Financing

• Budget Development and Program Financing
B&A staff have considerable experience in assisting clients with forecasting the costs of public programs. This includes developing budget models specific for each client based upon the parameters that they want to measure their program. Specifically for Medicaid programs, we assist clients in determining where federal matching dollars are not being exercised and help to create policies—both in operations and in cost reporting—so that states can take advantage of all federal dollars available to them. See Projects in This Category
• Disproportionate Share and Upper Payment Limit Program Financing
B&A staff have experience in working with state agencies making DSH and UPL payments as well as private sector clients receiving these payments. We examine the formulas used to make payments and run models that simulate alternative formulas based upon policy changes requested by the client. B&A assists in facilitating discussions between parties as to the advantages of specific DSH and UPL policies based on federal law. See Projects in This Category
• HIFA and Other Waivers
Peter Burns is one of the leading experts in the nation for assisting states in seeking approval of their HIFA waivers. B&A staff assist states in all aspects of the application process—including development of a concept paper, meeting with stakeholders on the design of the waiver, analyzing historical policies and costs that impact the waiver application, developing budget neutrality models, writing the waiver application, and negotiating with CMS.

Mr. Burns is the co-author (with Dr. Gretchen Engquist) of an issue brief published by the State Coverage Initiative titled Health Insurance Flexibility and Accountability Initiative: Opportunities and Issues for States. See Projects in This Category

• Institutional Reimbursement System Development
B&A staff have considerable experience in developing new reimbursement systems as well as updating or rebasing existing payment systems. Our staff have set rates paid to inpatient hospitals, outpatient hospitals, nursing facilities, and ICFs/MR. Our tasks usually include not only the actual calculations but also the development of issue papers related to specific methodological considerations that can be shared with the state and its providers. B&A staff also provide technical support to provider-based workgroups throughout the process, forecast hospital-specific impacts, assist in writing the state plan amendment and in negotiations with CMS.

B&A staff has also conducted independent evaluations of existing reimbursement methodologies to assist states in developing options to reform their systems or to ensure compliance with federal access to service requirements. See Projects in This Category

Operations

• Development of Request for Proposals
B&A has assisted states in writing RFPs for a variety of Medicaid services. We provide technical assistance in developing the parameters of the scope of work required for the vendors that will be responding to the RFP as well as researching legal matters that should be included in the RFP. In addition to writing draft RFPs for state staff to review, we assist in answering questions from the bidders conference as well as developing tools for evaluating the submitted proposals. See Projects in This Category
• Litigation Support
B&A staff can serve as arbitrators in settlements as well as technical resources for the legal team working on the lawsuit. We can assist in developing supporting cost evaluations or analysis of particular Medicaid laws and regulations. We have successfully assisted parties in the past come to settlement on long-standing disputes over payments to hospitals for indigent care and in support of states’ rate setting methodologies for hospital services.
• Program Design and Operations
B&A has worked with states both in the initial concept stage of a new program as well as the intricate details of putting a program into operations. Examples of areas where we assist states include writing policy/provider manuals, developing job descriptions and tasks, and assisting in information systems development (e.g. eligibility and payment).

For public programs targeting specific populations, B&A have been instrumental in developing consumer-directed programs. Aspects where we have assisted have included setting rates paid to providers, creating an assessment tool to determine the level of services needed for each person, and implementing a fiscal intermediary program for the state agency to use for its clients in the consumer-directed program. See Projects in This Category

• Program Monitoring
B&A staff have been asked to provide both continuous monitoring for Medicaid programs as well as one-time efforts to improve operational performance. This has included developing monitoring manuals for budgeting, service utilization, and members' access to services. B&A also conducts focus studies to address state concerns on specific program operations. See Projects in This Category
• Public/Private Insurance Initiatives
An area of great interest in recent years among state leaders is how to leverage public funds or delivery systems to provide insurance coverage to citizens in the private sector. B&A staff have worked with states as they have explored options ranging from direct subsidies to employees of small businesses to developing reinsurance programs or high-risk pools. Because each state takes a unique approach to this complex issue, we work with state staff to understand what has been tried already, what has worked and what has not worked in the state, and what are the targeted priorities of the initiative. In this way, we can provide a customized approach to what state officials and stakeholders are seeking from the initiative. See Projects in This Category
• Readiness Reviews
Another aspect of the procurement process which B&A has experience is in preparing for and conducting readiness reviews. We customize the readiness review protocol for each engagement, gaining input from state staff on the areas that they would like particular focus. In addition to conducting the reviews, we write up our findings in a report to the client, assist in giving feedback to the entity being reviewed, and conduct re-reviews when necessary. See Projects in This Category

