between maternal feeding practices and beliefs and overweight in preschoolers. Journal of Developmental and Behavioral Pediatrics. 2001 Dec;22(6):391-408. Jain A, Concato J, Leventhal J. How good is the evidence linking breastfeeding and intelligence? Pediatrics. 2002; 109:1044-105. Chamberlin LA, Sherman, SN, Jain A, Powers SW, Whitaker RC. The challenge of obesity prevention: perceptions of WIC health professionals. Arch Pediatr Adolesc Med. 2002 Jul, 156 (7) 662-668.

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Tirodkar M, Jain A. Food Messages on African American television shows. American Journal of Public Health. 2003; 93(3): 439-441. Reviews, Editorials & Policy Briefings Daum, RS, Jain A, Goldstein KP. Combination vaccines: some practical considerations (commentary). Annals of the New York Academy of Sciences, 1995; 754:383-7. Jain A, Davis MM. Recent Advances: Pediatrics. BMJ. 2001 Jun 16; 322 (7300):1469-1472. Jain A. Treating nicotine addiction. BMJ. 2003 Dec 13;327(7428):1394-5. Jain A. NICE recommends faster, easier access to care for MS patients. (news article) BMJ. 2003 Nov 29;327(7426):1247. Policy Narratives & Creative Writing Jain A. In the Moment. Zoom out. Ambulatory Pediatrics. 2007 Jan;7(1):5. Jain A. Crossing the Atlantic. Health Affairs. 2008, March-April; 27(2): 500-506.* Jain A. Uncharted. Ambulatory Pediatrics. 2008, May-June; 8(3): 150-1. Jain A. Quality of life. Hospital Drive. In press. Jain A. How much does Zozo weigh today? Health Affairs. 2010, March; 29(3): 551-553. Jain A. For the love of salt. NPR. April 21, 2010. Manuscripts in Preparation or Submitted for Publication Saxena H, Jain A. Stigmatizing attitudes, beliefs, and behaviors among clinicians caring for obese adolescents. Jain A, Zhang J, Lewin A, Horn I and Huang ZJ. Are Asian American children obese? Jain A, Johnson K, Sheer J, Hiyashi S, Joseph J. Beyond coverage: a systematic review of interventions to improve the delivery of preventive services for children insured by Medicaid.

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KATHRYN KUHMERKER MANAGING DIRECTOR

EDUCATION

1981 Masters in Health Systems Administration (MBA), Union College 1971 B.A., Anthropology, State University of New York at Binghamton

EXPERIENCE

Ms. Kuhmerker joined The Lewin Group in February 2008 as a Managing Director in the States and Payers practice. Ms. Kuhmerker brings her extensive experience in State government activities and approaches to her consulting practice. With the major focus of her State career being health care, culminating in her tenure as New York State’s Medicaid Director, she brings substantial Medicaid and general health care program knowledge to the firm. She has strong management skills, as demonstrated by her ability to plan, budget, manage, and implement programs, within budget and on time. In addition to her expertise in Medicaid and overall health care areas, Ms. Kuhmerker’s experience has also given her a broad understanding of numerous program areas (such as health information technology, mental health, mental retardation and developmental disabilities, housing, transportation and financing), as well as the interplay of executive, legislative, judicial and advocacy perspectives. She is a former Executive Committee member of the National Association of State Medicaid Directors. She is also the President and Treasurer of a small foundation, the Gifts of Time Charitable Foundation. The following is a summary of her health care and management experience:

Program Design and Implementation:

 Negotiated and implemented New York State’s Family Health Plus program. Was a major participant in the initial legislative/executive negotiations to establish this Medicaid- expansion program for adults in New York State. Once enacted, assumed primary responsibility for implementing the program. This included managing the development and negotiation of the waiver submission to the federal government, establishing a matrix organization in the Department of Health to ensure that all needed expertise was incorporated in the program’s establishment, coordinating all eligibility and claims payment system changes and training all necessary state and local government personnel who would be involved in program operations. The program was implemented within budget and expected time frames and now provides access to health insurance coverage to over 700,000 individuals.  Developed, negotiated and implemented the New York State Medicaid program’s emergency response to the September 11, 2001 World Trade Center attack. Within eight days of the attack, developed, negotiated and implemented a streamlined, consumer- focused health care program that provided 342,000 individuals in New York City with immediate access to health care for a four-month period. Once the program was in operation, developed, negotiated and implemented a transition program to the regular Medicaid and Family Health Plus programs to enable as many individuals as possible to maintain health insurance coverage.

