Medicaid

Our expertise and flexible solutions help ensure Medicaid health plans can offer comprehensive, sustainable care for Medicaid beneficiaries.

The complexity of Medicaid beneficiaries, combined with the variability of programs and requirements between each state, requires payors to partner with an experienced pharmacy benefit manager (PBM) that can expertly navigate this changing market and help deliver cost savings and quality care. 

Cost Management Strategies

CVS Health cost management solutions are tailored to meet the unique needs of government payors. Our customizable tools provide flexibility to reduce costs and improve quality, including a variety of Medicaid formulary templates and pharmacy networks with state-specific designs that meet regulatory requirements. Using our utilization management expertise we have designed a clinically-effective formulary with Medicaid-specific criteria for prior authorization, step therapy, and quantity limit programs.

Our adherence programs and market-leading engagement capabilities also play an essential role in helping contain cost and population health management. The Health Engagement Engine (HEE) enables real-time, actionable information at the point of care for at-risk members to provide personalized outreach, help improve therapeutic outcomes by enhancing adherence, and reducing adverse drug events and associated payor costs.

Client Success:

2% 
savings realized for medicaid client with 1 million members by deploying narrow networks across multiple states
$90M 
combined savings for three clients who adopted our formulary template in combination with other programs
165% 
improvement in member utilization of MinuteClinic by state plan
~80% 
cost savings between MinuteClinic visits compared to Emergency Room visits
  • 2% savings realized for medicaid client with 1 million members by deploying narrow networks across multiple states
  • $90M combined savings for three clients who adopted our formulary template in combination with other programs
  • 165% improvement in member utilization of MinuteClinic by state plan
  • ~80% cost savings between MinuteClinic visits compared to Emergency Room visits

Innovative Strategies for Quality Performance Improvement

Medicaid quality programs can be complex. Because Medicaid is a joint federal-state program, the Centers for Medicare and Medicaid Services (CMS) allows each state to establish its own priorities, measures, and incentives. This has resulted in significant variations in the types of programs, and number and types of measures used from state to state.

Overall, incentives tied to quality are increasing, with many states reporting planned expansion or addition of pay-for-performance initiatives.2 This means payors have a significant opportunity to earn incentives through incremental performance improvements. With our range of assets, we are uniquely positioned to help payors execute strategies to meet performance goals, including flexible clinical programs designed to help improve key Healthcare Effectiveness Data and Information Set (HEDIS) measures. 

The breadth of our state-level experience gives us unique insight into various state programs. Our dedicated Medicaid Quality Consultative Services team partners with clients to develop innovative solutions to reach and engage members, expand access to care, increase performance, and maximize quality incentives. 

CVS Health Programs Support Medicaid Quality Measures

Measure Pharmacy Advisor Condition Alerts Minute Clinic HealthTag CVSH Total Solutions
Controlling High Blood Pressure (CBP) Yes Yes Yes Yes Yes
Comprehensive Diabetes Care: Hemoglobin A1C (HbA1c) Testing Yes Yes Yes
Comprehensive Diabetes Care: Hemoglobin A1C (HbA1c) Poor Control Yes Yes Yes
Medication Management for People with Asthma (MMA) Yes Yes Yes Yes
Antidepressant Medication Management (AMM) Yes Yes
Cervical Cancer Screening (CCS) Yes Yes
Flu Vaccinations for Adults Age 18 and Older (FVA) Yes Yes Yes
Breast Cancer Screening (BCS) Yes Yes
Adult Body Mass Index Assessment (ABA) Yes Yes Yes
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) Yes Yes
Adolescent Well-Care Visit (AWC) Yes Yes
Measure Pharmacy Advisor Condition Alerts Minute Clinic Health Tag CVSH Total Solutions
Controlling High Blood Pressure (CBP) Yes Yes Yes Yes Yes
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing (HA1C) Yes Yes Yes
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control Yes Yes Yes
Medication Management for People with Asthma (MMA) Yes Yes Yes Yes
Antidepressant Medication Management (AMM) Yes Yes
Cervical Cancer Screening (CCS) Yes Yes
Flu Vaccinations for Adults Age 18 and Older (FVA) Yes Yes Yes
Breast Cancer Screening (BCS) Yes Yes
Adult Body Mass Index Assessment (ABA) Yes Yes Yes
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) Yes Yes
Adolescent Well-Care Visit (AWC) Yes Yes

† Customized HealthTag Messages

Our ability to tailor programs to client-specific objectives is what sets us apart, allowing us to support other target initiatives including Managed Long Term Service and Supports, and Aged, Blind, and Disabled.

Consultative Decision Support, CMS and State Government Presence

Both state and federal health care policy decisions can have enormous impacts on government payors and their members. Our Government Services team works closely with the executive branch, Congress, governors, and state legislatures in all 50 states, Puerto Rico and the District of Columbia, closely monitoring any proposed policy reform. Our advocacy efforts are focused on helping policy makers understand payors' perspectives about solutions to some of the toughest challenges around health care cost, quality and access.

We also provide extensive analytic support for actuaries through our Medicaid Rate Guide reporting package.

Considerations for your business
  • Have you implemented the right cost management strategies to ensure you are maintaining optimal Medical Loss Ratio to operate effectively in a Value-Based Payment Model?

  • Are you developing strategies and innovative solutions to take advantage of the Mega-Rule (Medicaid and CHIP Managed Care Final Rule)?

  • Are you adequately supporting your Aged, Blind and Disabled groups in managing their complex conditions?

Have a question about our Medicaid programs?

1. http://www.kff.org/medicaid/fact-sheet/medicaid-pocket-primer/  https://www.nytimes.com/2017/06/21/upshot/gop-health-plan-is-really-a-rollback-of-medicaid.html
2. http://www.kff.org/medicaid/report/implementing-coverage-and-payment-initiatives-results-from-a-50-statemedicaid-budget-survey-for-state-fiscal-years-2016-and-2017/

*versus a control group

CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

Unless otherwise noted, all data is from CVS Health Enterprise Analytics.