May 29, 2025 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions Incarcerated individuals often leave prison with complex health needs and little support waiting for them outside. Medicaid’s Section 1115 reentry waivers offer a chance to change that, but translating policy into impact takes more than paperwork. It requires strategic design, on-the-ground knowledge, and systems that don’t fall apart after the pilot phase. To help states navigate this terrain, Acentra Health convened a panel of Medicaid and corrections leaders from Washington, Arizona, and Michigan, states at the forefront of reentry innovation. Together, they shared lessons learned, pitfalls to avoid, and strategies that can scale nationwide to serve this at-risk population. The result? Five grounded insights that can help states turn reentry waivers into real-world results. Build a Data Foundation Early: Design with Evaluation in Mind All successful programs are built on clear goals and the ability to measure progress, as well as performance, over time. From the start, it’s important to think about how you’ll collect and use data. Not just to coordinate care, but also to assess what’s working (or not) at every point in the member’s journey. States like Arizona and Michigan are already investing in systems that track care before and after release. This helps them evaluate outcomes like ER use, medication continuity, and recidivism. As Vikki Wachino, Executive Director of the Health and Reentry Project (HARP), put it, “states are really eager to know if these efforts are working, and that means building evaluation plans early, not after launch.” Pro Tip: Before launching, map how data will flow across Medicaid systems, correctional health records, and MCOs both before and after release to set the stage for smoother coordination, stronger impact, and better outcomes. Account for Wide Variation in Facility and Community Readiness Facility readiness varies widely, from clinical s

May 8, 2025 – By Nilay Patel, Executive Vice President and General Manager, HealthTech Systems Across the country, Medicaid programs face growing demands for greater agility, stronger compliance, and better overall experience for the people they serve. In this environment, the state of Utah has emerged as a blueprint for what is possible when vision, technology, and strategic partnership align. Utah’s recent Centers for Medicare & Medicaid Services (CMS) certification of its modernized Provider Reimbursement Information System for Medicaid (PRISM) represents more than a technology achievement. It signals that the future of Medicaid systems is modular, data-driven, and built on thoughtful collaboration. Achieving CMS certification is a rigorous process that signifies the gold standard for clinical and operational excellence. Certification is not simply a milestone to reach. CMS certification is a federal vote of confidence that a state’s Medicaid Enterprise System meets the highest performance, security, and compliance standards. Earning that trust through transparency and integrity is critical in today's environment. PRISM was developed through close collaboration between Utah's Department of Health and Human Services (DHHS) and the Acentra Health team, with Acentra Health’s evoBrixSM platform to support key Medicaid functions such as provider management, claims processing, member eligibility, and financial reporting. The final CMS certification validates the last major release, which included claims and related modules, and completes a multi-phase rollout. And the results speak for themselves. Since August 2024, the system has maintained 99.5% production uptime and achieved a perfect record of error-free federal data submissions. These outcomes are critical benchmarks that protect data integrity and help avoid the compliance risks that can arise from reporting gaps. The larger story is about the intentional design choices and commitment to stewardship that made these results

Dec 6, 2024 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions Youth transitioning out of residential facilities face numerous challenges, including inadequate healthcare and social support. Justice-involved youth (JIY) are at high risk for poor health outcomes, recidivism, and struggles with reintegration into society. In recognition of these needs, the Omnibus Reconciliation Act of 2022 mandated that states receiving Medicaid funding must provide health and social risk assessments to JIY 30 days before and post-release. With a compliance deadline looming at the start of 2025, state agencies must act quickly and proactively to establish systems that meet these requirements. Understanding the Mandate: Why It Matters The federal mandate recognizes the need for continued support of the JIY population in order to help their successful reentry into society. However, for state Medicaid agencies, the mandate presents a complex challenge that requires specialized knowledge, collaboration, and, often, comprehensive support services. By proactively aligning with the 2025 federal mandate, enhancing assessments, and implementing coordinated aftercare services, states can offer targeted, tailored services to the JIY population and prevent their return to the justice system. State agencies should prioritize the following three initiatives to be successful: Understand Their Needs through Specialized Assessments Comprehensive support systems that include health risk assessments, case management, and coordinated care significantly reduce the risk of recidivism and offer these young individuals a better chance at a stable future. It's critical for your agency to deliver assessments that consider the immediate health risks and the social factors-such as housing and employment-that play a crucial role in long-term success. For example, Acentra Health uses an advanced care management platform and sophisticated analytics to seamlessly integrate health risk and