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 Managed the implementation of New York State’s new Medicaid Management Information System. During her tenure as Medicaid Director, one of the major on-going activities was managing implementation of the State’s new Medicaid Management Information System (MMIS). Established a Steering Committee to help guide the project, ensure that it continued to be consonant with other State and national information technology activities and met the needs of all involved stakeholders. Tracking systems were established to manage project development, implementation and any remediation that might be necessary after initial implementation. Among the many challenges that were met during this project were the redirection of resources to address the September 11 World Trade Center attack, implementing new Health Insurance Portability and Accountability Act (HIPAA) requirements, and establishing transition programs to ensure continued provider cash flow.

Program Evaluation and Improvement

 Conducted a survey of State Medicaid Pay-for-Performance programs. This survey, designed to be both a reference tool and to provide contextual background to State Medicaid program activities, provides an environmental scan of State Medicaid pay-for- performance activities, including both current and planned programs. The survey catalogued programs by major groupings (such as involved provider groups, types of measures, types of incentives), examined concerns and issues which influenced Medicaid Directors when establishing such programs, and identified program trends. Research was conducted via written surveys, reviews of available literature, and in-depth interviews.

Operations and Performance Reviews

 Assessed the performance of the Missouri Medicaid Program (MO HealthNet). This engagement included a comprehensive review of the MO HealthNet program to identify, evaluate, measure, and prioritize opportunities for immediate and mid-term savings to address a serious State budget shortfall in FY2010 and FY2011. As part of this engagement, Lewin also developed comprehensive reports on MO HealthNet’s pharmacy, clinical services, long term care, high cost individuals, and non-emergency medical transportation programs. A final operational program review recommended changes to the overall structure, policies, management, and oversight of the Medicaid program, with particular emphasis on the State’s long term care programs, care management initiatives for the ABD and chronically ill populations, and the financing structure for the program. Separate studies of program integrity activities and the impact of health care reform have also been conducted, with further analyses of program areas being considered.  Conducted Medicaid cost containment analyses. Beginning in 1975-76, and numerous times thereafter, participated in and/or directed analyses of the New York State Medicaid program to identify areas for cost containment. These analyses were conducted under the auspices of external control agencies as well as the agency responsible for the Medicaid program, and generally required the ability to manage an interagency team. In all cases, the analyses were conducted under significant time constraints and required an understanding of program and fiscal data, opportunities which had arisen due to federal and State legislative and program changes, other legal and regulatory constraints, establishment of

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reasonable implementation timeframes, development of necessary statutory and regulatory amendments, as well as an understanding of the political environment.

State and Federal Policy and Legislation

 Developed recommendations for a Report to Congress on four proposed Medicaid regulations. Ms. Kuhmerker participated in the development of proposed federal regulations on Medicaid programs nationwide, including impacts on provider reimbursement and non-federal financing methods such as certified public expenditures and intergovernmental transfers. This independent study was required by Congress to respond to Congressional concerns regarding the potential impact of these four regulations.  Managed the development and negotiation of New York State’s Preferred Drug List (PDL) and Prior Authorization programs. Recognizing that New York’s pharmacy costs were the fastest growing component of the State’s Medicaid program, directed staff in the development of numerous cost containment and program restructuring efforts in the pharmacy area. Within existing statutory requirements, several major program changes were developed, including establishment of a PDL and expansion of the existing prior authorization program. Due to advocacy concerns, the existing statutory framework was modified so that no action could be taken without explicit legislative authorization. After three years of negotiations, which focused on demonstrating to the legislature and advocates that the processes would be open and public, new enabling statute was adopted and the programs were able to begin to be implemented.  Coordinated the review and negotiation of federal Medicaid disallowances and deferrals. Worked with internal and external counsel, program and auditing staff on a variety of Medicaid funding deferrals and disallowances including school supportive health claiming and intermediate care facility certification. Activities included assessing the involved federal rules, regulations and interpretations, developing a thorough understanding of the state activities that were under scrutiny, developing appropriate arguments to defend State action, determining appropriate corrective actions and negotiating with federal staff.

