Expertise of Kip Piper
Medicaid Policy, Finance, and Business
Kip Piper’s Medicaid Expertise
Table of Contents
Knowledge is of no value unless you put it into practice.
Any fool can know. The point is to understand.
It is my business to know what other people do not know.
Kip Piper’s Medicaid Expertise
Medicaid Policy
Federal and State Medicaid Policy
- Federal Medicaid statutes: Title XIX and Title XI of the Social Security Act.
- State Medicaid statutes.
- Centers for Medicare and Medicaid Services (CMS) regulations and subregulatory guidance.
- State Medicaid agency regulations and policy and payment manuals.
- Medicaid State Plans.
- Federal Medicaid waivers and waiver terms and conditions.
Medicaid Policymaking
- Medicaid legislative and oversight process in Congress and State Legislatures
- Federal rulemaking process and Medicaid guidance development in CMS.
- State Medicaid agency rulemaking and manual development.
- Medicaid State Plan Amendments (SPAs).
- Medicaid waiver application process.
Drafting Medicaid Policy
- Medicaid legislation and regulations.
- Proposed Medicaid State Plan Amendments.
- Federal Medicaid waiver applications.
- State Medicaid policy and payment manuals.
Skilled Medicaid Policy Advisor and Problem Solver
- Medicaid policy intelligence: Insights and assessment of short and long-term policy, political, fiscal, and regulatory risks, challenges, and opportunities.
- Medicaid market and competitive intelligence.
- Development of Medicaid reform proposals and options.
- Medicaid policy and fiscal research and analysis. State and national legislative and regulatory research and analysis.
- Medicaid policy advocacy, outreach, issues management, crisis management, and strategic communications.
Kip Piper’s Expertise
Medicaid Finance and Budgets
Medicaid Financing
- Federal and State matching rates for Medicaid benefit costs and administrative costs.
- Federal financial participation (FFP):
- Medicaid expenditures eligible for federal matching funds and federal limitations.
- Section 1115 waiver expenditure authorities for federal matching funds on Medicaid costs not otherwise matchable.
- Sources of the State share of Medicaid
costs:
- General Fund revenues (e.g., State income taxes and sales taxes).
- Medicaid provider taxes and federal limitations.
- Intergovernmental transfers (IGTs) and federal limitations.
- State Medicaid agency tracking and reporting of Medicaid benefit costs and administrative costs. Spending projections for CMS and federal claiming.
State Medicaid Budgeting
- State-level Medicaid budget development:
- Medicaid spending and enrollment forecasts.
- Governor’s budget instructions and spending and savings targets.
- State Medicaid agency development and submission of budget requests to the Governor and State Budget director.
- Governor’s budget for Medicaid.
- Medicaid changes and directives through the State budget process (e.g., eligibility, covered benefits, payment methods and rates, care delivery, waiver initiatives, cost containment initiatives, and Medicaid administration).
- State legislative budget and
appropriations process:
- Review of the Governor’s Medicaid budget and proposals from legislators, State Medicaid agency, and stakeholders.
- Hearings, negotiations, debate, and amendments.
- Budget adoption with Medicaid appropriation(s) and any policy changes or legislative directives.
- Annual or biennial budget and appropriations, with adjustments or supplemental appropriations if needed.
- Governor’s approval of legislative budget or veto or line-item vetoes. Legislative veto override process.
- Medicaid trust fund mechanisms in some States.
Federal Medicaid Budgeting
- Federal Medicaid budget development:
- President’s budget for the next federal fiscal year, including projected federal Medicaid costs, major Medicaid legislative proposals, planned major Medicaid regulations or administrative changes, and CMS’ operating budget.
- Development of Medicaid budget projections and legislative and regulatory fiscal estimates by the White House Office of Management and Budget (OMB).
- Congressional budget and appropriations
process:
- House and Senate procedures and committee jurisdictions.
- Congressional Budget Office (CBO) federal Medicaid expenditure projections, scoring of the President’s budget and Medicaid proposals, and accuracy issues.
- Budget reconciliation.
- Medicaid legislative changes.
- Continuing, consolidated, or omnibus appropriations bills.
- Annual federal appropriations for Medicaid program and CMS program management.
Medicaid Cost Management
- Design of Medicaid cost containment and budget savings options.
- Creative, multidisciplinary strategies,
tactics, and skills to:
- Contain Medicaid costs and cost growth.
- Generate desired budget savings.
