Rhode Island Negotiates Transformative Medicaid Waiver and Implements Medicaid Savings Initiatives that Keep Budget on Track

“The work product by John Stephen is significant and was instrumental in helping the State obtain the unprecedented Global Medicaid Waiver. The Waiver provided the state with immediate savings of $7 million in FY 2009, and $16 million in projected savings in FY 2010, through securing additional federal revenue for costs not otherwise matched (CNOMs).Over the five year period, CNOMs will save the State $100 million. In addition, John assisted in securing the $3.5 million information technology planning grant, which has the potential to grow to several million dollars over the agreement”

-Donald L. Carcieri, Governor of Rhode Island

Transforming the State’s Medicaid Program

John Stephen worked with Governor’s Office and DHS to transform Rhode Island Medicaid with the first ever Global Compact Waiver. This creates enormous opportunity for the state. In crafting the waiver, John worked alongside DHS Secretary Gary Alexander and:

  • Constructed waiver concepts through a review period involving state agency, legislature and stakeholder input. The concepts developed for the Global Waiver included the rebalancing of the long term care system by expanding access to and availability of community based care alternatives, improving health outcomes through better service coordination and innovative care management strategies, and achieving greater efficiencies in service design and delivery through smart purchasing, greater competition and rate and payment reform.
  • Originated a Standard Terms and Conditions (STC) document to lay out the proposal that will give Rhode Island unrivaled flexibility to modify Medicaid service delivery and benefits to meet the needs of the state’s beneficiaries in the most efficient and effective way possible.
  • Led efforts to identify all programs in the state budget that were funded by the state without any federal participation, but covered low income populations that were at-risk for institutional care. Successfully assisted in negotiations to include these populations in the Wavier, resulting in over $100 million in additional federal funds over the 5 year period.
  • The Waiver established a new expedited 45 day approval process for any changes to benefits or program during the 5 year demonstration period; established new levels of care for the determination of nursing home eligibility that will serve to place priority on high quality and less expensive community based placements over costly nursing home care, and gave consumers meaningful choice; allowed for benefits in any optional and mandatory program to be “customized” to fit the needs of the person; allowed for priority to be placed on preventative services; established a healthy choice account that will reward healthy behaviors with appropriate incentives; and allowed new purchasing strategies that focus on quality and competition.
  • Reasonably estimated savings for DHS attributed to the Global Waiver over the 5 year period to be $388 million.

In addition, the Rhode Island Governor’s Office and DHS brought in John Stephen to improve operations and meet budgeted savings goals targeted by the Legislature. John and his team:

  • Assessed the status of FY 09 Medicaid initiatives and quickly determined that, of the $109 million in budgeted Medicaid savings initiatives, only $47 million was on target to be achieved.
  • Expeditiously and methodically examined all processes within DHS and other HHS agencies to find areas for additional savings opportunities without impacting direct services. In doing so, the team also drew upon its pool of programmatic experts to offer detailed analysis of program efficacy and opportunities for savings.
  • Immediately developed a corrective action plan to meet state budgeted savings objectives. Produced a workable strategy to achieve realistic reductions to get agencies back on track.
  • Identified an additional $60 million in new Medicaid savings initiatives that were inserted into a supplemental budget to ensure that the budgeted savings were on track. John helped DHS refine existing savings initiatives, identified new initiatives that focused on areas, such as, nursing home diversion and transition, shared and independent living arrangements for persons with disabilities, emergency room diversion, competitive purchasing strategies and more cost-effective pharmacy benefit management.
  • Developed business process improvements to upgrade flexibility and reduce demands on staff resources. These improvements included the development of a program management office that brought accountability and results to each Medicaid reform initiative, and area of operation. John’s team assisted Secretary Alexander in drafting detailed plans of action for each major Medicaid reform savings initiative and put in place appropriate dashboards to track performance and measure outcomes.

John worked together with the DHS team in Rhode Island to develop ways ensure that the change efforts will produce quantifiable results.

Generating Media and Stakeholder Communications Strategy

Without public support, no public reform effort can succeed. John and his team worked with its state partners to craft an outreach strategy to explain the Medicaid and savings initiatives to the public, the legislature and interested stakeholder. In the process, John:

  • Crafted targeted message maps, press releases, talking points and media strategy for state leaders to discuss both Medicaid reform and HHS efficiency efforts to meet savings goals.
  • Built an outreach plan to share impact of state changes with various stakeholder groups. Coordinated efforts to segment message for differing audiences.
  • Assisted state leaders in preparing testimony message for state legislative hearings.


“John Stephen’s efforts helped save Rhode Island taxpayers millions of dollars and have given our state more flexibility to manage Medicaid than any other state in the nation. John’s work was an unqualified success, and our state is tremendously grateful for his expertise and the results it has delivered.”

-October 26, 2010, Rhode Island Governor Donald L. Carcieri