SELECTED PRESENTATIONS AND PUBLICATIONS

Kuhmerker, Kathryn and Sheils, John, Impact of the Patient Protection and Affordable Care Act (PPACA) on State Governments, Webinar, May 26, 2010 Kuhmerker, Kathryn, President-Elect Obama’s Health Care Plan: Impact on State Medicaid Programs or “Things Medicaid Directors Will Be Thinking About,” Breakfast Meeting, November 14, 2008 Kuhmerker, Kathryn and Oleske, Iris, Managing Outside the Workplan, Managing Internal and External Implications, MMIS Implementations, MMIS Conference, August 2007 Kuhmerker, Kathryn and Hartman, Thomas, Pay for Performance in State Medicaid Programs: A Survey of State Medicaid Directors and Programs, The Commonwealth Fund, April 2007

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JOEL MENGES MANAGING DIRECTOR EDUCATION

M.P.A., Health Policy Studies, Syracuse University B.S., Economics/Political Science, Kalamazoo College

EXPERIENCE

Mr. Menges’ career focus is on designing and improving managed care programs for Medicaid, Medicare, and other high-need populations. During his 16 year tenure at Lewin, he has worked on Medicaid assignments in thirty states (AZ, CA, CO, CT, DE, FL, GA, HA, IA, IL, IN, KS, MA, MD, MI, MN, MO, NC, NM, NY, OH, OR, PA, RI, SC, SD, TX, VA, WA, and WV) and Medicare managed care initiatives in ten states (AZ, CA, FL, IN, MA, MD, NJ, NY, OH, and TN). He has more than 20 years of experience in the analysis and development of managed care programs and provider reimbursement systems. He is a nationally recognized leader in the Medicaid managed care industry, having worked with dozens of State Medicaid agencies and Medicaid health plans. He has played a lead role in many prominent studies/reports that Lewin has conducted in the Medicaid managed care arena, and he is regularly invited to present at national Medicaid managed care conferences. Recent projects include: Medicaid Managed Care  Directed an engagement throughout the past decade for a Medicaid managed care program, New York’s HIV Special Needs Plan (SNP) initiative. The centerpoint of Lewin’s work has been annual capitation rate-setting. However, Mr. Menges and the Lewin team have played a broader and instrumental role in the creation and preservation of this fragile program, with additional tasks including evaluations to assess/demonstrate the program’s impacts on inpatient hospital, outpatient hospital and pharmacy utilization, assisting in health plan monitoring efforts, and generally serving as the “go to” firm for whatever special challenges arise.  Directed a comprehensive assessment of Connecticut’s HUSKY program, a capitated Medicaid managed care initiative, preparing a written report that was submitted to the State Legislature and testifying at two key hearings about the program’s future. Mr. Menges also assisted in a comprehensive assessment of Pennylvania’s HealthChoices program, a capitated Medicaid managed care initiative. During 2005 he led the investigation of the program’s financial impacts and he presented testimony at a State Legislative hearing during 2007.

Procurement-Related Experience

 Assisted several state Medicaid agencies (CT, DC, DE, MD, NY, OR, TX, WA) in conducting Medicaid managed care procurements. Work has included drafting RFPs, developing scoring criteria, training reviewers, facilitating (and in some cases, conducting) proposal team scoring reviews, preparing actuarial data books, assisting in the preparation for and

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conducting of bidders conferences, drafting answers to bidders’ written questions, and conducting site visit “readiness reviews” of selected vendors.  Assisted in the proposal preparation for Chartered Health Plan, a District of Columbia MCO that recently won a contract renewal. Rate Setting, Risk Adjustment and Payment Methods