Nov 20, 2024 – By Verlon Johnson, Chief Government & Corporate Affairs Officer As always, Medicaid policy is shifting in ways that will profoundly impact state programs over the next few years. These mandates fall into four primary areas of focus: Justice-Involved Youth Services, Prior Authorization (PA) Modernization, Critical Incident Reporting, and Health Equity initiatives. Each mandate can significantly shape state Medicaid programs, and it is essential for Medicaid directors and state agencies to be vigilant and proactive in their preparations. Justice-Involved Youth Services and Reentry Care Federal mandates are placing new emphasis on ensuring care for justice-involved youth, particularly as they transition back into society. By January 2025, Medicaid programs must have processes in place for providing pre-release assessments, developing care management plans, and supporting the reentry process. State agencies should focus on creating robust assessment systems that prevent recidivism and ensure continuity of care. States should prioritize building systems that encompass both pre-carceral (before incarceration) and post-carceral (after incarceration) assessments and care plans. Oregon, for instance, is taking an active approach to implementing these services, focusing on reducing recidivism by maintaining continuous support. Prior Authorization (PA) Modernization The prior authorization process has long been a point of friction between healthcare providers and state Medicaid programs. The upcoming PA modernization mandate will focus on reducing provider abrasion and improving patient access to timely care. By January 2026, new business and technology standards will be required for the PA process, including the use of API integrations for provider access and peer-to-peer communications. State Medicaid agencies must invest in modernizing their IT systems to meet these regulatory requirements. CMS aims to streamline processes that previously caused delays, ensuring that ca

Oct 24, 2024 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions In today’s digital age, enhancing the client experience is key for any organization. It’s especially important in public health. State Medicaid programs are increasingly focused on delivering personalized, timely, and effective services. Better services drive improved health outcomes, higher beneficiary satisfaction, and enhanced organizational performance. One area that continues to demand a client-first approach is Medicaid eligibility assessments. This activity requires a strategic approach that harnesses human expertise and technology to maximize impact. Implementing a client-centered approach to service delivery can be challenging, especially for agencies serving diverse regions and unique communities. However, turning these challenges into opportunities is where the real impact begins. State agencies should adopt a top-down commitment to a comprehensive client experience program, training staff on cultural competency and client-centric concepts, and aligning each role to a client-first model. It's also crucial to keep a consistent focus on the client in organizational meetings and communications, and establish a recognition system that encourages and celebrates client-centric behaviors. With a structured, client-focused approach at every level, agencies can greatly enhance Medicaid eligibility assessments and overall service delivery. Recommendation 1: Understanding Client Journeys and Diverse Populations To become a truly client-centric organization, it's essential to "walk in the shoes" of your clients. Every interaction should be carried out with empathy and respect, and documenting client journeys provides key insights for better understanding their needs. By seeing things from the client’s perspective, your organization can align its focus accordingly. Additionally, understanding the diverse populations you serve through Social Determinants of Health (SDOH) and Healt

Sep 9, 2024 – By Nilay Patel, Executive Vice President and General Manager, HealthTech Systems With more than 74.6 million enrollees, Medicaid is one of the largest healthcare programs in the U.S. Yet, outdated systems pose challenges to meeting the growing demands of Medicaid populations. Today, Medicaid accounts for one-sixth of all healthcare spending and half of long-term care spending, making it a large share of state budgets.¹ This significant financial commitment underscores the critical need for efficient, modernized systems. Recognizing the limitations of its older infrastructure, the Utah Department of Health and Human Services decided to overhaul its Medicaid system completely. This effort, recently discussed at the 2024 Medicaid Enterprise Systems Conference (MESC), provided valuable insights into how Utah’s successful implementation could serve as a model for other states facing similar challenges. Ensuring Success Through Rigorous Testing & Certification One key step in Utah’s system overhaul was its rigorous approach to testing and quality assurance. The state implemented a multi-phase testing strategy – including parallel testing and user acceptance testing (UAT) – to ensure every aspect of the new system was thoroughly vetted before going live. Did you know? Utah’s testing process involved around 30,000 test scenarios. This thoroughness was essential to identifying and addressing potential issues early, minimizing disruptions during the transition. Utah executed a three-month soft launch period before the official go-live date to ensure a seamless transition. This phase involved extra validation, comparing the new system against the legacy system to verify all functions. This careful approach allowed Utah to identify and resolve discrepancies, ensuring a smooth rollout. Another key component of Utah’s success was the early adoption of CMS certification processes. By engaging with these processes early, Utah maintained alignment with federal requirements, ensu

