Author: Sophia

Ohio Department of Medicaid calls for Exclusive Alignment through Next Generation MyCare Program

The Ohio Department of Medicaid (ODM) has recently initiated a significant shift in its Medicaid delivery model by inviting Managed Care Organizations (MCOs) to respond to the Next Generation MyCare Request for Applications (RFA). This new model aims to enhance care coordination and streamline health plan navigation through CMS-approved Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs). The phased implementation of the MyCare Ohio program will see the selection of no more than four MCOs to deliver these integrated services.

What is Changing?

With the introduction of the Next Generation MyCare program, ODM plans to reduce the number of participating MyCare plans from five to four, each required to provide notice to CMS of their intent to establish a FIDE SNP by Fall 2024 to align with a program start date of January 1, 2026. This change aligns with broader industry trends towards exclusive alignment and full integration of Medicare and Medicaid services. 

What is the Impact?

FIDE SNPs cover Medicaid benefits (often including behavioral health), coordinate care delivery and administrative functions, cover long-term services and supports and, as of 2025, require exclusive alignment. Ohio is not the first state to adopt this model and is, in fact, following the industry trend of an increasing number of states adopting this model. The shift is expected to deliver several key benefits:

  • Enhanced Care Coordination and Integration: Improved communication, data sharing and care coordination will lead to better delivery of care
  • Improved Quality Measures: Metrics such as follow-up after hospitalization and medication reconciliation are anticipated to show significant improvement
  • Increased Member Satisfaction: Simplified access to services and streamlined experiences will boost satisfaction
  • Operational Efficiencies: Streamlined administrative processes and better resource utilization for care management and increased transparency in care coordination through data integration and sharing

This move mirrors nationwide trends, with an increasing number of states adopting similar models. Legislation like the DUALS Act, underscores this shift, advocating for integrated care programs that combine Medicare and Medicaid contributions, assign a single care coordinator and develop comprehensive care plans delivered by interdisciplinary care teams. Although there may be opposition from several states, this legislation indicates a significant industry shift we are seeing towards integrated care. 

Regulatory Implications and Future Outlook

The Centers for Medicare & Medicaid Services (CMS) has emphasized the importance of FIDE SNP alignment in regulatory documents and are leaning on the states to help this full integration. Starting on January 1, 2030, D-SNPs will only be allowed to enroll individuals who are also enrolled in the affiliated Medicaid MCO (e.g, FIDE SNP). Additionally, SNPs must disenroll individuals not enrolled in both the D-SNP and the Medicaid MCO offered by the same parent organization. This policy will have significant impacts on organizations that provide D-SNPs but do not participate in the state’s Medicaid managed care program. 

Key Considerations for MCOs

As MCO’s prepare to respond to ODM’s RFA or adopt this model, they must consider several critical factors:

  • Regulatory Compliance: Adherence to across Medicare and Medicaid requirements, that vary by state, to avoid penalties and service disruptions
  • Comprehensive Care Coordination: Effective care planning and risk stratification across interdisciplinary care teams
  • Data Integration: Seamless data exchange process that encompasses member eligibility, claims and care management information which interfaces with state agency data for effective delivery of care and reporting
  • Provider Network Development: Building an adequate network that includes Medicare and Medicaid providers, behavioral health and long-term services and supports, which often include home and community-based services
  • Performance Reporting: Robust quality programs to demonstrate compliance and performance with plan requirements
  • Operational Readiness: Staffing and training requirements for the unique operational requirements of a FIDE SNP combined with the complex case mix of membership lead to effective operations, implementation and continued plan performance

As a consultancy focused 100% on healthcare, ProspHire is equipped to support health plans through competitive RFAs, readiness plans and plan go-live phases. Our experienced team provides advisory services while actively executing key initiatives to deliver value. ProspHire’s expertise includes implementing state requirements for exclusive alignment, health plan growth and expansion and operational and quality performance improvements. For additional insights, connect with us today.

Soaring to New Health Blog – Season 2, Episode 4: The Modern Dental Practice

In the rapidly evolving world of dental healthcare, technology plays a crucial role in streamlining operations and enhancing patient care. In a recent episode of ProspHire’s Soaring to New Health podcast, Chris Miladinovich and Dan Crogan explored the transformative impact of cloud-based dental practice management software. Their guests, Mike Huffaker, Chief Revenue Officer of Planet DDS, and Luke Laurin, Managing Director of Dental Practice Management at ProspHire, shared valuable insights into the benefits, challenges and future trends of adopting cutting-edge technology in the dental sector.

The Rise of Planet DDS

Mike Huffaker began by discussing Planet DDS, a leading provider of cloud-based dental software. Founded in 2003, Planet DDS has been at the forefront of innovation, offering solutions like Apex Imaging for cloud-based X-rays and Legwork, a marketing automation tool for dental practices. With a strong heritage in cloud technology, Planet DDS focuses on providing multi-location practices with flexible, future-proof solutions.

“Our heritage is cloud,” Mike emphasized. “We live, sleep and breathe cloud. We are a SaaS platform with a commitment to always being on the cutting edge.” This dedication to innovation ensures that practices using Planet DDS can continuously adapt to new technologies and stay ahead of the curve.

Challenges in Implementation

Transitioning to a new practice management software can be daunting, especially for multi-location practices. Luke Laurin from ProspHire pointed out that many dental practices face challenges in planning and resource allocation during the implementation phase. “A lot of organizations don’t plan accordingly from a resource perspective,” Luke noted. “It often ends up costing them more money in the long run due to budget overruns and unmet schedules.”

Luke stressed the importance of thorough planning, resource allocation and optimization of front, back and clinical office workflows to ensure a successful implementation. This planning phase is crucial for practices to not only transition smoothly but also to leverage the new software to its fullest potential.

Adoption and Change Management

Once a new software solution is implemented, driving adoption and managing change are critical. Mike discussed the importance of creating and documenting new workflows and standard operating procedures (SOPs) to ensure staff can efficiently use the new system. “You want to make sure you’re celebrating the success that your practices have in the adoption of the software,” Mike said. “This increases the buy-in and the probability of being successful.”

Strategic Acquisitions for Comprehensive Solutions

Planet DDS has been strategic in its acquisition approach, recognizing the diverse needs of dental practices. Mike mentioned that their acquisitions, such as Cloud 9 and Apex Imaging, allow them to offer integrated, best-in-class solutions tailored to different specialties within the dental field.

“We’ve been very thoughtful in trying to provide a comprehensive solution of best-in-class products that integrate together,” Mike explained. This approach ensures that dental practices can operate efficiently with tools specifically designed for their unique workflows.

Conclusion

The adoption of cloud-based dental practice management software, like that offered by Planet DDS, is transforming the dental industry. By focusing on scalability, thorough planning and strategic acquisitions, Planet DDS and ProspHire are helping dental practices navigate the complexities of modern healthcare technology. As the dental sector continues to evolve, embracing these cutting-edge solutions will be key to staying competitive and providing top-notch patient care.

For more in-depth discussion on ‘The Modern Dental Practice’, download the Soaring the New Health podcast where you find your podcasts. Or visit: Soaring to New Health Series | ProspHire.