 Assisted Delaware during 2004 in exploring a payment model whereby inpatient rates for Medicaid admissions would increase and inpatient rates for state employee admissions would decrease, keeping hospitals at the same overall reimbursement but garnering greater Federal funds through the Medicaid match to help alleviate State budget pressures.  Evaluated the financial feasibility of an Indiana hospital and its affiliated community health centers accepting global capitation payments from an area HMO. Tasks included developing per member per month budgets for all physician specialties.  Evaluated the adequacy of capitation payments to the District of Columbia’s Medicaid health plans, as well as opportunities to capitate the District’s uninsured coverage program.  Reviewed Washington State’s Medicaid capitation rate methodology to assess whether any opportunities for cost savings appear to exist in upcoming rate-setting and/or rate negotiation efforts.  Co-directed a project to establish capitation rates for the State of Kansas.  Directed a comparison of all 50 states’ Medicaid physician fee schedules, ranking each state’s fees on the basis of both the fee itself and the Medicaid fee as a percentage of Medicare’s allowed charge.  Designed a methodology for converting any New York hospital's payments from DRGs to per diem payments.  Provided ongoing developmental assistance to Managed Healthcare Systems of New York (MHSNY). Specific activities included derivation and negotiation of hospital and physician payment rates, submission of financial projections and other regulatory filings to State officials, and oversight of mental health and other provider contracting efforts.

Operations and Performance Reviews

 Evaluated the State of Ohio's Medicaid rate-setting methodology on behalf of a Cincinnati HMO, ChoiceCare. Also conducted an operational review of this HMO's entire Medicaid line of business.  Assessed, on behalf of the State of Oregon, the financial viability of 25 health plan applicants. Follow-on work involved assessing the State’s ongoing process for monitoring the financial strength of its participating plans.  Assisted the State of Missouri in a comprehensive assessment of its Medicaid program. Led a specific assessment of the pharmacy benefit, and directed much of the analytical work geared to identifying and prioritizing short-term and longer-term cost savings opportunities.

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 Worked with the Arizona Health Care Cost Containment System (AHCCCS) to identify components of the Medicaid benefits package that could be limited or eliminated in a manner that would cause the least beneficiary harm. Tasks included on-site participation on a Task Force discussion the benefits reduction options, and overseeing a modeling effort to estimate the net cost savings various benefits reductions would achieve – taking into account that elimination of a certain covered service could result in increased use of other covered services.  Assisted the California Healthcare Foundation in preparing a detailed report on high-cost Medi-Cal beneficiaries. The work included creation of a beneficiary-specific data file that supported a wide range of cost, usage, and condition-related assessments. SELECT PUBLICATIONS AND PRESENTATIONS

“Increasing the Use of the Capitated Model for Dual Eligibles: Cost Savings Estimates and Public Policy Opportunities,” prepared for Association for Community Affiliated Plans and Medicaid Health Plans of America, November 2008. “Analysis of Drug Rebate Equalization Act’s Savings to the Medicaid Program,” prepared for Association for Community Affiliated Plans, September 2008. “Medicaid Upper Payment Limit Policies,” “Overcoming a Barrier to Managed Care Expansion,” prepared for Medicaid Health Plans of America, November 2006. “Medicaid Capitation Expansion’s Potential Savings,” presented to Vice President Cheney’s staff, February 2006. Available at: http://www.lewin.com Comparative Evaluation of Pennsylvania’s HealthChoices Program, 2005, (authored cost- effectiveness section), http://www.lewin.com/Lewin_Publications/Medicaid_and_S- CHIP/ ComparativeEvalPAHealthChoices.htm Assessment of Medicaid Managed Care Expansion Options In Illinois, 2005, (project director and co-author), http://www.lewin.com/Lewin_Publications/Medicaid_and_S- CHIP/MedicaidMCExpansionOptionsIllinois.htm “Trends in Medicaid Managed Care,” presented with Nancy Beronja at Medicaid Health Plans of America’s inaugural conference, October 2005. “Medicaid Managed Care Cost-Effectiveness,” presented with Lisa Chimento to Florida legislators, January 2005. “Healthy NY—Program Overview and Evaluation Findings,” presented at National Association of State Medicaid Directors Annual Meeting, October 2003.

