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HMA Insights 鈥� including our new podcast 鈥� puts the vast depth of HMA鈥檚 expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the 鈥渄ually eligible鈥�). Dually eligible individuals residing in rural areas represent about 5 percent of all rural residents. They reside at the intersection of a public health crisis and a fragmented Medicaid and Medicare care delivery system. , this small population is at risk of falling through the cracks of this crisis and suffering a steep rural mortality penalty.
With support from Arnold Ventures, HMA prepared 鈥淭he Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit: Raising Rural Voices from New Mexico, North Dakota, and Tennessee to Create Action. The toolkit contains eight actionable solutions for federal and state policymakers to use and tailor to states鈥� needs. Ellen Breslin, Samantha Di Paola, and Susan McGeehan authored the toolkit, with research contributions from Rebecca Kellenberg and Andrea Maresca.
In 2022, HMA convened stakeholder roundtables in three states 鈥� including New Mexico, North Dakota, and Tennessee to identify the challenges facing dually eligible individuals living in rural areas and to propose solutions to these challenges. Informed by this process, HMA developed the Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit.
The toolkit is structured around three domains used to organize eight solutions. For each solution, HMA provides a description of the rural access challenge, the proposed solution, and the proposed tool. Each tool is powered by some type of lever available to the federal and state government. We anticipate that policymakers will build upon this toolkit through continued dialogue with rural communities. The toolkit鈥檚 framework, goals, and actionable solutions are summarized in the figure below.
HMA Principal Ellen Breslin, Consultant Samantha Di Paola, and Senior Consultant Susan McGeehan authored the toolkit, with research contributions from HMA Principals Rebecca Kellenberg and Andrea Maresca. Download the toolkit.
On February 2, 2023, 1pm ET, HMA will host a webinar on the HEARD toolkit. During this webinar, HMA experts and panelists including Dr. Kevin Bennett (USC-SOM Columbia, SC CRPH), Dennis Heaphy (DPC), Pam Parker (SNP Alliance), and Tallie Tolen (New Mexico Medicaid) will summarize and discuss the toolkit鈥檚 actionable solutions for improving rural dually eligible individuals鈥� health and social outcomes.
This week, our In Focus section highlights the Health Affairs article, Advancing Health Equity and Integrated Care for Rural Dual Eligibles, authored by聽Ellen Breslin, Samantha Di Paola, Susan McGeehan, Rebecca Kellenberg, and Andrea Maresca, 黑料网.
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the 鈥渄ually eligible鈥�). The rural health crisis is a health equity concern that affects all rural residents, including dually eligible individuals. There are 47 to 60 million people residing in rural areas. Twenty-one percent of dually eligible individuals live in rural areas鈥攖hat鈥檚 about 2.6 million people. Based on these numbers, the authors calculate that the dual eligible population residing in rural communities accounts for about 5 percent of the total rural population. Dually eligible individuals living in rural areas are at risk of falling through the cracks.
Dually eligible individuals lack access to adequate medical, behavioral health, home-and community-based services (HCBS) and other social services; those living in rural areas face even steeper challenges. Since dually eligible individuals are among the poorest of all individuals covered under Medicare, they are at significant risk of paying a steep rural mortality penalty.
With these challenges there are opportunities for innovation for the dually eligible population living in rural communities. The US can reverse the mortality-disparity rate trajectory. Public and private entities are interested in revitalizing rural America, confronting the rural health crisis, and harnessing the power of rural communities. Investment in the rural health care sector is essential given it is a major economic driver of rural communities.
HMA is creating a toolkit with actionable solutions to improve access to services and integrated care and health equity for individuals dually eligible for Medicare and Medicaid who live in rural areas across the country. 鈥婽his project is a follow-on project to a previous HMA project supported by Arnold Ventures. 鈥婭n 2021, HMA prepared a brief, Medicare-Medicaid Integration: Essential Elements for Integrated Care Programs for Dually Eligible Individuals, to increase and promote enrollment in integrated care programs (ICPs) meeting dually eligible individuals鈥� needs and preferences. Interviewees including dually eligible individuals helped HMA to identify 鈥渁ccess to needed services in rural areas鈥� as an essential element of ICPs. In response, HMA started a new project to create a toolkit with actionable strategies to improve access to needed services and improve integrated care opportunities, specific to dually eligible rural residents鈥� needs.
HMA designed the toolkit around four values: 1) rural health equity is an imperative for dually eligible individuals, 2) actionable solutions and innovations must come from the community, 3) there is no single pathway to integration, and 4) Medicare and Medicaid flexibilities are critical to inspiring innovations to advance health equity, access, and integration. The toolkit will provide actionable solutions for states with and without integrated care programs for dually eligible individuals to increase access to needed supports and services, care coordination, and integrated care programs. We expect that states and rural communities will use the toolkit as a foundation for mapping a holistic plan to advance access to care coordination and integrated programs for dually eligible individuals residing in rural communities. Other states may employ contractual tools listed in the toolkit to expand access to providers and new services; strengthen partnerships among entities serving the community such as community-based organizations, providers, and health plans; and increase community-wide accountability for meeting dually eligible individuals鈥� whole person-centered needs. The toolkit is scheduled for an early 2023 release.
