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Managed Care Programs
Medicaid Managed Care
Multi-stakeholder benefits decisions where employer groups, brokers, and members must align on coverage and cost.
Centene
Molina Healthcare
UnitedHealth
Elevance
Inside this journey
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Pre-Discovery
Align the room on outcomes, decision process, and constraints before deeper discovery.
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Stakeholder Alignment
Confirm decision roles, procurement timeline, evaluation criteria, and what ‘good’ looks like for each agency stakeholder.
Alignment Questions
What's Top of Mind for Your Medicaid Program?
- What's the single biggest priority for your Medicaid program right now?
- Which populations or geographies are you most focused on improving in the next 12 months?
- How urgent is progress on this priority from your perspective?
- What concrete change or signal would make you feel we’ve made meaningful progress in 12 months?
Are We Settling for Imperfect Networks?
- How many members silently can't reach essential care because the network looks adequate on paper but fails in practice?
- Which of these access gaps are you seeing most frequently?
- Which specific counties, ZIPs, or provider types are repeatedly failing access standards?
- How do you currently measure real-world access beyond provider directories (examples: secret shopper, appointment availability, member-reported access)?
- How long has the gap between measured adequacy and real access persisted in the areas you named?
Who Really Decides (and Who's Just Along for the Ride)?
- If the contract were awarded tomorrow, whose approval or influence would make or break implementation?
- For the top 3 stakeholders you selected, what does 'good' look like for each—what metrics, timelines, or assurances do they need to sign off?
- Are there informal influencers we should know about (for example, provider associations, advocacy groups, or federal reviewers)? Which ones and how do they sway decisions?
- Describe a recent internal alignment failure or near-miss—what happened, who pushed back, and what was the outcome?
- From initial technical recommendation to final sign-off, what is your usual internal decision timeline?
When the Money Talks, What Follows?
- What hidden funding rules or reporting constraints have forced you to change procurement scope or timeline in past procurements?
- Which funding or reporting constraints carry the most weight in your evaluation criteria?
- Tell us about a time funding or reporting requirements materially changed which vendor or model you selected. What shifted and why?
- How open is your procurement process to alternative payment models (APMs), pilots, or phased risk approaches?
Where Do Data and People Drop the Ball?
- If you trace a member's journey from enrollment to outcomes today, where do you lose visibility or trust?
- Which systems, vendors, or teams own the problematic data flows you named?
- How often do these data issues lead to reporting failures, audit findings, or operational emergencies?
- Describe one concrete example where a data breakdown directly affected care management, payment, or member experience and what you did to contain it.
- What would need to change to give you confidence in near-real-time visibility (people, technical feeds, SLAs, governance)?
How Much Risk Are You Comfortable Passing On?
- If a vendor underperforms on the highest-cost members, are you more likely to escalate, renegotiate, or accept outcomes—and why?
- Which KPIs do you expect to be tied to financial remedies or corrective actions?
- What types of financial or contractual guarantees are acceptable in your procurements (examples: withholds, shared savings/losses, liquidated damages)?
- How quickly do you expect a remediation plan to be implemented and show measurable improvement after a KPI breach?
- Share a past example where remedies were enforced (or not). What worked, what didn't, and what would you do differently?
If Everything Worked—How Would Members' Lives Be Different?
- Imagine your highest-need members are consistently improving—what concrete member experiences change first (access, continuity, outcomes, dignity)?
- Choose one population (e.g., SMI, SUD, LTSS recipients) and list the three measurable outcomes that would convince you the program works for them.
- How would provider behavior or network composition need to change to sustain those outcomes?
- Who inside your agency would celebrate these changes—and who might resist them? Why?
- Which stakeholder or external partner would be the most important advocate to ensure these outcomes are durable?
What Would Make You Say 'Yes' Without Sleepwalking Into Risk?
- What non-negotiable terms, evidence, or artifacts would make you comfortable awarding a multiyear capitated contract tomorrow?
- Which specific artifacts do you routinely require during evaluation (pick all that apply)?
- When in the procurement process do you expect to see technical proof-of-concept, pilots, or end-to-end data tests?
- What governance structure and meeting cadence would you demand post-award to manage performance and risk?
Ready to Move From Talk to Measurable Change?
- After this conversation, what is the single most important decision or next step you'd like from our team?
- What deliverable from us in the next two weeks would be most useful for your internal evaluation?
- Who from your team should be included in follow-up technical sessions (names, roles, and decision authority)?
- What timeline for a technical deep-dive or site visit would be acceptable to you?
- Are there any immediate red flags, political constraints, or non-negotiable needs we must know before designing a proposal?
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Current State Mapping
Document existing Medicaid operations, gaps in network adequacy, care management workflows, data flows, and failure modes.