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ANN OSBORN, MBA ASSOCIATE DIRECTOR

EDUCATION M.B.A., concentration in Healthcare Administration, University of Chicago Graduate School of Business, Chicago, IL B.A., Biological Sciences, concentration in Behavioral Psychopharmacology, University of Chicago, Chicago, IL

EXPERIENCE Ann Osborn joined The Lewin Group as a principal in April 2008. Since that time, Ms. Osborn has functioned as a consultative and project management expert for all aspects of provider network development and management including health care services pricing, provider reimbursement, network adequacy measurement and access compliance, and contracting. She is also engaged in Medicaid and Medicare Managed Care payer and program assessment, and health plan system operations. Ms. Osborn has done extensive work with providers, health plans and state governments. In addition, Ms. Osborn is proficient at pricing and cost impact analyses, strategic planning and project management, reimbursement methodologies, government programs (fee-for-service, managed care, and cost reporting), and utilization & cost trend analysis.

Medicaid Experience

 Reviewed submitted provider agreement templates for compliance with state regulations and reasonableness from Managed Care Organizations participating in the Mountain Health Choices program in West Virginia.  At the Osborn Group, retailored state Medicaid data reporting process, coordinating the input of all stakeholders including primary care physicians, special interest groups, medical societies, payers, and state agencies, resulting in streamlined reporting methodology with vastly increased levels of trust and cooperation and enhanced quality analysis and oversight.  Performed impact analyses of proposed benefit changes and influenced revisions to more positively impact desired changes in member behavior.  Developed a medical record summary tool for Medicaid providers to facilitate tracking of utilization and patient compliance resulting in enhancement of analysis and the implementation of quality oversight.

Rate Setting, Risk Adjustment, and Payment Methods  Considerable health care expertise in coding and reimbursement methodologies; cost and utilization analytics; pricing, incentive programs, and provider contracting; and managing large and disparate claims, benefits, provider, & eligibility files.  As Director of Network Management at UnitedHealth Networks, provided training on Medicare and state-specific Medicaid program structure and reimbursement methodologies.

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Procurement-related Experience  At UnitedHealth, oversaw network management, contracting, and provider service for hospitals and academic faculty groups.  At the Osborn Group, negotiated provider/healthplan contracts for hospitals, hospital- based physicians, specialists, ambulance, SNFs, ASCs, etc. Created health plan contract amendments for compliance with state and federal mandates and coordinated implementation of mandates internally. Medicare Experience  Studied the pertinent clinical guidelines, historic practice patterns, and specialty-specific utilization trends by condition, and has identified the variances across geography (rural, metro, etc) and eligibility (aged, disabled) type. Extensive knowledge of cost-sharing and benefit structures.  Developed concise and defensible criteria for “reasonable access” of enrollees to Medicare Advantage network providers. Through analytics, interviews, literature searches, and extensive mapping of providers, by specialty, the criteria were defined, and then tested against several ‘live’ means.  Serves as a benefits, reimbursement, and analytics subject matter expert in the investigation of the adverse issues affecting Medicare FFS beneficiaries related to 1) observation services and 2) the coordination of benefits.

Other Relevant Experience  At United Health Group, oversaw the relationships between UHG’s provider networks teams and its Medicaid and Medicare Advantage health plans. Responsible for adherence to compliance activities related to provider access, sanctions, reimbursement and coding.

o Developed the tools for use by the stakeholders to ensure maximum operational effectiveness including analytics to identify high cost areas to review for remediation, and to develop provider pay-for-performance programs. Conducted analyses of unit costs, utilization, incentive programs, physician profiles, and the impact of rate revisions for all provider types. She was responsible for ensuring staff understanding of and compliance with government program regulations and financing mechanisms. PREVIOUS PROFESSIONAL EXPERIENCE UnitedHealth Networks, Vice President, Government Programs (Fall 2006 – April 2008) UnitedHealth Networks, Director of Network Management (Mid-Atlantic Region) (February 2003 – Fall 2006) UnitedHealth Networks, Senior Healthcare Analyst (October 2001 – February 2003) The Osborn Group (Fall 1998 – October 2001) Robert Wood Johnson Foundation Grant to the Maryland Department of Health & Mental Hygiene for the Improvement of Healthcare Quality through Optimal Encounter Data Integrity, Project Lead (1999 – 2000)

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Commonwealth of Virginia’s Task Force on Rate Setting for the Virginia Medallion Medicaid products, Virginia Hospital & Healthcare Association Representative (1997 – 1999). D.C. Commissioner’s Task Force on Medicaid Managed Care, District of Columbia Hospital Association Representative (1992 – 1993).