Today鈥檚 blog is the next in our series highlighting significant developments in the Medicare program. In our first article we covered the Centers for Medicare and Medicaid Services鈥� (CMS) calendar year 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. This week we are highlighting a few key policy developments in the proposed rule that governs payment levels and policy updates for hospital outpatient departments and ambulatory surgical centers (ASCs).
As we discussed last week, this is a pivotal moment for the Biden Administration鈥檚 Medicare policy agenda. Because the rulemaking cycle takes about 18 months, CMS needs to begin the process of collecting input on new proposals this year if it intends to finalize proposals before the end of the President鈥檚 first term. Additionally, the CY2023 rule represents an important transition year for CMS as it navigates the COVID-19 related anomalies in the data used to calculate payment levels.
Health care plans, providers, and facilities are continuing to transition to value based payment strategies, making it increasingly important to assess the entire environment of Medicare payment rules as these payment systems are the basis of financial benchmarks, quality incentives, and other key components of value-based payments. In addition, these payment rules provide insight into the cost pressures, incentives, and areas of misalignment throughout the health care system.
HMA experts are analyzing and closely tracking several issues in the CY 2023 hospital outpatient prospective payment system (OPPS) proposed rule. A brief summary of some of the most important proposed policy changes for the outpatient hospital setting are included below and highlight many of the Administration鈥檚 top health care priorities.
Policies to sustain access and address health disparities in rural communities.
Enhancing Medicare鈥檚 behavioral health payment and access policies beyond the COVID-19 public health emergency.
Uncertainty in the hospital outpatient prospective payment system (OPPS) rate increase due to future implementation of changes in 340B payment.
Increasing transparency of consolidation and mergers in the marketplace to help advance quality and affordability.
The remainder of our post delves into these issues and other notable proposals. Our post also includes analysis of the implications of these policies for stakeholders deserving.
Key Action Items for Stakeholders
The CY 2023 OPPS Proposed Rule was published on July 15, 2022, and all comments from stakeholders are due to CMS by September 13, 2022. We anticipate CMS will release their Final Rule in late fall 2022, before the new rules are implemented January 1, 2023.
The public comment period is also an important window of opportunity during which stakeholders can analyze the impact of CMS鈥檚 proposed policies, assess the proposals against other applicable pending federal and state payment policies, and consider how the proposals may impact business decisions. Further, the public comment period is essential for CMS to deepen its understanding of the impact of its policies on stakeholders. The agency benefits from hearing stakeholder鈥檚 perspectives, viewing their quantitative and legal analyses, and understanding the general stakeholder environment.
Rural Emergency Hospitals: Definition and Payment
The Consolidated Appropriations Act of 2021 (CAA) established a new provider type called Rural Emergency Hospitals (REHs) beginning in 2023. REHs are facilities that convert from either a critical access hospital (CAH) or a rural hospital with less than 50 beds, by choosing to close their inpatient capacity. Instead, these facilities provide emergency department services, outpatient services, post-hospital extended care services, and other defined services.
While the statute specifies many foundational aspects of REHs, CMS was given the authority to further define REH eligibility status and to specify the unique reimbursement mechanisms for REHs. All of these components will be vital to a provider or entity鈥檚 decision to pursue REH status.
On June 30, CMS the first component: Conditions of Participation (CoPs) for REHs, which defined REH status within the Medicare program. Within the CY 2023 OPPS Proposed Rule CMS proposed to define reimbursement and several other key components of REHs. Below we detail the key elements of REH reimbursement. In HMA鈥檚 blog next week we will offer greater detail on the COP and reimbursement policies.
REH policies proposed in the CY 2023 OPPS Proposed Rule:
REHs will receive a monthly facility payment of approximately $268,000 (or more than $3 million per year) beginning in CY 2023.
REHs will receive a 5 percent payment increase for all services covered under the Medicare OPPS.
REHs may provide outpatient services that are not otherwise paid under the OPPS (e.g., the Clinical Lab Fee Schedule) as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility (SNF).
Beneficiaries served at REHs will not be charged a copayment on the additional 5 percent OPPS payments, but standard OPPS cost-sharing requirements would still apply.
REHs must comply with all applicable provider enrollment provisions in order to enroll in Medicare.
REHs will have a unique quality reporting program distinct to REHs, in order to reduce reporting burden on these smaller facilities. CMS seeks feedback from stakeholders on the measures used for the REH quality reporting program.
REHs will be provided an exception from the Physician Self-Referral Law (commonly known as the 鈥淪tark Law鈥�).
Takeaway: The creation of REHs is both a significant change for the Medicare program and potentially a unique opportunity for small rural hospitals and health systems which own/operate rural hospitals. The Congress and CMS believe this model will address access to care concerns and health disparities present in rural communities. Many assert that under the REH approach, hospitals and health system providers serving rural communities may have greater flexibility to support the rural communities they serve.
Look for our additional analysis of the set of proposed REH policies next week.