- Optimize Medicaid outcomes and costeffectiveness.
- Expose and address significant cost inefficiencies in managed care programs.
- Identify and eliminate misaligned incentives.
- Improve budget predictability.
- Assessing the fiscal impact on State
Medicaid programs of:
- Federal mandates and regulations.
- Medicare cost shifting to Medicaid.
- Woodwork effects.
- Crowd out of private funding.
- Identify the capabilities a State Medicaid agency needs to manage and control costs and improve the performance of Medicaid providers and managed care organizations.
Medicaid Program Integrity
- Medicaid program policies, services, and provider types that at the greatest risk of waste, fraud, abuse, and gaming.
- Rapid identification and prevention of schemes for Medicaid waste, fraud, abuse, and gaming.
- Policies, practices, and systems to prevent inappropriate claims, reduce overpayments, support honest and competent providers, and optimize recoveries.
- Strategies and tactics to combat program integrity vulnerabilities and weaknesses unique to capitated Medicaid managed care.
- Advanced methods, tools, and data-driven capabilities to protect Medicaid program integrity, including artificial intelligence, game theory-based tactics, forensic decision support, and interdisciplinary teams.
- Understanding and addressing how complex, ambiguous, and antiquated Medicaid policies and processes unintentionally support bad actors.
Kip Piper’s Expertise
Medicaid Coverage and Access
Medicaid Covered Services
- Mandatory and optional covered services under Medicaid State Plans.
- Breath and variation in State Medicaid
program coverage of:
- Primary and preventive services.
- Acute and post-acute care.
- Emergency medical care.
- Specialty physician and other professional services.
- Prescription drugs and biologics.
- Diagnostic testing and services.
- Long-term services and supports.
- Behavioral health care.
- Issues, opportunities, and challenges of States’ use of Medicaid to cover nonhealthcare, non-skilled, school-based, social, and housing services.
- Alternative Medicaid benefit designs.
- State cost-sharing policies.
- Waiver-based coverage:
- Services potentially coverable under federal section 1115 research and demonstration waivers.
- Optional non-skilled supports coverable under federal section 1915 home and community-based services (HCBS) waivers.
Early and Period Screening, Diagnosis, and Treatment
- Federally mandated Early and Period Screening, Diagnosis, and Treatment (EPSDT) coverage for Medicaid enrollees under age 21.
- State Medicaid agency EPSDT policies and processes, including prior authorization requirements and medical necessity determinations.
- Issues and challenges for access to EPSDT services.
State Medicaid Coverage Decision Making
- State flexibility to determine the amount, duration, and scope of the specific mandatory and optional services for adults.
- State definitions and determinations of medical necessity.
- State options to use prior authorization, medical policies, and utilization controls.
Federal Medicaid Coverage Requirements and Limits on State Flexibility
- Federal requirements on:
- Access, sufficiency, and comparability of Medicaid-covered services.
- Federal restrictions on Medicaid premiums, coinsurance, and copayments, including Medicaid services and populations exempt from cost sharing.
- Access and coverage of EPSDT services.
- Out-of-state access to a covered service if not available in-state.
- Beneficiary and provider appeal rights.
- Federal coverage, access, and utilizationrelated requirements specific to, for
example:
- FDA-approved prescription drugs and biologics.
- Prescribed controlled substances.
- Medication-assisted treatment of opioid use disorders (OUD).
- School-based health services.
- Family planning services.
- Federally qualified health centers (FQHCs) and rural health clinics.
- Indian Health Service (IHS) facility services.
Kip Piper’s Expertise
Medicaid Reimbursement
Medicaid Reimbursement Methods, Rate Setting, and Payment Reform
- Fee-for-service (FFS) payment methods and rate setting.
- Cost-based payment methodologies.
- Episode-based, bundled, and global payment methods.
- Shared savings methodologies.
- Acuity-based reimbursement methods.
- Prospective payment methods.
- Separate billability for new therapies and diagnostics.
- Add-on payments for care management and coordination.
Value-Based Payment
- Value-based payment methods to improve
Medicaid outcomes, clinical quality, and
cost-effectiveness. Including for:
- Skilled nursing facility (SNF) services
- Physician services
- Inpatient and outpatient hospital services
- Managed care organizations (MCOs)
- Value-based payment alternatives for gene and cell therapies, high-cost prescription drugs and biologics, and genetic and molecular diagnostics.
- Shared savings model designs for Medicaid.