Sep 3, 2024 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions An Expert’s Guide for State Medicaid Agencies Stakeholder engagement isn’t just a buzzword: it’s the starting point for any Medicaid agency seeking to make better, more informed decisions. Gathering and applying stakeholder feedback can ensure that an agency’s programs are effective, inclusive, and well-received. Stakeholder engagement requires frequent and consistent communication with the right contacts. However, this can be difficult for government employees juggling competing priorities or from states with large geographies, diverse and economically varied populations, or a mix of urban, rural, and suburban communities. These challenges have led to a growing trend: Many states are partnering with third-party organizations to help create and implement their health programs. This is especially true for large health assessment projects, where third-party experts are better equipped to have in-depth conversations with stakeholders and gather insights that can enhance operations, improve program performance, and ensure equity for all. Understanding the Value of Stakeholder Feedback Collecting and analyzing stakeholder data is essential to understanding the priorities and needs of a state's population and provider networks. Feedback from stakeholders provides valuable insights that can inform policy and program decisions, ensuring that initiatives are aligned with the community's needs. Stakeholder feedback helps identify gaps in services, areas for improvement, and potential innovations. For example, by engaging with healthcare providers and patients, state agencies can better understand the challenges faced in delivering and receiving care. This information can lead to higher member satisfaction as programs are tailored to address the growing needs and preferences of the community. Greater satisfaction can also lead to improved health outcomes and member experiences. Another cr

Aug 29, 2024 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions Strategies to Enhance Member Experience Through Proactive Communication & Cutting-Edge Support Solutions Effective customer service centers are vital for exceptional healthcare. When people have health concerns, the last thing they want to do is navigate a complex web of appointments, paperwork, and conversations. Medicaid members are no different. Unfortunately, Medicaid members often receive varying levels of customer service support, with mixed reviews on the effectiveness of the services. This can cause great frustration and be a barrier to getting members the help they desperately need. That’s why it’s essential that Medicaid agencies—especially in populous and diverse states like New York, Texas, and Florida—develop call centers that can respond to members quickly and effectively. Here are four ways your Medicaid agency can deliver better customer service—and better outcomes—to its members: Communicate Proactively Anticipate member needs and reach out before issues arise. These outbound communications can help address common questions and concerns, reducing the volume of inbound queries. Tip: Collect data about the most common questions and send communications about these issues to avoid confusion and increase awareness. Industry insight: According to CMS, proactive communication and outreach can significantly improve healthcare outcomes by ensuring members are well-informed and engaged in their healthcare plan. Improve the Capabilities of Customer Service Representatives Onboarding and training are essential for preparing customer service staff to handle the specific needs of Medicaid populations. Additionally, effective training reduces staff turnover by creating a knowledgeable workforce capable of resolving issues efficiently. This leads to better service delivery, reduced wait times, and fewer call transfers— increasing customer satisfaction. Tip: If calls about

Aug 27, 2024 – By Susan Baker, Executive Vice President and General Manager, Integrated Health Solutions Ensuring Fairness in Healthcare to Address Social Determinants of Health Health equity is essential in Medicaid administration. However, delivering on it can be especially difficult in states like New York, Texas, and Florida. These states have large and diverse populations and face unique challenges related to race, ethnicity, socioeconomic status, and geographic location. States facing these unique challenges are partnering with innovative organizations with deep expertise in Medicaid programs. Based on an examination of programs across 45 states in the US, success starts with: Address Geographic Diversity Medicaid programs must tailor their approaches to address these unique challenges presented by urban, rural, and suburban areas: Urban Areas: Focus on reducing overcrowding in healthcare facilities and improving access to preventive care. Rural Areas: Address the shortage of healthcare providers and improve transportation to medical services. Suburban Areas: Ensure healthcare services are accessible and affordable for low-income residents. States such as New York—comprised of urban, rural, and suburban areas—are in a particularly difficult situation. However, Medicaid programs that customize their strategies based on geographic needs see better health outcomes and higher patient satisfaction. Harness Local Knowledge & Language Support Many Medicaid recipients speak languages other than English. Implementing multilingual training programs and hiring bilingual staff can help bridge language barriers and improve patient satisfaction. Recruiting providers from your agency’s communities can also help build trust and lead to better health outcomes. Train Providers on Industry & Local Best Practices Proper training for healthcare providers and administrators is essential for delivering equitable care. Training should include: Cultural Competency: Understanding the cultural