PRESENTATIONS AND SEMINARS American Association of Hospital Account Managers Quarterly Meeting: “Internet Opportunities for Managing Hospital Days in Accounts Receivable” Alexandria Hospital Annual Medical Staff Meeting: “Glastnost and Detenté: Opportunities for Collaboration in the Washington Metropolitan Area” American Guild of Patient Account Managers annual meeting presentation: "Physician Contracting: Contract Language...Perils and Opportunities" HealthCare Council seminar: "Managed Care Contracting in Home Health: Trends and Expectations" American Guild of Patient Account Managers annual meeting presentation: "Physician Contracting: What to do...What to Avoid" Healthcare Financial Management Association Presentation: "Managed Care: A Multi-faceted Perspective" American Association of Health Insurance Auditors annual meeting presentation: "Managed Care Contracting: Trials and Tribulations"

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JOHN SHEILS VICE PRESIDENT

EDUCATION M.S., with Honors, Public Policy, School of Urban and Public Affairs, Carnegie-Mellon University B.S., summa cum laude, Political Science, State University of New York at Brockport

EXPERIENCE Since Mr. Sheils joined the firm in 1980, he has worked to establish The Lewin Group as one of the few independent sources of non-partisan analyses of the financial impacts of public coverage expansions and other health reform initiatives. He has testified before various Congressional committees and commissions on health reform options and is regularly quoted in the press. He often works directly with members of Congress in evaluating and developing health reform initiatives. Mr. Sheils has also delivered numerous policy briefings to state task forces, federal commissions, private associations and industry representatives on national health policy. Mr. Sheils has specialized in financial analyses of the impact of health reform proposals at the state and national levels. He directed analyses of the impact on the Patient Protection and Affordable Care Act (ACA) on payers and providers. He is currently developing estimates of changes in health plan enrollment under the ACA at the state, county, and health plan levels. He has specialized in the use of microeconomic databases and micro-simulation techniques to analyze health, retirement, tax and income maintenance policy issues. He is the architect of The Lewin Group Health Benefits Simulation Model (HBSM). His experience at The Lewin Group includes: Federal and State Policy and Legislation  Estimated the cost and coverage impacts of the ACA signed into law by President Obama. Includes analysis of state and local government spending; private employer costs by firm size, industry, and current insuring status; family health spending by demographic group; and health care providers. The study featured long term impacts estimates through 2029.  Directed studies comparing the cost and coverage impacts of the House and Senate health reform bills for the Peterson Foundation. Included analyses of the legislation’s impact on: federal health spending and revenues and for other stakeholder groups including employers, families, state and local governments and providers.  For the Office of The Assistant Secretary for Planning and Evaluation (ASPE), DHHS, developed estimates of the cost and coverage impacts of proposals to expand health insurance coverage including President Bush’s tax deduction proposal and the Congressional Tax Credit plan. Included estimation of changes in coverage, federal tax revenues and other stakeholder impacts.  Estimate the cost and coverage impacts of proposed legislation in Wisconsin that would cover all workers and their families under a program emphasizing a combination of health savings accounts (HSAs) and managed competition to control costs. The client was a