Medicaid Provider Payment Methods and Rate Setting
- Medicaid payment methods, options, and
rate setting for skilled professional
services, including:
- Skilled nursing facilities.
- Inpatient hospitals.
- Outpatient hospitals.
- Physicians and clinics.
- Home health agencies.
- Pharmacies.
- Behavioral health providers.
- Community health centers.
- Medicaid payment models for innovations
in the life sciences:
- Cell and gene therapies.
- Genetic and molecular diagnostics.
- Pharmaceuticals and biologics.
- Advanced imaging and medical devices.
- Medicaid reimbursement methods and
rate setting for non-skilled support services
under waivers or State Plan options:
- Personal care and similar supports in the home.
- Assisted living facility services.
Federal Medicaid Payment Requirements and Limits
- Federal standard for State Medicaid rates to simultaneously promote efficiency, prevent overutilization, ensure quality of care, and provide access in Medicaid comparable to access outside Medicaid for the general population.
- Federal standard for State Medicaid rates
to simultaneously promote efficiency,
prevent overutilization, ensure quality of
care, and provide access in Medicaid
comparable to access outside Medicaid for
the general population:
- Inpatient and outpatient hospitals.
- Skilled nursing facilities (SNFs).
- Intermediate care facilities for individuals with intellectual disabilities (ICFs/IID).
- Pharmacy dispensed prescription drugs.
- Durable medical equipment.
- Federal requirements for annual capitation rate setting.
- Federal Medicaid limitations on:
- Supplemental payments.
- Disproportionate share hospital (DSH) payments.
- Graduate medical education (GME) payments.
- Federal exclusion of room and board costs from assisted living facility reimbursement.
Kip Piper’s Expertise
Medicaid Drug Benefits
State Medicaid Coverage of Prescription Drugs and Biologics
- Medicaid prescription drug coverage under the State Plans (an optional service every State covers).
- Mandatory coverage of FDA-approved drugs and accepted indications when medically necessary. Exclusion of drugs of any manufacturers who decline to sign a national rebate agreement.
- State Medicaid drug formulary development, drug coverage decisionmaking, preferred drug lists, prior authorization guidelines, medical necessity criteria, and utilization controls.
- Specific therapeutic drug classes state Medicaid programs may exclude from coverage.
- Federal limits and exclusions on Medicaid drug copayments and coinsurance.
Medicaid Reimbursement of Pharmacy Dispensed and Physician Administered Drugs
- Medicaid pharmacy claims submission process and online adjudication.
- Pricing factors used to reimburse
pharmacies for Medicaid drug ingredient
costs (drug product, excluding dispensing
fee). Typically, the lesser of usual and
customary (U&C) and two or more pricing
methods, such as:
- Maximum allowable cost (MAC).
- Average acquisition cost (AAC).
- Submitted ingredient cost.
- Federal upper limit (FUL).
- Average sales price (ASP).
- Wholesale acquisition cost (WAC).
- Medicaid payment rates pharmacy dispensing fees and other pharmacy professional services. Federal requirements for Medicaid dispensing fee rates.
- Medicaid uses average sales price (ASP) and other pricing methods to reimburse physician-administered drugs and biologics.
Medicaid Drug Rebates
- Medicaid Drug Rebate Program (MDRP):
- National drug rebate agreement between manufacturers and Centers for Medicare and Medicaid Services (CMS).
- Statutory Medicaid drug rebate amounts and calculations: Base rebate amounts for brand and generic drugs, best price rebates, and inflation-adjusted rebates.
- State supplemental drug rebates:
- State-negotiated supplemental drug rebates and supplemental drug rebates negotiated through multi-state consortiums.
- Value-based arrangements (VBAs) for high-cost groundbreaking drug therapies approved by the FDA under an accelerated or other fast-track pathways.
- Role of Medicaid preferred drug lists (PDLs), prior authorization, step therapy, and other utilization controls to drive market share to drug products with the lowest cost net of rebates.
- Relationship of Medicaid drug coverage
and rebates to required participation of
manufacturers in:
- Federal 340B Drug Discount Program, including 340B ceiling prices on drug products.
- Federal Supply Schedule (FSS), including Federal Ceiling Price (FCP) and Most Favored Commercial Price (MFC).
Medicaid Drug Rebate Management and Reporting
- CMS Medicaid Drug Programs (MDP) System.
- State Drug Utilization Data (SDUD) system. Tracking and reporting of pharmacydispensed and physician-administered drugs and biologics across Medicaid delivery systems.