Current State
Opening: Tell Us Where You’re Starting From
- In one short paragraph, how would you describe your current Medicaid managed care landscape today (contract types, populations covered, geographic scope)?
- Which enrollment model(s) do you operate now?
- Which beneficiary groups are included in your managed care contracts today?
- Who on your team is typically the point person for operational discussions with an MCO (title/role)?
- How confident are you that your current contracts and operational model give your agency the visibility you need?
Where the System Is Leaking — what keeps you up at night?
- If you had to name the single most worrying access or quality gap in your program today, what would it be and why?
- Which provider shortages feel most critical in your state right now?
- Where do you see network adequacy failing most often (rural counties, specific regions, certain specialties, or populations)?
- Tell us about a recent incident or trend that highlighted an access or care quality failure. What happened, who was affected, and how long did it take to detect?
- How do these gaps emotionally land with your leadership and impacted communities (frustration, political pressure, fear of audit, other)?
Who Really Decides 'Good' — and Is Everyone Aligned?
- Do different agency stakeholders have conflicting definitions of success for managed care outcomes, and what is the most consequential disagreement?
- Which stakeholders must be satisfied for a procurement to move forward (select all that apply)?
- What non-negotiable procurement criteria do you expect an MCO to meet (network size, behavioral health capacity, rural provider plan, data interoperability, financial strength, other)?
- How do political and budgetary cycles constrain what you can realistically require of MCOs (short procurement windows, budget cuts, legislative priorities)?
- Which timeline do you need us to respect for alignment and decision-making?
Walk With Us Through a Member’s Day — where do handoffs break?
- Pick a representative high-need member type (e.g., child with complex chronic condition, adult with SMI and SUD, elderly dual-eligible). Briefly describe a typical day and where the system fails them.
- Which parts of the member journey see the most frequent delays or errors?
- Describe how your care management workflows are currently structured (state-run, delegated to MCOs, shared), and where accountability blurs.
- When a high-risk member needs cross-sector services (housing, behavioral health, substance use treatment), how are referrals tracked and closed today?
- How often do you see member churn or misalignment in eligibility causing service interruptions, and what is your current mitigation approach?
Data Highways and Dead Ends — tell us where the data stops
- If your data systems had to pass a 'fitness to manage care' test, where would they fail first and why?
- Which data sources are reliable and timely for operational decision-making today?
- What are your biggest pain points with data handoffs to MCOs (latency, formatting, matching, consent, vendor portals)?
- How do you measure data quality now (key indicators like completeness, timeliness, accuracy), and what thresholds do you consider unacceptable?
- Who owns fixes when a data feed fails—a state team, the MCO, or a vendor—and how quickly are issues typically resolved?
When Things Break: known failure modes and local workarounds
- What recurring operational failures do you see (e.g., high claim denial rates, provider contract delays, incomplete encounter submissions), and which is most damaging?
- For each failure you named, what temporary workarounds are in place, and what is the human or fiscal cost of those workarounds?
- How long does it typically take from first report of a failure to full remediation?
- Which failure modes trigger formal escalation to leadership or federal partners?
- What internal metrics or dashboards are most helpful when diagnosing operational failures?
Snap Your Fingers — what would change everything?
- If you could lock in three measurable improvements in 12 months, what would they be (be specific and include target thresholds)?
- Which of those targets would be judged by external parties (legislature, CMS, advocates) versus internal leaders?
- What trade-offs would you be willing to accept to reach those improvements faster (narrower network, phased rollout, pilot populations) — and which trade-offs are unacceptable?
- How would you like to see success measured and reported (metrics, cadence, public dashboards, narrative reports)?
- Which acceptance criteria would make you comfortable signing off on an MCO-delivered solution (e.g., appointment waits < X days, claims submission latency < Y days)?
Red Flags and Non-Starters — what would make an MCO unacceptable?
- What are the absolute deal-breakers that would disqualify an MCO from consideration?
- Which minimum capabilities must an MCO demonstrate before contracting (select all that apply)?
- Do you require past performance examples from similar states or are local/regional references acceptable?
- What minimum technology or interoperability standards must be met (e.g., specific APIs, CCDA support, real-time eligibility)?
- How important is demonstrated success with vulnerable populations (e.g., SMI, SUD, duals) in your evaluation weighting?
Practical Next Steps — what do you want us to do next?
- Which type of discovery or validation would you prefer next: rapid technical deep-dive, joint site visits, pilot program, or written capability assessment?
- What specific artifacts or access will we need from you to run a meaningful discovery (data extract samples, provider directories, claims test files, stakeholder interviews)?
- Who will be the required owners on your side for a 60–90 day discovery (names/titles and availability windows)?
- What is a realistic timeline for decision milestones (e.g., discovery complete, pilot start, procurement next steps)?