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consortium of the Wisconsin Health Project, state legislators, the AFL-CIO, and other stakeholder groups in Wisconsin. The bill was ultimately adopted by the state Senate.  Authored The Lewin Group comparison of the 2008 Presidential candidate’s health reform proposals on coverage and costs for the federal government and major stakeholder groups. Included estimation of the impact of high-risk pool proposals and simulation of proposed underwriting rules for the individual and small group insurance markets.  Evaluated the state’s methodology for estimating the impact of Dirigo Health on health spending in Maine for the Maine Chamber of Commerce. Also conducted an independent assessment of the estimates used to set the Dirigo savings offset payment (SOP), which was established to pay for the program. Provided a detailed review of the methods and data used by the state. Included our own review of the available data, and benchmarking the various estimates against other health spending growth estimates in neighboring states.  In New York, for the United Hospital Fund, directed an analysis of several options for expanding insurance coverage in New York State, including mandatory and voluntary approaches to expanding coverage. This analysis included looking at methods to expand coverage in the state through public programs only, such as Medicaid expansions and tax credits.  In Colorado, directed an analysis of several options for achieving universal coverage in the state in support of a Governor appointed commission of public and private stakeholders (i.e., the “208 Commission”). Worked with the authors of four different universal coverage proposals to refine and analyze their impacts. One of the options for coverage expansion was supported by an employer contribution proposal.

SELECTED REPORTS AND PUBLICATIONS “Ideas for Financing Health Reform: Revenue Measures that Also Reduce Health Spending,” Statement of John Sheils before the Senate Committee on Finance, May 12, 2009 “People Without Health Insurance at Some Time in 2007 -2008: National and State Level Estimates,” (report to Families USA), The Lewin Group, February 18, 2009 “Updated Cost and Coverage Impacts Analysis for the Healthy Americans Act (HAA) (S.391): The Wyden/Bennett Bill,” The Lewin Group, March 11, 2009 “Opening a Buy-In to a Public Plan: Implications for Premiums, Coverage and Provider Reimbursement,” (presentation to Senate Republicans and staff), The Lewin Group, February 11, 2009 “President Obama’s Health Care Reform Proposal and Congressional Alternatives,” (Keynote address for the Insure the Uninsured Project conference), Sacramento Ca., February 4, 2009 “The McCain and Obama Health Care policies: Cost and Coverage Compared,” The Lewin Group, October 8, 2008 “Cost Impact Analysis for the Health Care for America Proposal,” (report to the Economic Policy Institute), The Lewin Group, January 30, 2008

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“Estimated Cost and Coverage Impacts of the Universal Health Care Choice and Access Act (S. 1019),” (Senator Coburn’s proposal), The Lewin Group, June 3, 2008 “Cost and Coverage Impacts of the President’s Health Care Reform Proposal and a Congressional Tax Credit Proposal,” (report to The Office of the Assistant Secretary for Planning and Evaluation (ASPE), DHHS), The Lewin Group, February 13, 2008 “Compendium of Cost and Coverage Analyses Provided to the Health Care Coverage for the Uninsured (HCCU) Group,” (report to the Robert Wood Johnson Foundation (RWJF)), The Lewin Group, August 2006 “Estimates of the Cost and Coverage Impacts of Proposals to Expand Health Insurance Coverage in New York,” (report to The United Hospital Fund and The Commonwealth Fund), August 25, 2006 “The Wisconsin Health Plan (WHP): Estimated Cost and Coverage Impacts,” (report to the Wisconsin Health Project), The Lewin group, June 4, 2007 “Technical Assessment of Health Care Reform Proposals,” (report to The Colorado Blue Ribbon Commission for Health Care Reform), The Lewin Group, September 24, 2007

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JEFFREY L. SMITH VICE PRESIDENT