- Drug manufacturer quarterly reporting of Average Manufacturer Price (AMP) and Best Price (BP) for each drug product.
- State Medicaid agency invoicing and collection of statutory and supplemental rebates from drug manufacturers.
Kip Piper’s Expertise
Waivers and Demonstrations
Federal Medicaid Waiver Uses, Limitations, Precedents, Components, and Procedures
- Section 1115 Medicaid research and demonstration waivers and federal expenditure authorities for Medicaid costs not otherwise matchable in statute.
- Section 1915(c) Medicaid home and community-based services (HCBS) waivers for personal assistance and other non-skilled supports for older adults and persons with disabilities.
- Section 1915(b) Medicaid managed care freedom of choice waivers.
- Section 1115A Medicare and Medicaid innovation waivers.
- Section 402/222 Medicare and Medicaid waivers to test payment reforms and services.
Drafting of Waiver Applications
- Waiver program design, rationale, goals, and objectives.
- Requests for waivers of specific federal statutes and regulations and federal matching funds.
- Detailed impact analyses.
- Proposed innovations and policy changes (e.g., covered services, benefit design, eligibility, payment reforms, care delivery reforms, and Medicare-Medicaid dual eligible initiatives).
- Federal budget neutrality models.
- Research design, evaluation plan, and implementation plan for federal review.
- Negotiation support for waiver special terms and conditions (STCs).
Kip Piper’s Expertise
Medicaid Care Delivery
Risk and Non-Risk Options
Advantages, disadvantages, and real-world costs of Medicaid delivery systems, including:
- Risk Insurance: Medicaid Managed Care Organizations (MCOs).
- Non-Risk Administrative Services Only (ASO) Models.
- Value-based purchasing models for Medicaid care delivery.
- Accountable Care Organizations (ACOs) and Shared Savings Arrangements.
Competition and Contracting Options
- Procurement-based contracting with onetime competition on MCOs’ proposal writing skills.
- Certification-based contracting with ongoing competition on enrollment, choice, access, outcomes, costeffectiveness, and provider participation.
- Competitive, performance-based ASO contracting without added costs of risk insurance.
Carve Outs from Capitation
- Design of carve-outs from capitation to:
- Protect access, outcomes, and quality.
- Preserve choice and continuity of care.
- Prevent excess State Medicaid costs.
- Prevent cost shifting to taxpayers.
- Protect Medicaid program integrity.
- High-priority service carve-outs, including:
- Skilled nursing facility services.
- Pharmacy services and pharmacy benefit management.
- Cell and gene therapies.
Proposal Development
- Medicaid proposal development process
- Comparative qualitative and technical analysis of winning and losing proposals.
Managed Care Procurement
- Proposal evaluation and technical scoring process.
- Vendor capability assessments and readiness reviews.
- Contracting process for risk insurers and non-risk contractors.
Federal Requirements and Controls
- Complex federal regulation and control over State Medicaid managed care program policies and operations.
- Federal specifications for State MCO contracts with Medicaid MCOs.
- Federal requirements for MCO capitation rate development and annual rate setting.
- Federal data reporting requirements.
Medicaid Managed Care Integrity
- Oversight, accountability, transparency, and compliance of Medicaid health plans.
Kip Piper’s Expertise
Skilled Nursing Facilities
Medicaid Eligibility and Coverage of Skilled Nursing Facility Services
Federal and State Medicaid Policy
- Skilled nursing facility services as mandatory Medicaid State Plan benefit.
- Eligibility criteria for Medicaid skilled nursing facility (SNF) coverage:
- Financial eligibility.
- Skilled care needs and functional limitations.
- Medicaid skilled and intermediate levels of care.
- Individual assessments and reassessments. Comprehensive patientcentered care planning.
- The range of direct care services that Medicaid skilled nursing facilities must provide according to individual resident needs. Examples: skilled nursing and nurse aide services, medical services, rehabilitation and therapy services, medication administration, assistance with daily living needs, behavioral health care, transportation, medical social services, and individual and group activities.
Medicaid Skilled Nursing Facility Reimbursement, Rate Setting, and Payment Reform
- State Medicaid SNF payment
methodologies, including:
- Cost-based reimbursement methods.
- Acuity-based reimbursement methods.
- Value-based payment and incentives for outcomes, quality, and efficiency.