- Finally, what would make you feel confident that an initial engagement with an MCO is worth your agency’s time?
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Outcome Discovery
Define target outcomes, measurable success signals, procurement evaluation priorities, and constraints tied to federal/state funding and reporting.
Discovery Questions
Starting Point: What Are We Solving Together?
- What single outcome — above all others — would make this contract a clear success for your agency?
- Which internal stakeholders care most about that outcome and why?
- How have you historically measured progress against that outcome (specific measures or data sources)?
- What recent events, audit findings, or policy changes made this outcome a priority now?
- If we could show an early signal of success within 90–180 days, what would you want it to be?
If Everything Keeps Looking the Same, What Will Break Next?
- Which downstream consequence worries you most if outcomes don't improve?
- Which measurable signals would indicate we’re on a failing trajectory before it becomes a crisis?
- Which populations would suffer first or most (e.g., SMI, children in foster care, dual-eligibles)?
- How would continued underperformance affect your relationship with CMS or your state budget office?
- Tell us about a recent example where a missed target had tangible consequences — what happened and how did it feel to your team?
- On urgency: is this a 'fix now', 'fix this procurement', or 'monitor and improve over time' priority?
What Does Winning Actually Look Like — Beyond the Scorecard?
- When you picture a Medicaid member whose life has tangibly improved because of this contract, what changed for them?
- Which three KPIs would convince you the MCO is delivering real value (list in order of importance)?
- Which equity or access indicators must be explicitly tracked (e.g., by ZIP, race/ethnicity, SDoH)?
- Which targets are non-negotiable vs. aspirational (please list non-negotiable targets and timelines)?
- Which outcomes would you accept being measured initially by proxies (short-term signals) versus final outcomes (claims-based, lagged measures)?
Metrics That Matter: Signals You Can Trust
- Are your current performance measures giving you real visibility or just comfort that 'something' is being tracked?
- Which data sources do you consider reliable for monitoring performance (select all that apply)?
- How timely do you need these data streams to be (pick the minimum acceptable cadence)?
- Which measures currently lag, are noisy, or are frequently disputed during reviews?
- Would you accept interim dashboards and rapid-cycle analytics in lieu of fully validated reports during the first 6–12 months?
- What level of data validation and audit trail do you expect before you’ll act on an MCO-reported signal?
Money, Match, and Must-Haves: Funding Constraints That Shape Everything
- If federal or state funding rules forced a single prioritization, what gets protected and what gets cut?
- Which funding or regulatory constraints are most likely to limit design choices (select all that apply)?
- Are there statutory or budgetary timing constraints (fiscal year, legislative windows) we must design around?
- How much flexibility does procurement allow for re-allocating savings to new programs (e.g., social supports)?
- Describe any pending audits, budget shortfalls, or legislative pressures that would constrain risk-bearing or incentive models.
Evaluation Day: How Will You Pick a Winner?
- What legacy rule or implicit preference do you think most skews procurement decisions today — and are you open to changing it?
- Which evaluation criteria will carry the most weight in your scoring (select up to three)?
- Do you require pass/fail thresholds on any dimension (e.g., network adequacy, behavioral health capacity)? If so, list them.
- How will demonstrations, pilots, or conditional awards factor into final selection?
- Who has final sign‑off and what are their three non-negotiable concerns at award time?
- How important are innovations (e.g., SDoH investments, value-based arrangements) compared with baseline compliance and price?
Tradeoffs You're Willing to Make (and Those You Aren't)
- If forced to choose one priority for the next contract term — access, cost containment, or quality improvement — which should win and why?
- Which compromises are acceptable (for example: slower network expansion for stronger provider performance)?
- Which tradeoffs are absolute no‑go (list specifics)?
- Would you consider a phased rollout or targeted pilot (geography or population) to balance delivery risk with ambition?
- What is your tolerance for penalty-based vs. incentive-based performance levers?
Reporting & Compliance: The Small Print That Can Sink a Contract
- What reporting deadline or compliance obligation would you consider a contract showstopper if missed?
- Which reports are mission‑critical for CMS/state (select all that apply)?
- What submission cadence and SLA windows are minimally acceptable for key reports?
- How do you currently validate encounter/claims completeness and timeliness?
- Describe the remediation steps you expect when a report is late or data quality fails (escalation path, penalties, corrective action).
- Are there specific audit or documentation standards (e.g., record retention, PII controls) the MCO must meet beyond baseline?
Governance & Decision Rhythm: Who Moves the Needle?
- If a key KPI began deteriorating tomorrow, who do you want in the room first and what authority should they have?
- What governance cadence do you prefer for performance review (select all that apply)?
- How do you distinguish between decisions that require full state approval versus operational discretion by the MCO?
- Who are the decision-makers, advisors, and implementers we should map into a RACI for performance issues?
