Insights

Blue Plan Defines Strategy to Enter Medicaid Business

A Blue plan engages T2C to define its strategy to enter the Medicaid market.

Background:

Our client was a regional Blue Cross Blue Shield health plan that wanted to evaluate if, how, and when to expand into a state Medicaid market. Due to the client’s lack of experience in the technology, operations, and compliance requirements unique to Medicaid, T2C was engaged to develop a Medicaid Readiness Assessment and Strategy.

Challenges:

This health plan was focused primarily on their commercial line of business, traditional Blue products, and the operations and technology necessary to support them. The state in which they operated did not utilize managed care organizations as delegated entities. If our client was going to participate in their state’s Medicaid program, they would need to do so by offering a Medicaid Enterprise Service capability – enrollment, claims processing (MMIS), care management, pharmacy benefit management, or data warehousing. Our client needed an external point of view to assess their capabilities, identify gaps, and recommend a strategy.

Solution:

In one month’s time, T2C conducted a readiness assessment and made recommendations to our client’s executive leadership team.

To conduct the assessment, T2C reviewed all of the plan’s core technology and operational processes, including: member enrollment, claims, provider enrollment, customer service, care management, and health informatics. We conducted interviews with operational leaders in each area and observed their technology platforms in use. We utilized the Medicaid Information Technology Architecture (MITA 3.0) and assessed our client’s maturity against this reference architecture.

To determine potential entry strategies, we evaluated the landscape of current Medicaid vendors within the state. We researched prior RFPs, scopes of service, and vendor contracts across several Medicaid processes for the state then evaluated different potential value propositions for our client. For each one, we determined the magnitude of effort required and the likely competitive response.

As an entry strategy, we also evaluated potential partnerships with other companies operating in this space and emerging vendors who might be seeking entry into this space. Based on our assessment, we narrowed the field to three potential partners and prepared detailed assessments of each.

Our project culminated in an executive briefing that included background on the Medicaid program, our analysis, and final recommendations.

Value:

T2C has extensive knowledge and depth in the Medicaid and Medicare programs. With the changes driven by the Affordable Care Act, we are continually called upon to assist health plans in defining their market strategies. Beyond defining the business strategies, we also create pragmatic and achievable operational and technological strategies to support a variety of government programs.