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Driving Innovation and Transformation in Medicare, Medicaid and Other Government Health Programs
U.S. Medicaid and Medicare enrollment and federal spending continue to grow, proving the need for enhanced services. In fact:
- 1 in 5 US citizens are covered by Medicare
- 1 in 2 US children are covered by Medicaid
- 1 in 5 Medicare Advantage enrollees is in a Special needs plans (SNP)
- 2025 Medicaid enrollment figures represent an 18% decline from total Medicaid/CHIP enrollment in March 2023, but are still 8% higher than enrollment in February 2020, prior to the pandemic
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Medicaid AI
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Prepare your Business for Medicaid and Medicare Growth
Our team has the credentials to be your trusted partner and deliver services across the Medicaid and Medicare continuum
Medicaid Strategy: Synthesize outputs from market and capabilities assessments to determine optimal Medicaid strategy and/or build a compelling business case and operational roadmap for market entry
Procurement & Implementation: Understand the bid and procurement landscape, develop and execute state-specific bid strategies, design and build a comprehensive implementation plan, execute implementation and track ongoing performance against quality benchmarks
Population Health Management (PHM) & Value-Based Care (VBC): Incorporate digitally-enabled PHM capabilities and VBC models into operations to drive medical cost efficiencies and improve outcomes
Ongoing Operations & Compliance: Drive effective monitoring and oversight of your plan to sustain high quality operational and compliance performance, leveraging and enhancing core middle office functions
Rate Advocacy: Analyze complex datasets to develop capitation rates in compliance with actuarially sound practices and regulatory requirements
Member Care & Quality Improvement: Deliver end-to-end support across medical value management, high-performing provider networks, and digital/customer experience to improve outcomes and member engagement
Differentiated & Compliant Operations: Design and execute financial and operational turnaround strategies, including operating model diagnostics, redesign, and transformation
Innovative, Tailored Products: Provide actuarial and data-driven insights, RFP and bid support, and strategic guidance on product design and market positioning
Strategic Growth Initiatives: Develop flexible, end-to-end strategies for marketing, member conversion, and pre- and post-merger integration
Our team is ready to partner with you to prepare for and implement upcoming H.R.1 provisions, from enrollment changes to Rural Health Transformation strategies
Regulatory Translation & RFP Strategy: Interpret provisions to inform future RFP / bid response strategies, translating compliance requirements into clear solution needs.
Capability & Readiness Assessment: Analyze existing infrastructure and processes to understand readiness and identify gaps / solution needs.
Cross-functional Governance Design: Establish clear decision rights, escalation paths, and coordination to support compliance and timely execution.
Data Platform Modernization: Modernize and integrate data platforms to enable interoperability, improve data quality, and support state reporting and oversight requirements.
Advanced Analytics & Monitoring: Implement real-time monitoring, reporting, and predictive analytics to track performance, risks, and compliance indicators.
AI Adoption Strategy: Define and operationalize AI use cases to automate workflows, enhance insights, and improve scalability while meeting regulatory expectations.
Workflow Optimization: Redesign end-to-end workflows to reduce friction, improve efficiency, and support new compliance and reporting requirements.
Care Model & Program Transformation: Transform care delivery and care management programs to improve outcomes while meeting evolving regulatory and value-based care expectations.
Member & Provider Engagement Strategy: Design digital and multi-channel engagement strategies to educate, activate, and support members and providers through regulatory and program changes.
Network Assessment and Value-based Care Strategy: Evaluate provider network adequacy, performance, and alignment with value-based care (VBC), new regulatory requirements, and evolving care delivery models.
Vendor Evaluation & Selection: Identify and recommend technology and service vendors that align with provision requirements, rural health funding, interoperability needs, and long-term transformation objectives.
Rural Health Transformation Readiness and Roadmap Design: Evaluate clinical, operational, financial, and digital capabilities to determine opportunities and define a phased, outcomes-driven roadmap that aligns with initiatives with funding requirements, community needs, and goals.
Rural Health Model Implementation: Design and implement scalable care delivery, workforce, and operating model changes that expand access, improve quality, and strengthen rural financial viability.
Our team regularly supports pro bono engagements with community organizations and smaller centers, including a recent project with a residential behavioral health center focused on improving its services and care offerings. Please reach out if you are interested in pursuing a social impact engagement.
- Detailed RFP Competitor Analysis
- Automated Reporting and Interactive Dashboards
- Competitor Benchmarking
- AI-Driven Contract Reviews
- Detailed Medicaid Requirements Matrix
- Provider Credentialing Support
- Business Development & Capture Strategy Support
- Bid Response Support and First-draft Generation with Proposal CrafterTM
- Implementation Planning and AI-enabled Delivery
- Program Mobilization and PMO Support
- Compliance Readiness and Preparation
- Implementation Readiness Review Support
- Mock Audit and Live Audit Readiness
- Change Management Strategy
- Medicare Intelli-Hub
- CMS Universe Analyzer
- Product and Market Simulation
- PBP Analytics and Landscape Model
- MA Plan Landscape Evaluator
- Recovery and Resilience
- Mock Audit and Live Audit Readiness
- Short-term Stars & Quality Turnaround Playbooks and Execution Support
- Long-term Stars & Quality Capability and Strategy
- Operating Model Redesign and Governance Transformation
- Our dedicated Government Health Team of over 200+ members has extensive breadth and depth of experience and includes actuaries, strategists, operations executives, analytics, product / pricing, clinicians / medical directors, quality and risk / regulatory experts.
- We have actively supported more than 25 state Medicaid plans, providing assistance across business development efforts and the full Medicaid bid cycle, Our experience spans a wide range of populations, including general Medicaid, Foster Care, LTSS, and D-SNP. We have served in diverse roles, from capture director through implementation lead.
- Over the past five years, we have completed numerous engagements and supported numerous Fortune 25 companies as well as National, Multi-state, and Regional Plans in their Government Programs journeys, enabling successful outcomes and improved service to their members.
- 100+ years of payer experience across leadership
- 25+ state programs
- 15+ Duals engagements
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Where to find us:
We attend and sponsor many industry events / conferences throughout the year. Want to meet up in person? Reach out to connect!
Contact us
Nichole Montgomery
Partner, Government Programs Implementation & Operations Transformation, PwC US
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