- What form of reporting (dashboard, narrative exec summary, raw data extracts) is most likely to spur action from your leadership?
Next Steps & Early Signals: What Would Give You Confidence to Proceed?
- What concrete proof points would make you comfortable awarding a contract within 30–60 days?
- Which early deliverable from the MCO would reduce your perceived risk most (choose one)?
- How important are references and site visits compared to documented KPIs and operational demos?
- Are you open to contracting models with shared savings or downside risk tied to specified KPIs?
- Realistically, what is your ideal timeline from final selection to contract execution and go‑live?
- What would be a reasonable first milestone you’d require within 30 days of contract signing?
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Solution Experience
Translate state priorities into realistic scenarios showing how the MCO will deliver network adequacy, manage high-need members, and meet reporting requirements.
Experience Workshops
- Solution Experience Kickoff — Context & Alignment
- Network Adequacy Scenario Walkthrough
- High-Need Member Journey Simulation
- Reporting, Compliance & Audit Scenario Validation
- Solution Experience Executive Validation & Sign-off
- MCO to provide sample encounter/claims files, a data lineage map, and a draft reporting SLA within 3 business days.
- MCO to deliver a sample network adequacy dashboard and provider capacity roster for the scenarios.
- State to confirm acceptance thresholds for appointment wait-times, provider-to-member ratios, and telehealth substitution rules.
- If gaps exist, MCO to provide a recruitment/contracting timeline and interim access measures within 5 business days.
- State Current State for High-Need Management
- Prove the MCO's operational ability to identify and manage high-need members end-to-end.
- Obtain state validation on care pathways, escalation SLAs, and expected KPI improvements.
- Identify pilot cases or cohorts for a live proof-of-concept if requested.
- MCO to supply de-identified sample case packets and mapped care pathways for review.
- State to confirm KPIs and thresholds for success (e.g., % reduction in avoidable ED visits) for each journey.
- Schedule a follow-up case review meeting to track initial pilot outcomes or adjustments.
- Current State: Data & Reporting Gaps
- Prove the MCO can deliver required reports and data within the state's timelines and accuracy thresholds.
- Agree on reconciliation processes, SLAs, and remediation timelines for any discrepancies.
- Identify any system integrations or data extracts the state must provide and schedule their delivery.
- Current State Snapshot
- State to confirm required report elements, acceptable tolerance levels for accuracy, and preferred delivery formats.
- If gaps are found, MCO to provide a time-bound remediation plan with milestones and owner assignments.
- Reconfirm Current State & Consequences
- Secure executive-level validation that scenario proofs meet or define path to meet acceptance criteria.
- Obtain commitment on next commercial and operational steps toward mutual commit and deployment.
- Establish governance, owners, and timelines for outstanding gaps and escalation.
- Produce a one-page acceptance summary signed by both parties that lists accepted scenarios, KPIs, and open gaps with owners.
- Schedule mutual-commit meeting to finalize commercial terms and confirm deployment readiness activities.
- Create a risk register with owners and initial mitigation steps for items needing remediation prior to go-live.
- Produce a single-sentence current-state definition that all participants validate.
- Surface and quantify the top consequences that make the problem urgent.
- Agree the one-sentence future-state outcome to be proven by every scenario.
- Lock the scenario list, required evidence, and owners for follow-up sessions.
- State to provide one-sentence current-state statement and supporting evidence (utilization, complaint counts, audit findings).
- MCO to draft one-sentence future-state outcome tied to measurable KPIs and share within 48 hours.
- Both parties to confirm scenario list and deliverables with owners and delivery dates.
- Restate Network Current State
- Demonstrate, with state-supplied data, that the MCO can meet access standards in targeted scenarios.
- Obtain explicit state validation or a prioritized gap list for network remediation.
- Agree on measurable network adequacy KPIs and reporting cadence tied to contract terms.
- Consequence Mapping
- Consequence: Utilization & Budget Impact
- Consequence: Access, Cost & Compliance Risks
- Review Agreed Future State & Success Signals
- Consequence: Funding, Audit & Compliance Risk
- Scenario A — 90-Day Encounter & Claims Reconciliation
- Scenario A — Rural Primary Care Access
- Journey A — Complex Chronic Multi-morbidity
- Define Target Future State
- Summary Walkthrough of Scenario Proofs
- Decision & Acceptance Criteria Confirmation
- Journey B — Behavioral Health + SDOH Instability
- Scenario B — Quality Measure Submission and Corrective Action
- Scenario B — Specialty Access (SMI / SUD / Pediatrics)
- Select & Scope Scenarios
- Prework & Evidence Checklist
- Proof Artifacts & SLAs
- Clinical & Ops Proofs
- Next Steps Toward Mutual Commit and Deployment Readiness
- Operational Proof Points
- Validation & Remediation Plan
- Open Risks, Escalation & Governance
- Validation: Audit Simulation Outcome
- Validation and Acceptance Decision
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Solution Scope
Define covered services, care coordination modules, provider network commitments, quality metrics, reporting deliverables, and acceptance criteria.
