Healthcare Access and Markets

States turn to PCG to organize their commercial health insurance regulatory compliance. They work with us to establish managed care procurement and contract oversight.

States regulate their private insurance markets and operate Medicaid managed care and fee-for-service programs to assure healthcare access to residents. This includes access to both physical and behavioral healthcare. 

We assess and help plan for state and county behavioral health system capacity. And for all these points of healthcare access, we help states decide on rules and methods for eligibility.

Services Include

Health Plan Compliance

We offer technical support to State Insurance Departments for the annual health plan form reviews in the individual and small group markets, both on and off the Exchange. Our compliance consultants help states create customized review tools and checklists, and we train staff and carriers on how to use them. We bring subject matter expertise to specialty areas of review, including mental health parity and non-discriminatory benefit designs, preventative services cost sharing compliance and establishment of benchmark plans. Our pharmacists consultants bring clinical perspectives to health plan formulary reviews. Our health plan compliance extends to Medicaid managed care.

Market Stability and Innovations

States are increasingly using Section 1332 waivers to stabilize premiums in their individual market through establishment of a reinsurance program. PCG can provide end-to-end waiver design and development as well as support financial management of approved reinsurance initiatives. But Section 1332 permits much wider insurance market reform than just reinsurance. Using this vehicle, states may explore re-establishing high risk pools, creating a state insurance coverage mandate, a public option, different eligibility rules or new incentives to drive solutions for small business. We can help your state assess opportunities that are responsive to local needs.

Behavioral Health

PCG provides behavioral health system assessments for states and counties and prepares plans for building capacity to meet service demands.

Eligibility Policies

While federal law requires states to cover certain populations under Medicaid, states continue to have wide discretion in deciding which optional coverage categories to include. States may also use their "state plan" or waiver authority to establish conditions certain populations must meet to remain eligible. These may include, for example, community engagement, work requirements and premium payments. PCG helps states draft and submit Section 1115 waivers that shape approaches to who is eligible, when they are eligible and for what benefits.