- Methods of reimbursing different types of fixed and variable costs of a SNF: direct care services, support services, administrative and operating costs, and capital and property-related costs.
- Methods to support SNF workforce development, including improved recruitment and retention and increased education and training of new nurses and other professionals.
- Methods to support the modernization of SNF buildings, use of private rooms, and hospital-grade infection control systems.
- Drafting of State Medicaid SNF reimbursement manuals and SNF state plan amendments (SPAs).
- Medicaid SNF cost reporting, auditing, and rate-setting policies and procedures.
Medicare Coverage and Reimbursement of Post-Acute Skilled Nursing Facility Services
- Medicare Part A coverage of short-term
post-acute skilled nursing facility services:
- Skilled nursing services.
- Physical therapy (PT), occupational therapy (OT), and speech-language pathology (SPL) services.
- Medicare’s limited, short-term SNF coverage and schedule of required patient coinsurance.
- Medicare skilled nursing facility payment
methodology, including:
- Base rates for skilled nursing, PT, OT, SPL, and non-therapy ancillary services, and by urban or rural location.
- Adjustments for geographic wage cost index, case mix index with 25 patient groupings, and the number of SNF days.
- Medicare SNF market basket index.
State Licensure and State-Level Regulation of Skilled Nursing Facilities
- State licensing of skilled nursing facilities and SNF beds.
- State-level regulation of SNFs in addition to federal-level regulation, including staffing requirements, building and patient room standards, and additional data reporting.
- Drafting of State legislation and regulations on SNF minimum staffing standards, monthly reporting of direct care staff hours, and modernized standards allowing the use of certified medication assistants and flexible work schedules.
- State review and approval of SNF construction plans, renovations, and additions.
Medicaid and Medicare Certification and Surveys of Skilled Nursing Facilities
- Certification of SNFs for participation in Medicaid, Medicare, or both programs.
- Surveys and inspections of SNF of conducted by the State Survey Agency and the Centers for Medicare and Medicaid Services (CMS).
- Federal regulations and sub-regulatory
guidance governing processes and
procedures for:
- Certification of Medicaid SNFs, Medicaid SNFs, and dually participating SNFs.
- Surveys, inspection, and monitoring by States and CMS.
Federal SNF Regulations and Sub-Regulatory Guidance
- Federal requirements of participation for skilled nursing facilities in Medicaid and Medicare.
- Highly detailed federal regulations and
guidance governing all facets of Medicaid
or Medicare reimbursed SNFs, including:
- Skilled and support services, staffing, quality of care, quality of life, care management, resident rights and protections, patient safety, infection control, and administration.
- Federal quality measures and quality ratings.
- Detailed data gathering and reporting.
- Enforcement, civil monetary penalties, Medicaid and Medicare termination, and other sanctions for non-compliance.
Kip Piper’s Expertise
Life Sciences Access
Medicaid Access to Life Science Innovations for High Needs, High-Risk Medicaid Patients
- Cell and gene therapies for infants, children, and young adults with deadly and devastating conditions.
- Genetic testing, molecular diagnostics, and laboratory-developed tests with high accuracy, validity, and clinical utility.
- Pharmaceuticals and biologics for severe or life-threatening conditions, often no other treatments available.
- Advanced imaging technologies.
- Software as a medical device (SaMD).
- Advanced medical devices.
- Artificial intelligence and machine learning
Clinically Sound, Cost-Effective Medicaid Coverage, Financing, and Reimbursement of Life Science Innovations
- Creation and assessment of Medicaidrelevant evidence dossiers and evidencebased clinical and economic cases for Medicaid access and coverage.
- Appropriate application of the Medicaid requirement for early and periodic screening, diagnosis, and treatment (EPSDT) for children and youth under age 21.
- Modernization of Medicaid medical policy
and coverage decision-making capabilities,
including:
- Data-driven, outcomes-focused systems and analytical supports. Incorporate artificial intelligence and health economics and outcomes research tools.
- Up-to-date decision-relevant medical necessity and prior authorization criteria.
- Practical and timely application of published clinical guidelines.
- Positive alignment of appropriate utilization controls with high-risk conditions, outcomes, clinical utility, and disparities reduction.
- Safeguards to ensure accountable, measurable, and medically necessary patient access regardless of the delivery system (e.g., fee-for-service, capitated managed care, non-risk ASO).
- Design of value-based, outcomes-based payment methods for cell and gene therapies, genetic and molecular diagnostics, high-priority drugs, and advanced medical devices.