Unlocking Medicaid: Strategies for Health Tech Startups with Oystehr

Unlike government Medicare programs, Medicaid is generally administered at the state-level. For health tech start-ups interested in participation in state Medicaid plans, the enrollment and participation process differences may seem daunting.

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What is Medicare?‍

Medicaid refers to a state and federal-funded benefit plan under state administration. The program covers approximately eighty-seven million people and enrolls individuals within mandatory coverage for certain qualifying conditions or life situations such as low-income, qualified pregnancy, disabilities, and classification under predetermined poverty thresholds. The Affordable Care Act (ACA) created threshold calculations based on a person or family’s modified adjusted gross income (MAGI) to determine eligibility in most cases.

To save state funds and promote equity in efficient care, initiatives incentivize comprehensive, quality episode management without the fee-for-service mentality of traditional healthcare. High-volume, complex patient populations are the common denominator for Medicaid programs. In 2021, 41% of US births were from Medicaid beneficiaries. The New Jersey Perinatal Episode of Care currently operates under a three-year pilot phase to evaluate alternative payments for perinatal, labor, and postpartum care. The 60-day period is an episode of care for both maternal and infant management within the APM. Payment models exist across state programs and show markers of success. As of 2022 the majority of states had incentive or reform programs in place for Medicaid populations. These include Patient Centered Medical Home, ACA Health Home, ACO, and other defined programs to promote care quality. 

Medicaid - A place for venture?

As highlighted in a previous post, reforms to CMS Medicare programs were successful. These same reforms translate well to state programs, with some modification accounting for the variability and diversity of regulations around Medicaid participation and member management across states.

Healthtech startups can find room in existing arrangements to offer improved patient management in an effort to improve equity, control cost, and manage care. Most states emphasize behavioral health, chronic disease, and perinatal or birth quality incentives. Startups which offer services built around measure focus areas are uniquely positioned to engage with Medicaid-participating providers to see how they may potentially lend services to these populations.

Enrollment and Participation‍

A great starting point for enrollment across states is the CMS Medicaid state-by-state guide found here. CMS also publishes an additional page on specific provider requirement guidance for Medicaid. The Center for Connected Health Policy has further created a guide to Telehealth reimbursement policy. 

A startup could engage directly with providers in these arrangements, promoting services and the patient population it supports. Medicaid-participating practices have insight into patient management under a defined episode and could leverage services rendered by startups. These providers have an understanding of the complex reimbursement and incentive landscape of specific states. 
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A Powerful Tool for all Health Startups‍

Many APMs require a comprehensive view of patient management: they leverage HIEs, multisite EHRs, care coordination, and insurer claim data to understand and address care gaps, cost, hospital admissions, or outcomes. Care Coordination, post-discharge medication reconciliation, transitions of care (TOC), and patient quality metric fulfillment all depend to some extent on an exchange of data across platforms in order to be effective.

Oystehr connects APIs to health information exchanges to obtain - where appropriate and in accordance with legal requirements - a holistic view of patient status for quality and efficient care. These attributes all lend themselves especially well to startups looking for a lightweight, custom solution for their specific use cases.

Medicaid’s complex landscape is best understood by working with state plans and providers directly enrolled in their programs. The innovation space for Medicaid beneficiaries is established, significant, and purposeful. If your startup is interested in engaging in these types of programs, there are avenues to do so. 

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Interested in learning more about how Oystehr can accelerate and enable your startup practice? Contact us here.
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Frequently Asked Questions

1. What is the difference between Medicaid and Medicare?
   Medicaid is a state and federally funded program that provides medical assistance and health benefits to eligible individuals, primarily those with limited income, medical conditions, and specific life situations. Medicare, on the other hand, is a federal program that provides health coverage to individuals aged 65 and older, as well as certain younger people with disabilities.
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2. How do startups participate in state Medicaid plans?
   Startups interested in participating in state Medicaid plans, which may include managed care plans, can start by understanding the enrollment process, which varies from state to state. They can engage directly with Medicaid-participating providers and familiarize themselves with the specific requirements outlined by the Centers for Medicare & Medicaid Services (CMS).
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3. What are some focus areas for startups targeting Medicaid populations?
   Startups focusing on Medicaid populations often emphasize areas such as behavioral health, chronic disease management, and perinatal care to address health disparities and improve health outcomes. These sectors offer opportunities for startups to address critical needs within Medicaid populations and reduce medical expenses.
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4. How can startups leverage technology to support Medicaid programs?
   Startups can leverage technology solutions such as health information exchanges (HIEs), electronic health records (EHRs), and care coordination platforms to support Medicaid programs and manage medical bills and expenses. These tools enable startups to access comprehensive patient data and deliver tailored solutions for Medicaid patients and covered services.
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5. What are alternative payment models (APMs) in Medicaid programs?
   Alternative payment models (APMs) in Medicaid programs are payment structures that incentivize providers to deliver high-quality, cost-effective care while managing medical expenses. Examples include bundled payments, accountable care organizations (ACOs), and patient-centered medical homes (PCMHs), which aim to improve health outcomes and reduce health disparities among Medicaid beneficiaries.
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6. How can startups navigate the complex reimbursement landscape of Medicaid?
   Startups can navigate the complex reimbursement landscape of Medicaid by working closely with state Medicaid plans, managed care organizations, and providers to understand reimbursement requirements and covered services. They can also leverage resources such as the CMS Medicaid state-by-state guide and telehealth reimbursement policies to ensure timely payment for medical services rendered.
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7. What role does Oystehr play in supporting startups targeting Medicaid populations?
   Oystehr provides startups with a comprehensive solution for managing patient data, coordinating care, and improving health outcomes within Medicaid populations. By connecting APIs to health information exchanges and managed care plans, Oystehr enables startups to access holistic patient information for efficient and quality care delivery while minimizing medical expenses and disparities.