EDUCATION

Bachelor of Science in Finance, Arizona State University

RELEVANT EXPERIENCE

Mr. Smith is the Market Lead for Lewin’s States and Payers Practice and is responsible for overseeing all client relationships and ensuring that his team provides quality services on time and within budget. Prior to joining Lewin, Mr. Smith served as Vice President, Finance for AmeriChoice where he was responsible for all aspects of revenue for AmeriChoice’s Medicaid and Medicare programs including analytics and operations. He led the Revenue team supporting all AmeriChoice new business and reprocurement efforts as well as the Encounters team responsible for the submission of encounter data to state Medicaid programs. Prior to joining AmeriChoice in 2008, Mr. Smith had a 23-year career at Mercer Consulting as a consulting Principal serving in various capacities including Actuarial Practice Leader of Mercer’s Government Human Resource Consulting (GHSC) practice, member of GHSC’s Leadership Committee, member of GHSC’s Business Planning committee, and Client Leader to several of GHSC’s most notable clients, including the states of Colorado, Georgia, Maryland, New Jersey, New Mexico, New York, Oklahoma, and North Carolina. During his time at Mercer, Mr. Smith worked with more than 25 states on Medicaid managed care and uninsured initiatives. He led the risk-adjusted rate work group for Mercer’s GHSC and guided the development of new analytical tools for the government practice including the use of risk assessment, predictive modeling, pay-for-performance, and efficient networks.

Medicaid Managed Care  Managed comprehensive projects to develop, procure, and implement Medicaid managed care in numerous states.

Rate Setting, Risk Adjustment, and Payment Methods  Created, staffed, and led AmeriChoice’s Medicaid actuarial and risk adjustment teams.  Drove AmeriChoice risk score improvement leading to increased revenues in 2008 and 2009.  Implemented risk-adjusted capitation rates in the states of Colorado, Delaware, Florida, Maryland, New Jersey, New York, and Pennsylvania.  Developed a risk-adjusted pay-for-performance program for Alabama’s Medicaid program.  Spoke at national conferences on risk adjustment implementation issues.

Other Relevant Experience  Member of AmeriChoice’s Finance senior leadership team responsible for achieving AmeriChoice’s Winning Priorities in revenue adequacy and accuracy.  Improved encounter submission processes at AmeriChoice.

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 Member of GHSC Leadership Committee responsible for implementing GHSC’s strategic business plan.  Managed a staff of 60 actuaries and financial analysts as GHSC’s Actuarial Practice Leader.  Served as Account Executive for many of GHSC’s major clients.

Health Reform  Conducted strategic analyses of statewide health care reform to cover the uninsured, including estimating the cost impact to the state, employers, and individuals in Arizona, Georgia, New Mexico, and North Carolina.  Conducted health care reform projects for the national health care systems of Spain and Colombia.

PREVIOUS PROFESSIONAL EXPERIENCE AmeriChoice, Phoenix, AZ – 2008 to 2010:  Vice President, Finance (Revenue) – Developed and led AmeriChioce’s actuarial pricing team, encounter corrections team, risk adjustment team, and revenue reconciliation team.

Mercer, Phoenix, Arizona & St. Louis, Missouri – 1985 to 2008, Government Human Services Consulting – Phoenix, Arizona  Strategic Business Planning Committee – Developed the strategic business plan for the GHSC.  Client Leader – Acted as Client Leader for many of GHSC’s most notable Medicaid clients including the states of Colorado, Georgia, Maryland, New Jersey, New York, North Carolina, Oklahoma, South Carolina, and Vermont.  Leadership Team – Implemented and oversaw GHSC’s strategic business plan, identified staff recruiting and training needs, budget, and financial performance.  Risk Adjustment Project Team Leader – Led all risk adjustment projects for GHSC including those for the state Medicaid programs in Arizona, Colorado, Delaware, Florida, Maryland, New Jersey, New York, Pennsylvania, and Spain’s national health care system.  Actuarial Practice Leader – Managed the GHSC’s Actuarial Practice overseeing work products, staffing, training, and budgets for 60 actuaries and financial analysts serving 30 state Medicaid clients.

Health and Benefits – Phoenix, Arizona and St. Louis, Missouri  Consultant – 1985 to 1995 – Consulted to employers on a variety of health and benefit topics including benefit design, renewal negotiation, post-retirement medical liabilities, and flexible benefit plans. Clients included America West Airlines, Anheuser Busch, Del Webb Corporation, Emerson Electric, Monsanto, Peabody Coal Company, Southwestern Bell, State of Missouri Retirement System, and St. Louis County Government.

General American Life Insurance Company, St. Louis, Missouri – 1981 to 1985:  Underwriter – 1981 to 1985 – Underwrote group life and medical accounts.

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Cost Proposal

Bound under separate cover.

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