Cost Containment Initiatives Implemented in the Last Three Years

Alaska	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Narrow provider networks • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: N/A
Alabama	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Case management for high-cost enrollees • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers)
Arizona	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Centers of excellence – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
California	• Benefit Design Initiatives: – Value-Based Insurance Design – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Narrow provider networks – Risk-based contracts with health care providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Behavioral health management strategies or benefit carve out
Colorado	• Benefit Design Initiatives: – Value-Based Insurance Design – Reference Pricing • Provider Payment and Network Design Initiatives: – Centers of excellence – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease), – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Behavioral health management strategies or benefit carve out – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Connecticut	• Benefit Design Initiatives: – Value-Based Insurance Design – Right to Shop • Provider Payment and Network Design Initiatives: – Narrow provider networks – Tiered provider networks – Centers of excellence – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Annual spending growth target or cap – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Delaware	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Centers of excellence – Risk-based contracts with health care providers – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Case management for high-cost enrollees – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Florida	• Benefit Design Initiatives: – Right to Shop • Provider Payment and Network Design Initiatives: – Centers of excellence – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Georgia	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Case management for high-cost enrollees • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Hawaii	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Iowa	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Centers of excellence • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: N/A
Idaho	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Risk-based contracts with health care providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Illinois	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: N/A • Other Initiatives: N/A
Indiana	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: N/A
Kansas	• Benefit Design Initiatives: – Value-Based Insurance Design – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) – Right to Shop • Provider Payment and Network Design Initiatives: – Tiered provider networks – Centers of excellence – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Annual spending growth target or cap – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Kentucky	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Centers of excellence – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Louisiana	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Narrow provider networks – Tiered provider networks – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Massachusetts	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Narrow provider networks – Tiered provider networks – Centers of excellence – Risk-based contracts with health care providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate) – Behavioral health management strategies or benefit carve out
Maine	• Benefit Design Initiatives: – Value-Based Insurance Design – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Narrow provider networks – Tiered provider networks – Centers of excellence – Risk-based contracts with health care providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Annual spending growth target or cap – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Michigan	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Minnesota	• Benefit Design Initiatives: – Value-Based Insurance Design – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Tiered provider networks – Centers of excellence – Risk-based contracts with health care providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Missouri	• Benefit Design Initiatives: – Right to Shop • Provider Payment and Network Design Initiatives: – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Mississippi	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Centers of excellence – Pegging provider reimbursement to a reference price, such as a percentile of the Medicare rate (sometimes referred to as “reference pricing”) – Risk-based contracts with health care providers – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Case management for high-cost enrollees – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Montana	• Benefit Design Initiatives: – Reference Pricing – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Centers of excellence – Pegging provider reimbursement to a reference price, such as a percentile of the Medicare rate (sometimes referred to as “reference pricing”) – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Case management for high-cost enrollees • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers)
North Carolina	• Benefit Design Initiatives: – Reference Pricing • Provider Payment and Network Design Initiatives: – Pegging provider reimbursement to a reference price, such as a percentile of the Medicare rate (sometimes referred to as “reference pricing”) – Risk-based contracts with health care providers – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Nebraska	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Narrow provider networks – Tiered provider networks – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: N/A • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
North Dakota	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Risk-based contracts with health care providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
New Hampshire	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
New Jersey	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Tiered provider networks – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification) – Procurement strategies (e.g., reverse auction, invitation to negotiate)
New Mexico	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Centers of excellence – Risk-based contracts with health care providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Nevada	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Narrow provider networks – Centers of excellence – Direct negotiation or contracting with providers • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
New York	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Direct negotiation or contracting with providers • Utilization Management Initiatives: N/A • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Ohio	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Oklahoma	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: N/A
Oregon	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Tiered provider networks – Centers of excellence – Pegging provider reimbursement to a reference price, such as a percentile of the Medicare rate (sometimes referred to as “reference pricing”) • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: `–` Annual spending growth target or cap
Pennsylvania	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: – Narrow provider networks – Centers of excellence • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Rhode Island	• Benefit Design Initiatives: – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Centers of excellence – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: N/A
South Carolina	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Centers of excellence – State sets a site-neutral fee schedule – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: N/A
Tennessee	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Narrow provider networks – Centers of excellence – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Annual spending growth target or cap – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Texas	• Benefit Design Initiatives: – Right to Shop • Provider Payment and Network Design Initiatives: – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home) – Risk-based contracts with health care providers – Centers of excellence • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Utah	• Benefit Design Initiatives: – Reference Pricing – Right to Shop • Provider Payment and Network Design Initiatives: – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Narrow provider networks • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Behavioral health management strategies or benefit carve out – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Virginia	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Procurement in 2018 for FY2020
Vermont	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Washington	• Benefit Design Initiatives: – Value-Based Insurance Design • Provider Payment and Network Design Initiatives: – Centers of excellence – Risk-based contracts with health care providers • Utilization Management Initiatives: – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) • Other Initiatives: – Annual spending growth target or cap – Procurement strategies (e.g., reverse auction, invitation to negotiate)
Wisconsin	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: N/A • Other Initiatives: – Annual spending growth target or cap – Procurement strategies (e.g., reverse auction, invitation to negotiate)
West Virginia	• Benefit Design Initiatives: – Value-Based Insurance Design – Reference Pricing – Wellness incentives that result in an increase or decrease in premiums or cost-sharing based on enrollee’s achievement of a target health metric (i.e., BMI, cholesterol level) • Provider Payment and Network Design Initiatives: – Centers of excellence – Pegging provider reimbursement to a reference price, such as a percentile of the Medicare rate (sometimes referred to as “reference pricing”) – Risk-based contracts with health care providers – Direct negotiation or contracting with providers – Primary care-based initiatives (e.g. worksite clinics, near worksite clinics, DPCs, patient-centered medical home), Narrow provider networks • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers) – Auditing of claims (e.g., utilization auditing, payment accuracy, fraud identification)
Wyoming	• Benefit Design Initiatives: N/A • Provider Payment and Network Design Initiatives: N/A • Utilization Management Initiatives: – Case management for high-cost enrollees – Disease management for enrollees with one or more chronic conditions (e.g., diabetes, heart disease) – Prior authorization and other methods of utilization management (e.g., primary care physician referral for specialty care) • Other Initiatives: – Price transparency initiatives (e.g., member shopping tools – plans/providers)