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Newsletter Volume 15, Issue 7

Summary of this issue

Earlier this month I sent an update on what Mostly Medicaid is doing to help with the Medicaid response to COVID-19 (link to past issue). 

We have made substantial progress on our plan. 

Updates include: 

  • Our online Medicaid 101 course is now live and free
  • Job Services is now live and free
  • COVID-19 and Medicaid Curator is now live and free
  • Our virtual conference dates are set and registration is available
As you explore these new goodies, you will need a free account on our website (if you don't already have one).

In addition to these efforts, we also are releasing great new content on 2 topics not related to COVID-19. Our podcast series on Interoperability and Medicaid Buy in each have new episodes you can check out using the links below. 

New newsletter format
We have also revised our approach in the newsletter to be more long form so you can get more content and value all in one place. Along these lines, we are excited to include guest thought leadership pieces (like the ones from Dr. Craigan Gray and Amogh Rajan in this issue). Would love your nominations for these moving forward.

We still provide links out for more info, but are trying to provide a richer experience for newsletter readers. Would love your feedback on this change if you want to send me a note. 

-Clay F

P.S. I share the contact info for our team leads below. You can also reach me with or 919-727-9231.


Our Summer 2020 Virtual Conference is going to be huge! 

June 16-17 & June 23-24
  • 30+ speakers confirmed
  • Hear from Medicaid Directors, Health Plans and Private Sector Executives
  • Registration is completely free!
We will be sending out learning ovbjectives information for each session so you can prioritize your attendance times. 
Visit the conference landing page to Learn More/ Register
Sarai McDowell on our team is leading these efforts. You can also send her an email to or call her @ 901-730-2149
A note from Sarai

The Marketing Buzz

As we plan and organize our first ever conference (while drinking insane amounts of coffee), I've gotten the true pleasure of chatting with some of the coolest people in the Medicaid industry. They all agree on one thing - there's going to be loads of education at our conference. And that's our goal: for you to leave with your education tank full and running over; with new goals for yourself and team; to meet new people; and to perhaps leave with a fresh perspective on the Medicaid world. We'll get to hear from state agencies on what they're doing in light of COVID-19, tech firms that are helping communities still receive care, people making a difference. We are so excited to share with you these few days packed with rich information, sprinkled with some fun. I hope you'll join us and I get the chance to meet some more really cool people (virtually) in the Medicaid world. 

FREE Medicaid COVID-19 Curator Service is now live

As most of you have seen over these past 15 years, one of the things we do best is pull together a LOT of information and curate it for you. We used to share online Evernote notebooks of articles, etc, and recently we started provided our detailed outlines for all our Medicaid news shows in the show notes. In keeping with that, we are standing up a dedicated source of curated information on COVID 19. 

Access for the COVID-19 Curator service is completely free with a free account on our website. 
Access COVID-19 Medicaid Curator services with a free account on our website

New Podcasts Released!

Topic: Medicaid Buy In, State Health Marketplace Evolution and the Public Option

Our Critical Conversations in Medicaid series continues with a new topic: Medicaid Buy In, State Health Marketplace Evolution and The Public Option
Episode 1: Henry Chao
Henry Chao is Chief Technology Officer (CTO) at FEI Systems. As CTO, Mr. Chao leads FEI’s enterprise architecture activities. He guides solution development for both Federal and State Medicaid initiatives. In addition, he coordinates product alignment with FEI’s State and commercial health care business. Prior to FEI, Mr. Chao was the Deputy Chief Information Officer and Deputy Director of the Office of Information Services at the Centers for Medicaid & Medicare Services (CMS). In these roles, he was a key agency executive driving improvements and optimization of operational systems and effective change management. At CMS he also served as CTO...
Listen now
Episode 2: John Sweeney and Cheryl Gardner

John Sweeney
WEX Health

John Sweeney is a thought leader on the WEX Public Sector team, focused on connecting WEX innovation to evolving client needs in the Medicaid and health marketplace verticals. Prior to joining the WEX team, John served in various other healthcare technology roles throughout his 20+ year career, including nearly 10 years at IBM companies...

Cheryl Gardner
Gardner Strategies

Cheryl Smith Gardner is the founder of Gardner Strategies, a health policy and strategy company. Cheryl combines functional knowledge and experience in state health policy design with a notable background in strategic management and program administration. Her clients include state government agencies, technology firms, and policy shops....


Listen now

Topic: Interoperability

Episode 1: Dr. Don Rucker
Dr. Don Rucker, the National Coordinator for Health Information Technology, comes to the Office of the National Coordinator for Health IT (ONC) from the Ohio State University where he was Clinical Professor of Emergency Medicine and Biomedical Informatics and Premise Health, a worksite clinic provider, where he served as Chief Medical Officer...
Listen now
Episode 2: Lynda Rowe
Ms. Lynda Rowe is Senior Advisor for Value-Based Markets at InterSystems, and has for two decades held senior-level positions in health information technology. She was most recently an executive in the health market at Booz Allen Hamilton, where she led a number of consulting projects for the Centers for Medicare and Medicaid and the Office of the National Coordinator within HHS. She provided leadership for quality measurement, health information technology use and adoption...
Listen now
Episode 3: Kris Vilamaa
Kris has over nineteen years of behavioral health, health information
technology and health policy experience. Kris has led major state system transformations including planning for Medicaid Transformation,  development of new behavioral health treatment standards, service definitions and leading large information technology system implementations. He has worked with state and county health
departments, managed care organizations...
Listen now

Our Medicaid 101 course is now entirely FREE and live!

