21st Century Cures Act

By Margot Jones, Jay Peck and Margot Thistle, with assistance from EVV Workgroup Implementing the 21st Century Cures Act 


On December 7, 2016 Congress passed the 21st Century Cures Act (the “Act”), which was signed into law on December 14, 2016. The Act is aimed at modernizing health care delivery, improving quality and targeted improvements in the area of cancer treatment, mental health care, opioid addiction, and other focused areas. One such modernization effort requires states to implement Electronic Visit Verification (EVV) systems for personal care services and home health care services providers by 2019 and 2023, respectively.  These EVV systems will help ensure that beneficiaries receive the care that is being billed to Medicaid. 

Additionally, the Act allocates over $1 billion in grant funding over the next two years for states to combat the opioid epidemic. States began the application process for grant funds in early 2017, and efforts are now underway in a number of states to implement new programs and services focused on treatment and prevention. Below we highlight one way PCG has identified to leverage existing claims data to implement reforms.  

This Act is largely funded through the Prevention and Public Health fund established in the Affordable Care Act (ACA). For more information on additional modernization and reform elements of the Act, please click here

Paving the way for EVV implementation across all states 

Section 12006 of the Act requires states to implement EVV systems for Medicaid-reimbursed personal care services and home health care services providers by 2019 and 2023, respectively. Failure of a state to adhere with the timelines outlined in the Act will result in the gradual decrease of a state’s Federal Medical Assistance Percentage. The Act also outlines federal financial participation available for EVV implementation with 90 percent for the design, development, or installation of such a system, and 75 percent for the operation and maintenance of the EVV system. 

The growing Home and Community Based Services (HCBS) population and the recent reports highlighting fraud amongst personal care service providers has ignited conversation on the necessity for real-time, mobile oversight technologies. While the medical well-being and cost benefits of HCBS services are undeniable, the success of such programs hinge on the implementation of robust provider monitoring tools. EVV systems offer the desired transparency into in-home care activities and the actions of providers using sophisticated validations to ensure the right provider is providing the right service at the right place and time.

PCG is an active participant in this dialogue as we seek to better understand states’ needs in order to refine our flexible and scalable EVV product line.  

Utilizing Medicaid claims data to target opioid abuse

In April 2017, the U.S. Department of Health and Human Services (HHS) announced the first round of state targeted opioid prevention and treatment grant approvals, with $485 million to be administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). The grant funding sets forth stipulations around the use of the opioid abuse prevention and treatment. The funds are to be used for treatment, recovery, and preventative services with an administrative costs cap for costs associated with grant implementation. 

PCG receives and utilizes Medicaid claims data in certain states as part of our longstanding program integrity efforts. This work has centered around ensuring programmatic and provider compliance, as well as audit services.  This data could provide states with the opportunity to run timely data analytics regarding opioid utilization across the state to pursue the following initiatives: 

  • Expand effective prevention strategies for non-medical use of prescription drugs and building recovery capital in high need areas

  • Provide technical assistance in high need areas involving prevention strategies

  • Modify drug management systems to create a more robust programs

  • Improve the strategic targeting and performance reporting of peer mentoring/coaching programs, transportation, and re-entry coordination services

Through the use of this data, states can identify potential over prescription and abuse, individuals at high risk for addiction, and individuals who require treatment, then create metrics that can be used to monitor behavior and enforce regulations.  Such data can also help to gauge a treatment’s effectiveness, and track how individuals who have received treatment fare over time. States can craft effective, comprehensive responses to the ongoing opioid crisis with the assistance of claims data analytics and formulate relevant solutions to address vulnerability within the state.