Utah Medicaid prepares for end of PHE and transition to PRISM


Boram Kim


The Utah Department of Health and Human Services (DHHS) continues to prepare for strategic changes to the state Medicaid program. 


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Utah Medicaid said the months leading up to and following the end of the public health emergency (PHE) will be critical to ensuring a smooth transition for members. It has developed a communication toolkit that outlines the department’s response to the expiration of continuous coverage provisions. 

DHHS will provide advance notice to members 60 days prior to the end of PHE and is making preparations to submit baseline eligibility data and a Medicaid redetermination plan to CMS before the PHE’s continuous coverage expires. 

Since her appointment in February, Medicaid Director Jennifer Strohecker has been focused on the members who will be impacted by the unwinding to transition them to CHIP or state exchange plans. 

“Utah did take advantage of [the PHE’s] provision to offer COVID-19 services to the uninsured, [as] they will lose their eligibility immediately when the PHE ends,” Strohecker said. “Also those who [are] over income, or perhaps they have another type of insurance, or other factors.

Those are the types of things we’re focusing on, is making sure that we’re planning and being able to establish review timeframes for people so that we’re minimizing the peaks and valleys of our work. We can just be planned on the back end of who we’re going to review over the 12 months, when we’re going to review them, and really get them set up on a nice schedule so that our staff is prepared.”

Her team is working on developing a live dashboard that will display the required Medicaid eligibility metrics and data for CMS as part of the state’s transition planning. 

Staff and stakeholder preparation is another area Strohecker has been focused on. 

DHHS is in the process of developing and implementing comprehensive training programs on eligibility and reimbursement.

The Department of Workforce Services (DWS) oversees Medicaid eligibility reviews and has been trained on the coming changes and transition protocols. 

DHHS will also transition to a new Medicaid Management Information System next year. The old system will be replaced by the Provider Reimbursement Information System Medicaid (PRISM), which aims to create an online cloud database for the state’s claims record. 

DHHS took the current system offline on Thursday for testing PRISM and plans to conduct a soft launch in January and a final provider access launch in April. Strohecker does not anticipate any impact on eligibility reviews from the testing and implementation of the new system aside from interface, as DWS and reimbursement have remained independent of each other. 

“[PRISM] will provide efficiencies to our providers who are submitting claims,” Strohecker said. “They can submit claims and see their adjudication in real time if they want to go straight through the system. It’s a huge benefit. They can still use a third-party processor if they want, but if they want to submit directly into this system, they can see a paid or denied claim and why that claim is denied [in] real time.

It also allows providers to submit prior authorization requests or requests for services that may be done through traditionally a faxed or paper method. This can all be done online. They can see the status of that request, which is fantastic. Before it took a phone call to say, ‘Where are you with my request?’ and now [providers] can see the status of that online, [providing] much enhanced functionality for the state as well. [PRISM] also lightens the manual work and the administrative burden that the state has in so many different areas in the way we do our papers.”

Strohecker added she is looking forward to the proposed rules and new policies from CMS after the PHE ends.

Utah Medicaid is awaiting federal approval and guidance on its 1115 waiver amendment proposals to CMS to provide Medicaid Coverage to Justice-Involved Populations as inmates transition from correctional facilities back into the community.

Strohecker is also working with the One Utah Health Collaborative to drive value and improve access to and utilization of prevention services. Strohecker said collaboration with accountable care organizations and fee-for-service providers on developing performance improvement projects, which involve gathering information systematically to clarify issues or problems and intervening for improvements, to advance areas such as wellness visits and immunization for children and adults. 

“We want to continue really focusing on those on-the-ground type of interventions that lead to better disease management or improve disease outcomes or even [a] cure,” Strohecker said. “We’ve been running a Hepatitis C program that’s an adherence based program where we outreach to a member. We will speak with them about their medicine and really offer to work with them and coach them over their 8 to 12 week treatment. At the end of this treatment, there’s a cure to Hepatitis C. If we can see adherence to these medicines, we can get them to a cure.

It’s been really rewarding to see that this work is aligning with our patients. As they’re prescribed these therapies and they start treatment, our pharmacists and our pharmacy staff have been able to work with them to help get them to that cure spot. Our goal has been to be over 90% cure rate or treatment completion rate. We’ve been able to achieve that which has been really exciting.”