Scope Configuration
- Provider Contracting and Credentialing
- Rural Provider Recruitment and Incentive Programs
- Operate 24/7 Nurse Advice Line
- Deliver Complex Case Management for High-Acuity Members
- Provide Behavioral Health Crisis Response Services
- Coordinate Substance Use Disorder Treatment Placements
- Administer Pharmacy Benefits and Prior Authorizations
- Provide LTSS Care Coordination and Waiver Management
- Operate Maternal & Child Home Visiting Program
- Coordinate SDoH Referrals and Community Resource Navigation
- Manage Hospital-to-Home Transitions of Care
- Operate Member Services Call Center
- Administer Grievances and Appeals Processes
- Deliver Population Health Analytics and Regulatory Reporting
Scope Questions
Provider Contracting and Credentialing
- What provider types must be included in the initial network?
- What network adequacy standard should the MCO meet (time/distance or state-defined thresholds)?
- How many existing provider contracts will transfer to the MCO at go-live?
- Do you require expedited credentialing or provisional enrollment pathways?
- What credentialing turnaround time should be guaranteed?
- Are there specific payor enrollment, taxonomies, or state provider ID requirements we must adhere to?
Rural Provider Recruitment and Incentive Programs
- Which rural geographies or designations are priority for recruitment?
- Which incentive types should be included in the program?
- What is the target number of new rural providers to recruit in the first 12 months?
- Will telehealth be used to augment or substitute in-person services in rural areas?
- Do you require integration of recruited providers into the state provider directory and public access dashboards?
- Describe known barriers to rural recruitment (workforce, broadband, transportation, credentialing) we should plan for.
Operate 24/7 Nurse Advice Line
- Is 24/7 clinical triage required or are extended business hours sufficient?
- Do calls need multi-language support and which languages are required?
- Is integration with the MCO CRM/EHR for call documentation required?
- What average answer/response time SLA should be met?
- Should the advice line schedule appointments, coordinate transport, or directly dispatch services?
- Which reporting metrics do you require (call volume, dispositions, escalations, follow-up outcomes)?
Deliver Complex Case Management for High-Acuity Members
- Which member cohorts are in-scope for complex case management?
- What case load ratio is expected for care managers (cases per FTE) for each cohort?
- Which care coordination activities must be included (care planning, home visits, medication management, BH coordination)?
- Is secure access to state clinical systems and claims/encounter data required for case managers?
- Which outcomes/KPIs must be tracked for complex case management (ED visits, admissions, member-reported outcomes)?
- Is in-person outreach required in rural/remote settings and at what frequency?
Provide Behavioral Health Crisis Response Services
- Which crisis response modalities are required?
- What target response time is required for mobile crisis teams?
- Should crisis services be available 24/7?
- Do crisis services need formal integration with 911/law enforcement or community first responders?
- Which populations are prioritized for crisis services (youth, SMI, SUD, general adult)?
- What reporting and outcome measures are required for crisis interventions (stabilization rates, subsequent ED usage, diversion metrics)?
Coordinate Substance Use Disorder Treatment Placements
- Which levels of SUD care must be covered (outpatient, IOP, residential, detox, OTP/MAT)?
- Do you require guaranteed placement within defined timeframes for urgent referrals?
- Is transportation or lodging support required to facilitate placements?
- Must the MCO provide recovery support services (peer support, housing navigation, employment supports)?
- What documentation and prior authorization requirements should be supported for placement approvals?
- Are formal partnerships required with certified providers, OTPs, or state SUD programs?
Administer Pharmacy Benefits and Prior Authorizations
- Will pharmacy benefits be managed by an internal PBM, external PBM, or state-run arrangement?
- Do you require real-time benefit checks and formulary decision support at point-of-prescribing?
- Which drug classes or workflows should trigger prior authorization?
- What turnaround times are required for standard and urgent prior authorizations?
- Are formulary exception, step therapy, or clinical pathway protocols required?
- What pharmacy utilization and spend reporting is required for regulatory and contract compliance?
Provide LTSS Care Coordination and Waiver Management
- Which LTSS programs or waivers are in scope (HCBS waivers, I/DD, PACE, NF services)?
- Is provider network development for home health and HCBS providers required?
- What processes are required for waiver slot management and eligibility redetermination?
- Are person-centered planning and independent assessment processes mandated in contract?
- Which performance metrics for LTSS care coordination must be tracked (service delivery timeliness, member experience, re-institutionalization)?
- Is coordination with state waiver case managers, Area Agencies on Aging, or MCO LTSS teams required?
