How Home Care Providers Establish Credibility With Managed Medicaid Plans

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Home-based care providers — both big and small — are struggling at the negotiating table with Medicare Advantage (MA) plans. But they’re also struggling in negotiations with managed Medicaid plans.

While MA plans and managed Medicaid plans operate a bit differently, providers are having similar issues with both. Proving value to health plan leaders is central to those issues.

“There’s more data readily available to them when it comes to Medicare Advantage, and I think payers are a little bit more well-trained and comfortable with how certified home health is connected to the rest of the health care system,” Care Advantage CEO Tim Hanold told Home Health Care News. “That’s versus Medicaid, which feels exploratory to them. In one way, I think there is a bigger hurdle there because you’re probably doing more credibility work upfront.”


The Richmond, Virginia-based Care Advantage is a home-based care company that has 38 locations throughout Virginia, Maryland, Delaware, Washington, D.C., and North Carolina. The company offers both personal care and home health care services.

Showing value

One of the things that will always hurt providers at the negotiating table is a lack of density in a market. They need to prove that they can make an impact on spend for managed Medicaid plans to listen.

Though selling home care to Medicaid payers might include more legwork at the beginning, there tends to be less “noise” past initial conversations, Hanold said.


However, those initial conversations – which include that “value” topic – tend to be the biggest part of negotiations.

“Whenever it comes to personal care, LTSS, HCBS, big payers and providers are still figuring out the overall core value,” Hanold said. “The first part of this is developing credibility and understanding that this is a real part of the health care system and it’s not just a staff, bill and pay shop. I feel like a lot of my initial conversations with payers are about the care we provide in the home and how it can have real positive outcomes on things they care about.”

The things they care about, according to Hanold: keeping members out of the ER, out of the hospital, and reducing costs overall.

“There’s also value in just the information that can be captured for the MCO in the home,” he said. “Medicaid sees that and, [from my experience], is truly interested in the consumer and member experience.”

One of the biggest value-adds that Care Advantage leans on when in conversation with managed care organizations is the consistency that comes with having one caregiver for a member over an extended period of time.

A member having a consistent caregiver has been shown to improve patient outcomes and satisfaction.

“The satisfaction — both from a member and the MCO — can often be tied to the individual who is providing the most face time with a member or a patient,” Hanold said. “Something we’re still getting our arms around with the MCOs is that with caregiver consistency — there’s a really long-term bond and trust that is coming together. We haven’t really tapped into those positive behaviors and habits that we can enable with that caregiver in the home over a period of time. Because trust really matters. Trust scales.”

Getting beyond the friction

Perception also plays a big role in the success of a provider-payer relationship in the managed Medicaid world.

“Payers in the provider space are seen as the bad guys,” Jamie Swann, director of GBD Special Programs at Anthem, told HHCN. “They’re seen as the people that don’t want to give you what you want, what you need and the ones who are going to hold up your pay. So it can be really difficult sometimes to form those relationships because — almost out of the gate — it’s seen as this contentious relationship.”

Swann’s role is within Anthem Health Keepers, which is a part of Elevance Health (NYSE: ELV).

Keeping the patient at the center of negotiations is a good start, she said. But there also needs to be give and take on both sides. Anthem and Care Advantage, for instance, have had a harmonious relationship.

“The individual that we’re all caring for should be at the center of everything,” she said. “Here at Elevance, we have quality incentive programs for our agencies so that we can make some quality payments when they’re providing quality care. There is an opportunity for us to work together to put a little more money in the agency’s pockets, especially working with those Medicaid individuals. And to improve outcomes for the sickest individuals. But it takes both sides. It takes us coming to the table and it takes the agencies coming to the table.”

In 2021, Swann helped seal a risk-based deal with Care Advantage to better support Anthem’s Medicaid long-term support services members in Virginia.

“I know that when I have a member that can’t seem to find an agency, I can usually reach out to Care Advantage and we can work something out,” Swann said. “So, that’s really helpful for us.”

Companies like Elevance Health see the value of personal home care in the larger health care space, but working with those providers is a less simple equation.

“What makes it difficult now is if you talk about traditional home health, you go in, change a wound vac and go out — it’s very cut and dry,” Swann said. “But when you talk about personal care providers, or even private duty nursing, those individuals are not providing a traditional medical service, so it gets more difficult to enter into a value-based arrangement.”

The ability to deliver valuable data as a provider makes the equation more clear, however.

“Sharing data is an incredibly important component of building trusting credibility with the MCO,” Hanold said. “To them, they need to be able to look and say, ‘This is a willing provider and here they are tracking this information.’ Our job is obviously to continue to build credibility and show the sophistication of our care delivery system.”

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