The COVID-19 pandemic is having a profound impact on individuals, companies and governments alike. As unemployment rates have risen, state and federal income tax revenues have declined. Consumer spending is also down, which means that state sales tax revenues are shrinking. According to a survey conducted by the Kaiser Family Foundation, nearly every state indicated that the pandemic has driven significant adverse economic and state budgetary impacts. As a result, many states are concerned about providing Medicaid coverage, just as the numbers of individuals applying for Medicaid are on the rise.
To address these challenges, Medicaid payers are exploring different ways to reduce costs that won’t have a negative effect on beneficiaries. One promising approach is to proactively identify other insurance coverage options for high-cost members.
Commercial Insurance Enrollment for Newborns: An Overlooked Opportunity to Reduce Medicaid Costs
Based on sophisticated data and analytics that HMS has derived through artificial intelligence and machine learning, we have found that parents often fail to add newborn children to their commercial insurance. As a result, Medicaid becomes the primary payer for the child, resulting in costs that could be avoided. These costs can be significant, especially for premature infants. Neo-natal intensive care unit charges for a high-risk infant can easily surpass $500,000 in claim spend.
In response, HMS has developed an innovative program called PremiumAssistance+ that focuses on Medicaid members who are expecting a child. It can be deployed as a standalone service or as an add-on to an existing Health Insurance Premium Payment (HIPP) program.
PremiumAssistance+ follows a mother’s journey from pregnancy to birth, identifies coverage for the newborn and enrolls the infant in commercial insurance. The service identifies commercial health plan coverage before claims are ever submitted to Medicaid, and delivers value in four ways:
- Pre-emptive identification. Our continuous monitoring process catches high impact coverage and health events, before high-cost Medicaid claims are incurred. We pre-emptively monitor members for changes in coverage or health status and proactively identify non-typical premium assistance opportunities.
- Cost-benefit calculation. It predicts claims-related costs for high-cost conditions and compares them with premium payments, using historical claims costs and artificial intelligence.
- Multi-channel communications. Members are kept in the loop through phone, mail and digital outlets. These outreach campaigns motivate members to enroll in premium assistance.
- Full operational support. HMS provides end-to-end operational support, from identification to communication, enrollment and payment processing.
Medicaid payers appreciate PremiumAssistance+ because it reduces their medical claims liability and generates cost savings. They only pay wrap-around costs such as co-pays, co-insurance and deductibles.
Members experience a streamlined commercial insurance enrollment process for their newborns. Increased access to benefits and provider networks boosts member satisfaction levels.
Data Access, Streamlined Enrollment, and Enhanced Coordination Make the Difference
PremiumAssistance+ requires “Paid Claims Files” on a weekly basis, which captures claims further upstream. Accelerated access to data means there is more time to act on claims and generate more savings for Medicaid payers.
If HMS identifies through PremiumAssistance+ that a member has access to employer coverage, the member is notified that their newborn is a candidate for that plan and provided the benefits of enrolling them. This minimizes the likelihood of missed savings opportunities. By expediting the enrollment process, we also reduce member abrasion.
We also partner with client resources, such as case workers, to obtain valuable information like pre-authorization data. Enhanced coordination between parties leads to greater savings.
It differs from traditional HIPP programs because it pre-emptively monitors members for changes in coverage or health status and it proactively identifies non-typical premium assistance opportunities such as COBRA enrollment, newborns on commercial plans and direct-buy plans.
In addition to Maternal Health, opportunities exist for organizations to generate more savings through PremiumAssistance+. HMS has also developed similar programs for high-cost populations like individuals with chronic health conditions. To learn more about how your organization can start reducing Medicaid costs, feel free to contact us.