Operate Maternal & Child Home Visiting Program
- Which populations should be prioritized for home visiting (pregnant, postpartum, infants, high-risk families)?
- What visit frequency and intensity are expected for the program (standard schedule, high-intensity, custom)?
- Are specific evidence-based home visiting models required or preferred (e.g., Nurse-Family Partnership)?
- Must home visiting data integrate with Medicaid perinatal benefits and maternal health reporting systems?
- Is workforce training, cultural competency, and maternal mental health support required for home visitors?
- What maternal and infant outcome measures must be collected (e.g., postpartum visit rates, breastfeeding, immunizations)?
Coordinate SDoH Referrals and Community Resource Navigation
- Which social needs domains should be screened and managed (housing, food, transportation, utilities, legal, employment)?
- Do you require closed-loop referral capability to track referrals to community-based organizations?
- Is a specific technology platform for SDoH screening and referral required or preferred?
- What escalation paths are required for high-risk SDoH cases (care manager follow-up, community partner escalation, emergency services)?
- Are performance measures required for referral completion, time-to-service, and outcome impact?
- Please list priority community partners, vendors, or referral platforms you expect to be included.
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Mutual Commit
Finalize commercial terms, performance guarantees, KPI thresholds, reporting cadence, governance, and remedies for nonperformance.
Agreement Modules
- Master Services Agreement (MSA)
- Statement of Work (SOW)
- Commercial Terms & Rate Schedule
- Service Level Agreement (SLA)
- Performance Guarantees & KPI Matrix
- Reporting, Audit & Data Deliverables
- Data Use Agreement (DUA) & Business Associate Agreement (BAA)
- Network Adequacy & Provider Commitments
- Governance & Oversight Charter
- Acceptance Criteria & Go‑Live Readiness Checklist
- Corrective Action & Remediation Plan
- Termination, Transition & Exit Plan
- Change Order & Amendment Process
- Insurance, Bonds & Financial Assurance
- Acceptance Payment & Holdback Schedule
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Deployment
Operationalize rollout with readiness checks, enablement, and outcome validation.
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Pre-Deployment Readiness
Confirm data exchanges, encounter/claims readiness, provider contracts, staff training, and escalation paths are in place for go-live.
Readiness Questions
Starting Together: A Quick Snapshot of Where We Are
- Who will be our day‑to‑day operational contact, the executive sponsor, and the contract acceptance signatory? Please list names, roles, and best contact method.
- What is your targeted go‑live date and how fixed is it?
- How would you rate your agency’s overall deployment readiness right now?
- Which internal teams must be actively coordinated in the first 90 days (select all that apply)?
- Are there other concurrent projects, legislative deadlines, or events that could divert resources during launch? Please describe.
- What are the top three success criteria that must be true on Day 1 versus within the first 90 days?
If the Pipes Clog on Day One, Who Feels It First?
- If automated data feeds (encounters, eligibility, pharmacy) stopped flowing on day one, what is the first operational or member impact you would expect—and who would be most affected?
- Which data exchanges are mission‑critical for day‑one operations?
- Across those mission‑critical exchanges, which best describes the current state of mappings and transformations?
- How frequently are test and staging datasets refreshed to mirror production during integration cycles?
- Who (name/role/unit) owns monitoring and incident response for each interface?
- Have you documented failure modes and automated alerts for delayed/dropped feeds? If yes, what’s been tested?
Where Money, Rules, and Reality Collide: Claims & Encounters
- If a material batch of claims were delayed or lost for 30 days, what would the financial and programmatic consequences be?
- Which claims and encounter submission modes will be used at go‑live (select all that apply)?
- Which payer/clearinghouse/vendor systems will receive claims first? Please list system names and versions where known.
- What is your planned cadence for end‑to‑end claims reconciliation during early life support?
- Approximately what percent of your projected monthly claims volume has been simulated or passed in testing to date?
- Describe your denial triage and correction loop for the first three months—who fixes things, how quickly, and how are root causes addressed?
Providers: Contracts, Coverage, and the Real‑World Network
- If a significant provider group in a rural or high‑need region is not contractually active at go‑live, what happens to access, payments, and your compliance posture?
- What percent of critical specialties (behavioral health, SUD, SMI supports, LTSS) have fully executed contracts?
- Do you have contingency access plans for provider gaps (e.g., temporary enrollments, telehealth networks, emergency panels)?
- Who manages provider credentialing and contract activation and what is the current backlog (counts/timelines)?
- How complete and verified is your provider directory (fields: NPI, location, panel status, hours, languages)?
- What provider communications and training are scheduled pre‑go‑live for billing, care coordination, and escalation procedures?
Can Member Operations Hold the Line When Things Spike?