Quality and Planning

• Conduct Focus Groups
B&A staff have conducted focus groups with numerous stakeholders, including consumers and advocates for HCBS programs, uninsured state residents, small businesses who offer and those who do not offer health insurance to employees, and insurance brokers. For any focus group project, we work with the client to develop a semi-structured format to ensure that specific items are addressed while allowing for unfiltered feedback. B&A also assists in facilitating the set up of the focus groups and soliciting participation. The results of the focus groups culminate in a report of findings to the client. See Projects in This Category
• External Quality Reviews and Other Independent Evaluations
B&A staff have worked in the past on evaluating specific aspects of a state’s Medicaid program as well as a full evaluation of its entire program. Activities include analyzing existing policies, evaluating expenditures at the service or eligibility category level, interviewing state staff and other stakeholders, and researching best practices in other states. We summarize our findings in a report which we walk through with the client, highlighting both the aspects of the program that are successful and those that could be improved. For the latter, we provide specific recommendations for improvement and the level of effort required to implement the recommendations. See Projects in This Category
• Member & Provider Survey Development and Administration
B&A staff have experience in creating and administering surveys for various stakeholders. We develop customized cost surveys for state agencies to collect from their providers, specifically for community-based services. We also develop satisfaction surveys for state agencies to administer to their stakeholders (e.g. program members, providers, health plans). We assist states in the technical aspects of administering the survey (by phone, mail, and online) as well as analyzing the results in a summarized manner for decision makers. See Projects in This Category
• Strategic Planning
B&A has proficiencies to work with both public and private sector clients to develop strategic planning activities. We are able to assist in memorializing the strategies as well as implementing them. For any client, we first meet with all of the stakeholders involved to gain an understanding of where there is consensus in developing the strategic plan and where issues need to be resolved before the plan can be finalized. We take a customized approach to each strategic planning exercise, recognizing that the dynamics involved vary for each plan and must be addressed in a unique manner. See Projects in This Category

HCBS Waiver Programs

• Assessment Tools
B&A staff have expertise in creating and modifying assessment tools for the elderly, physicially disabled, and developmentally disabled populations. For the development of new tools, we typically convene a panel to finalize the tool and then conduct a pilot. Regression analyses are conducted to assess the inter-rater reliability of both pilot and full-scale implementations.

B&A has also developed tools to tie payments for individual budgets in HCBS programs to the assessment of client needs. See Projects in This Category

• HCBS Rate Setting
B&A is a leader nationally in the development of HCBS rates for both agency and individual providers of services for the developmentally disabled, the elderly and physically disabled, and persons with mental health needs. Often, our rate setting projects include conducting a provider survey of historical costs and utilization. Rates are not constricted to this data source due to limitations often seen in the data. Rather, it is used to reinforce the rates set using current market-based data that is specific to each state and specific to each HCBS service.

B&A will discuss with the outset the intent of the rebase and the level that the state wants to reimburse for specific items (e.g. employee benefits, admin costs, travel). These assumptions inform the customized approach to the rate development process. See Projects in This Category

• Implement Fiscal Intermediaries
Fiscal intermediaries are becoming common in the facilitation of consumer-directed HCBS programs. Early on, Gretchen Engquist assisted in the implementation of cash and counseling programs and FI implementations. She co-conducted a national survey for the Assistant Secretary of Planning and Evaluation (ASPE) for the Department of Health and Human Services of consumer-directed programs serving people with disabilities and seniors and co-authored the final report, “ASPE Consumer-Directed Support Service Program Inventory.”

Current B&A staff have written RFPs to procure FIs, conducted the readiness reviews, and assisted in developing the operational protocols from the state's side to interface with the FI. See Projects in This Category

• Individualized Budgeting
The B&A team has assisted in the development of individualized budget programs in Arizona, Louisiana, Ohio, Oregon and, currently, in Rhode Island. Each state has a unique approach to the development of individual budgets for HCBS programs. B&A staff discuss the conceptual framework with each state, recognizing existing or potential data limitations. Our funding levels a developed through regression analyses to ensure statistical validity. See Projects in This Category

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