PCG Health™ can help your state design a Medicaid plan that

  • Protects all of the state’s legal and financial interests;
  • Clarifies and provides guidance as to appropriate administrative practices;
  • Satisfies Centers for Medicare and Medicaid Services (CMS) requirements;
  • Preserves flexibility where appropriate.

CMS Requirements

State Medicaid plans represent a contract between CMS and the state, defining the individuals and families who may enroll in the Medicaid program, the services covered under the program, methods of reimbursement, methods of administration, utilization control, quality control,program integrity, third party recoveries, estate recoveries, coordination with other agencies and programs, provider agreements, and other important matters. CMS can, and often does, disallow millions of dollars in Medicaid federal financial participation (FFP) on state expenditures due to inconsistencies between state plan language and current state practices. Such inconsistencies may also expose the state needlessly to risk of litigation brought by recipient and provider organizations, adverse decisions in administrative hearings, and other disputes arising from audits and payment error reviews.

PCG Health helps states design and draft state plan amendments in areas such as

  • Coverage of services, service limitations,service authorization, and service practitioner credentialing;
  • Methods of calculating payment rates, including cost finding, cost allocation, audits, settlements, indirect cost rates, and time studies;
  • Disproportionate share hospital (DSH) payment adjustments;
  • Supplementary payments based on upper payment limit (UPL) requirements;
  • Coordination with Medicare Part A and Part B;Third party liability identification and recovery.

PCG Health Expertise

PCG Health’s consulting knowledge and experience is grounded in a thorough understanding of

  • Key provisions of federal Medicaid law, such as sections 1902, 1903, 1905, and 1923 of the Social Security Act;
  • CMS regulations on state plan development, submission, and approval under 42 CFR Part 430;
  • CMS regulations on state financial administration (42 CFR Part 433), eligibility (Part 435), service coverage (Part 440 and 441), reimbursement (Part 447), and service utilization (Part 456).
  • CMS State Medicaid Manual and policy issuance.

PCG Health consultants have extensive experience with CMS requirements and provide clients with unmatched consulting services on state plan design, including but not limited to

  • Ensuring consistency with all CMS requirements;
  • Verifying consistency with state law, regulations,operations manuals, and systems specifications where applicable;
  • Ensuring conformity of public notice requirements where applicable;
  • Estimating the impact on state expenditures and Federal financial participation (FFP).

By choosing PCG Health as your vendor for state plan design, you can be assured of a comprehensive range of consulting services meeting your objectives and CMS requirements.

Among our clients

  • State of North Carolina, Department of Health and Human Services
  • State of Tennessee, Bureau of TennCare
  • State of Texas, Health and Human Services Commission
  • State of Ohio, Department of Mental Health
  • State of Ohio, Department of Education


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More Information

For more information about PCG Health's State Plan Design Services please contact us at info@publicconsultinggroup.com or 1-800-210-6113.