- If member contacts spike 3x on day two (eligibility questions, access issues, denials), how would your operations absorb and resolve that volume without escalating to grievances?
- What is your member services staffing model at launch?
- What percentage of member services staff have completed role‑based training on the new rules, scripts, and escalation protocols?
- Which systems will member services use to verify eligibility, benefits, and view care plans (please list systems/versions)?
- How will grievances and appeals be triaged, tracked, and reported during the first 90 days?
- What rapid‑response steps are preplanned when a member issue trends (e.g., medication access, transportation failure)? Who executes them?
Audit, Reporting, and Compliance — Can We Produce the Paper Trail?
- If a federal or state reviewer requested a complete, auditable set of month‑one encounters and the transformation log tomorrow, could you provide it and explain every correction?
- Which reporting submissions are critical in the first 180 days (select all that apply)?
- How automated is your report generation, validation, and certification pipeline?
- What SLAs do you require for correcting invalid encounters/claims once discovered?
- Who owns data governance and where is the canonical store for encounters/claims?
- Describe your planned monitoring approach for the first 90 days (dashboards, thresholds, alert routing and owners).
What Would Let You Sleep at Night? Priorities, KPIs, and Next Steps
- If you could guarantee one single outcome at go‑live to avoid political, financial, or clinical fallout, what would you choose?
- Which three KPIs should we monitor daily for the first month to measure deployment health (select up to three)?
- What is your escalation governance — who convenes the war room, and what is the cadence for leadership updates?
- Are there pre‑approved remediation budgets, contractual penalties, or thresholds that would trigger specific actions we need to plan for?
- What approvals or signatures will move an item from 'in remediation' to 'accepted'—please list roles and handoff criteria.
- What is the single next step you want the MCO to take in the next 7 days to increase your confidence in deployment readiness?
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Deployment Enablement
Schedule tasks, coordinate state and MCO teams, onboard providers, and execute the rollout with clear sequencing and owners.
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Validation Checklist
Run end-to-end tests for claims, reporting, member services, grievances/appeals workflows, and document remediation until acceptance criteria are met.
Validation Checklist
Getting to Know Your Priorities
- In one short paragraph, what are the top three outcomes your agency must secure from the next MCO contract?
- Which member populations and geographies are highest-priority for improvement in the next contract?
- Which 2–3 priorities will most influence scoring or decision-making (select up to three)?
- Who will be the operational point-person for day-to-day MCO engagement (role/title)?
- What recent success or improvement in your Medicaid program would you most want a new MCO to replicate or scale?
Are You Settling for 'Good Enough'?
- How confident are you that contractual network adequacy and access targets today translate into real, usable access for members?
- Tell us about a situation where administrative measures suggested adequacy but members or providers experienced access barriers — what was the disconnect?
- Which provider types or specialties are hardest to staff in rural or underserved regions right now?
- How long have those access gaps existed in the most affected areas?
- When access problems surface, how does it typically feel for your staff and the community — frustrated, politically risky, administratively heavy, or something else?
Where Patients Fall Through the Cracks
- Where in your current care continuum are members most likely to experience avoidable harm, poor coordination, or dropped handoffs?
- Which specific workflows produce the most grievances, adverse events, or high-cost escalations (select all that apply)?
- Share a recent case or pattern that revealed a systemic failure — what went wrong, and what was the downstream impact?
- How quickly are these failure modes detected today, and who typically identifies them?
- What specific data or signals are missing today that would have flagged the problem earlier?
Imagine You Could Flip the Script
- If you could eliminate one recurring failure in your Medicaid delivery within 12 months, which would it be and why?
- What measurable indicators would convince you that this problem is solved (select up to 4)?
- What realistic targets would you set for those indicators in Year 1 after contract start?
- Who are the political and programmatic stakeholders whose visible buy-in would make success meaningful (select all that apply)?
- What trade-offs or short-term sacrifices would your agency accept to achieve that outcome (e.g., upfront investment, narrower panel, new processes)?
The Red Lines: Constraints You Can't Cross
- Which federal, state, statutory, or political constraints are absolute deal-breakers for any proposed MCO approach?
- Which reporting deliverables — frequency and format — are non-negotiable for your agency?
- Are there procurement rules that limit creative contract structures (for example, fixed scoring frameworks, prohibitions on gainshare, or required procurement attachments)? Please describe.
- How much latitude does your agency have to pilot non-traditional models (value-based arrangements, directed payments) within the contract?
- If a proposed performance model required supplemental state funding or waiver approvals, what approvals would be needed and how long do those processes typically take?
How Decisions Really Get Made
- Who truly decides which MCO wins — and what informal or political signals (not on the RFP) most often tip the scale?
- Which formal evaluation components and relative priorities drive scoring in your procurement (select all that apply)?
- Which external reviewers or advisory groups will provide input (and when) during evaluation?