Learn the fundamentals of Medicaid in less than 1 hour

Learning outcomes

1- Understand the definition and basic scope of the Medicaid program

2- Become familiar with the requirements for eligibility

3- Become familiar with Medicaid program trends

CEU Credits: 1
3 Lessons
Register for free and take the course!

New Medicaid Industry Jobs

Our Free Job Services Tool is now Live!

We have completely revamped how we push out job listings to our audience. The new solution allows you to search across our jobs database and makes it easier to apply. 

New job listings added each week. 
Check out all the new job listings in the Medicaid industry!

A word from Kris

Kris Vilamaa is our Chief Growth Officer, and one of his passions is impacting outcomes for mental health and behavioral health programs.
“Parity isn’t Parity”

I am currently working on a parity study with a state Medicaid agency and it has again shined the light on the successes and failures of the Mental Health Parity and Addiction Equity Act (MHPAEA). While it has helped improve the situation to a degree, advocates are disappointed in what it has failed to do. States and plans are attempting to meet the letter of the law, but there are challenges. The law was oversold in what it can accomplish. There are obvious differences in how behavioral health and physical health services are reimbursed and how the payment structures for services work. Those are not eliminated by MHPAEA. If you understand the law and operate within the bounds it establishes you can continue to keep unequitable structures in place. MHPAEA deals primarily with limits, both quantitative (unit limits, annual limits and aggregate limits) and non-quantitative (prior authorizations, network adequacy, etc.), but what the law and regulations say is that you can’t be more restrictive in how you treat mental health and addiction services versus medical and surgical services. We need to take another look at parity and what we want to accomplish. More creativity is needed in the drafting of laws and regulations and a better understanding of the real opportunities for improvement will benefit all of us.

Get in touch with Kris
Send him an email to or call him @ (334) 220-7834. 

Guest Thought Leader: Dr. Craigan Gray

Dr. Craigan Gray is the Chief Medical Officer of Salient Management Systems, former NC Medicaid Director and long time member of the Mostly Medicaid family. 

Medicaid Expansion: States are Avoiding the Elephant in the Room--Waiting Lists  

In the mad rush to expand health coverage to over 28 million able-bodied individuals, Medicaid seems to have lost its original focus. The Medicaid program is failing those it was designed to serve leaving more than 650,000 actually needy people languishing on Medicaid waiting lists.[i]

Congress created the Home and Community-based (HCBS) Waiver program in 1981[ii]  Under this waiver states may choose to extend home and community-based services to beneficiaries that would potentially otherwise qualify for care in an institution or nursing home. The objective of the waiver is to allow a needy Medicaid beneficiary to receive the care they require for survival at home without being placed in an institution. Among other things, the program provided home health services, habilitation, adult day care, personal care services, and psycho-social rehabilitation to eligible individuals. Most of the eligibles are folks with spinal cord injuries, severe intellectual disabilities, traumatic brain injury, or dehabilitating developmental disabilities. This is the precise population that Medicaid was designed to support. These services were designed to keep people out of institutional care and at home.[iii]  

The HCBS waiver is usually operated through the states' Medicaid program. Since these are waiver programs, it is optional so states can limit enrollment. When the enrollment hits the designated capacity, individuals are placed on a waiting list. The problem is that for some individuals the wait can be years or, in the case of some New Mexico beneficiaries, decades.[iv]  In fact, nearly 250,000 eligible individuals languish on waiting lists in "Affordable Care Act" Medicaid expansion states. At the same time these states have added over eight million able-bodied individuals to their Medicaid rolls through program expansion.[v]

Perhaps more serious is the fact that over 21,000 waiting list deaths have occurred since expansion began.[vi] While it is true that many of the deaths would have happened anyway as individuals waited, the staggering number begs the question of how many could have been prevented were these people provided the support they needed.