- Describe a procurement outcome in the last 3 years that surprised vendors — what non-obvious factor changed the result?
- What timeline and approval gates should vendors plan for from proposal submission to award and contract signing?
What Would Make You Say 'Yes'?
- Beyond price, what single commitment or capability from an MCO would make you confident enough to award a multi-year contract?
- Which performance guarantees or remediation mechanisms do you consider critical (choose up to three)?
- For Year 1, which KPI categories must be monitored and reported (select all that apply)?
- What reporting cadence and delivery format would keep your team informed without creating unnecessary burden?
- Operationally, what does acceptance at go‑live look like to you (specific thresholds or capabilities you require on Day 1)?
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Success
Review outcomes against KPIs, confirm continued compliance and member experience improvements, and maintain a shared channel for issues and enhancements.
Success Reviews
- Quarterly KPI & Outcomes Review
- Compliance & Regulatory Assurance Check-in
- Member Experience & Grievances Review
- Issues, Enhancements & Shared Channel Governance
- Continuous Improvement & Performance Guarantees Review (Executive Steering)
Issues & Enhancements
- Define an escalation path that ensures executives are briefed on sustained or material failures.
- Provide a compliance evidence bundle for open audit items within agreed timeline.
- Schedule a pre-submission review 10 business days before next state/CMS report due date.
- Maintain a rolling register of regulatory risks with assigned mitigations and RAG status.
- Opening and Scope
- Identify systemic drivers of grievances and prioritize fixes that reduce member harm and compliance risk.
- Agree on concrete member experience targets and monitoring cadence to ensure improvements are sustained.
- Ensure coordination between member services, care management, and provider relations for case closure and prevention.
- Deliver root-cause analysis for top 3 grievance categories and proposed remediation within 7 business days.
- Implement a two-week rapid-response pilot to reduce call center abandonment in targeted regions.
- Publish a monthly member experience dashboard and distribute to state and executive stakeholders.
- Review Shared Channel Purpose & SLAs
- Ensure the shared channel is the single source of truth for operational issues and that all high-severity items have owners and deadlines.
- Prioritize enhancements that materially improve KPIs or reduce recurring operational costs/risk.
- Opening and Objectives
- Update the shared channel backlog with owners, priority, SLA and expected close dates for all open items.
- Implement a weekly status digest to be sent to state and MCO leadership summarizing high-severity items.
- Create a prioritization rubric for enhancements that ties requests to KPI impact and regulatory urgency.
- Executive Summary of Performance
- Obtain executive alignment on any financial remedies and approve remediation or investment budgets as required.
- Approve a focused set of strategic actions that will demonstrably drive sustained KPI improvement.
- Reset governance cadence or escalation rules if current mechanisms are not preventing repeated breaches.
- Produce a reconciled financial impact statement for any triggered remedies and proposed settlement approach.
- Deliver a targeted investment plan (scope, budget, expected KPI impact, timeline) for executive approval within 10 business days.
- Schedule the next executive steering checkpoint with pre-reads distributed 3 business days in advance.
- Confirm which KPIs met, exceeded, or missed targets and quantify the operational and member impact.
- Establish a prioritized remediation plan with assigned owners, deadlines, and measurable acceptance criteria.
- Ensure transparent cross-party visibility into root causes and corrective actions.
- Deliver a one-page KPI variance report highlighting root causes and financial/member impact within 5 business days.
- Owner(s) to submit time-bound remediation plans for each missed KPI with metrics for success.
- Update shared KPI dashboard with weekly refresh cadence and access granted to state leads.
- Meeting Purpose & Regulatory Context
- Validate that all high-risk audit findings have active remediation plans with documented evidence paths.
- Confirm readiness for upcoming state/CMS submissions and identify any blockers.
- Agree on a governance cadence for compliance attestations and who will be notified on material changes.
- Executive KPI Dashboard Review
- Triage Open Issues
- Member Services Metrics
- Audit Findings & Corrective Action Status
- Financial & Remedy Review
- Variance & Root Cause Analysis
- Grievance & Appeals Trends
- Strategic Improvement Investments
- Prioritize Enhancements Backlog
- Encounter & Claims Data Integrity
- High-Risk Member Cases & Care Management Impact
- Governance & Escalation Adjustments
- Communication & Escalation Protocol
- Reporting Deliverables & Timelines
- Member Outcomes & Experience Signals
- Regulatory Risks & Mitigations
- Member Satisfaction & Outcome Signals
- Risk & Escalation Assessment
- Approvals, Decisions & Next Executive Checkpoint
- Owner Commitments & Timeline Review
- Decisions, Owners & Timelines
- Improvement Actions & Communication Plans
- Action Assignments & Evidence Requirements
- Wrap-up and Next Checkpoint