Even now, states like North Carolina struggle over Medicaid expansion. Nonetheless, the argument seems to be based on ideological grounds while not even considering the financial obligation to the over 12,000 beneficiaries on the State's waiting lists. [vii]  In fact, Medicaid has gradually become a "catch-all, open-ended" welfare program rather than considering the original intent of focusing on the most vulnerable populations. Spending on the nondisabled population has now grown to over $157 billion annually, creating an almost 700 percent increase since the Affordable Care Act was passed.[viii]

The solution to funding the needy waiting-list population appears to be limited by the stratospheric growth of the Medicaid program for able-bodied individuals. Any change seems difficult because once an entitlement is in place, it is politically impossible to take it away. Nonetheless, a rational consideration of the work requirement for able-bodied recipients is reasonable. Our national objective is not to make healthy Medicaid recipients dependent on government welfare. Keep in mind that the Medicaid program is not the same program that started in 1965, since the original vulnerable population has expanded to include millions of well, able-bodied individuals that were never considered originally.[ix]

A rising national debt of $22 trillion should make controlling the Medicaid budget a national emergency. Managing fraud and abuse, applying high-powered analytics such as New York's Salient Interactive Miner (SIM), and confirming regularly appropriate eligibility is just the beginning of productive change. Obama-era regulations limiting the states' ability to frequently evaluate eligibility appears to be compounding the problem.

The well, able-bodied-adult expanded Medicaid population needs a more standard health insurance program. They do not require the "correct or ameliorate" standard designed specifically for the complex population Medicaid was originally designed to support. This is the population that is dying while waiting for the financing that the expansion population is consuming. Our policymakers and legislative leadership must move the elephant out of the room or it will take more that a big shovel to clean up the mess.

Craigan L. Gray, MD, MBA, JD



[i] Mary O'Malley Watts and MaryBeth Musumeci, "Medicaid Home and Community-bases Services: Results from a 50-state survey of enrollment, spending, and program policies." Kaiser Family Foundation (2018), http// Community-Based-Services.   

[ii] Section 1915 (c) of the Social Security Act.

[iii] Cliff Binder, "Medicaid's Home and Community-Based Services State Plan Option: Section 6086 of the Deficit Reduction Act," Congressional Research Service (2008).

[iv]  Nicholas Horton, "Waiting for Help: The Medicaid Waiting List Crisis, March, 2018,

[v] ibid

[vi] ibid

[vii] Community and Work Disparities: A Program of the ADA participatory Action Research Consortium,

[viii] Nicholas Horton, "Waiting for Help: The Medicaid Waiting List Crisis, March, 2018,

[ix] Medicaid Program History,

Guest Thought Leader: Amogh Rajan

 is a Product Manager at Carrot Health and leads the development and delivery of the Health Module- a product that analyses the intersection between SDoH risks & clinical outcomes.
Let’s go beyond the buzz: social determinants of health (SDoH) is a phrase that’s been repackaged by healthcare, for healthcare. The concept itself, however, is more than half a century old and was first introduced in the 1943 paper, “A Theory of Human Motivation,” by American psychologist Abraham Maslow.

The World Health Organization (WHO) Europe defined the Social Determinants of Health in 2003, and that version that has been greatly iterated on today. In the U.S., SDoH assessments did not begin to appear within healthcare workflows until 10 years after that in 2013. Highly generic but non-billable Z-Codes did appear around 1999 as a part of the transition from ICD-9 to ICD-10, but healthcare organizations are still trying to wrap their heads around what these really are and how addressing them improves health outcomes and reduces costs.

One thing must be clarified right off the bat: SDoH is not clinical; it’s social. It impacts clinical outcomes, but to approach it as another clinical protocol is a major blunder.

Broadly, SDoH is defined by WHO as “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.” Though this statement might seem obvious, its understanding is incomplete without a review of Maslow’s Hierarchy of Needs.
In his 1943 paper, Maslow introduced the concept of “The Hierarchy of Needs,” a theory he expressed in the form of a five-tiered pyramid. The five tiers represent hierarchical human needs. Human needs lower down in the hierarchy need to be satisfied for us, as humans, to even care about needs higher up in the hierarchy. The five tiers within this pyramid are:
  1. biological and physiological needs,
  2. safety needs,
  3. the need to feel loved,
  4. the need for self-esteem, and
  5. self actualization.
Applied to healthcare, this hierarchy translates into what’s described by the medical industry as SDoH. SDoH is not the “thing” but the thing that gets you to the thing. Here’s what we mean:

Self-Actualization is the highest level in Maslow’s pyramid, i.e. the “desire” to live a healthy life. Satisfaction of needs lower down in the hierarchy does not guarantee a healthy life but instead motivates the patient/member to utilize healthcare appropriately, to care for themselves, to take their medications on time and to live a long fulfilling life. Health plans and providers need to understand this and strive to address human needs lower in the hierarchy by getting more involved with their communities. By doing so, they uplift their community’s desire to improve their health and thus health outcomes. In this light, addressing SDoH is not the thing (improved health outcomes) but what facilitates the thing (desire to live a better life) that then leads to the thing (improved health outcomes).

By looking at these needs as basic human needs, health organizations will avoid the mistake of medicalizing SDoH. It will empower health organizations to go beyond the buzz and clinical protocols as embodied by a set of highly general ICD-10 Z-Codes and SDoH assessments.

Amogh Rajan is a Product Manager at Carrot Health and leads the development and delivery of the Health Module- a product that analyses the intersection between SDoH risks & clinical outcomes.
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