Mental Health Services Furnished Remotely by Hospital Staff
For CY 2023, CMS proposes several updates to its remote services policy to plan for a transition from temporary policies enacted during the PHE to when the PHE is declared over. CMS proposes to:
Allow clinical staff of a hospital to conduct remote mental health and substance abuse services and to designate these services as hospital outpatient department services for purposes of reimbursement. Patients will be permitted to be in the homes and hospital clinical staff must conduct the service from inside the hospital facility. Further, CMS proposes new hospital outpatient codes for these services, and CMS will not permit these outpatient services to be conducted (and billed) in tandem with physician fee schedule services.
The agency will require an in-person service within 6 months prior to the initiation of the remote service and then every 12 months thereafter. CMS will allow exceptions to the in-person visit requirement based on beneficiary circumstances.
The agency is also proposing that audio-only interactive telecommunications systems may be used to furnish these services when the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.
Takeaway: As CMS wrote in the proposed rule, many beneficiaries may be receiving mental health services in their homes from hospital or critical access hospital staff during the COVID-19 PHE. The policy update could help minimize disruptions in continuity of care that might otherwise occur following the end of the PHE. The proposals also reflect CMS鈥� desire to adapt to changing beneficiary preferences and new methods of providing services that have evolved during the COVID-19 PHE.
Hospitals and health systems may benefit from these proposals because it will maintain and expand patient-provider access points and care coordination after the patient has left the hospital. Stakeholders will need to continue to assess beneficiary utilization of services furnished remotely, potential staffing changes to support these services, and community-specific access needs for remote mental health services. Stakeholders may have important perspectives to offer CMS through the regulatory comment proceed as the agency determines whether to finalize a requirement that hospital clinical staff be physically located in the hospital when furnishing services remotely using communications technology.
Payment Policies
CMS is proposing to update OPPS payment rates for hospitals and ASCs that meet their respective applicable quality reporting requirements by 2.7 percent. This update reflects the following factors:
Projected hospital market basket percentage increase of 3.1 percent; and
A 0.4 percentage point reduction for projected multifactor productivity.
In the context of the OPPS, CMS proposes to increase the OPPS conversation factor by 2.7 percent from CY 2022 to CY 2023, from $84.18 to $86.79. CMS estimates this will increase OPPS payments to providers from CY 2022 to CY 2023 by $1.8 billion.
In the context of ASCs, CMS estimates a proposed increase to the ASC conversation factor by 2.7 percent from CY 2022 to CY 2023, from $49.91 to $51.31. CMS estimates this change will increase industry-wide payments from CY 2022 to CY 2023 by $130 million. In addition, CY 2023 is the final year in which CMS will apply the productivity-adjusted hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023).
Consistent with CMS鈥檚 methods for updating other Medicare prospective payment systems during the 2023 regulatory cycle, the agency proposes to use claims data from CY 2021 and hospital cost report data from the June 2020 Healthcare Cost Report Information System (HCRIS) to update payment rates for CY 2023. Some stakeholders have expressed concern during this regulatory cycle that claims data continue to include anomalous trends influenced by covid cases and the cost data do not accurately reflect covid-related costs because the data primarily are associated with pre-COVID time period.
340B Payment Policy
CMS鈥檚 proposed rule acknowledges the recent Supreme Court decision in American Hospital Association v. Becerra (No. 20-1114, 2022 WL 2135490), which will have a significant impact on the 340B program. However, given the recency of this decision the agency formally proposed to maintain the current payment rate of Average Sale Price (ASP) minus 22.5 percent for drugs and biologics acquired through the 340B program.
In response to the decision, CMS stated that the agency will adjust 340B payment rates within the CY 2023 final rule. In its recent ruling, the Supreme Court held that HHS may not vary payment rates for drugs and biologicals among groups of hospitals without having surveyed hospitals鈥� acquisition costs. The decision relates to payment rates for CYs 2018 and 2019 but has implications for the CY 2023 rates.
CMS also stated that it anticipates applying a 340B payment rate of ASP plus 6 percent for specified drugs and biologics in the CY 2023 final rule. This would likely result in a budget neutrality reduction approaching 5% in the OPPS conversion factor.
Takeaway: Hospitals and federally qualified health centers (FQHCs) receiving 340B reimbursements will view the court ruling and potential increase to 340B payment rates as positive. However, it remains unclear at what exact level 340B payments will be set. Therefore, stakeholders may want to comment on the CY2023 policy options CMS is considering. Additionally, stakeholders should plan for CMS to conduct a survey of acquisition costs as it considers newly proposing changes to the payment rates. It remains possible that CMS will continue to apply the 340B cut for 2023 in light of a 2020 survey of hospital acquisition cost that it conducted. Future budget neutrality adjustments may also be necessary for any payments that are returned to hospitals due to the overturning of the 340B cut for 2018 and 2019.
Additional Issues for Stakeholder Consideration
In addition to the financing and policy issues discussed above, the wide-ranging rule contains numerous other policy proposals with direct and indirect implications on Medicare providers, beneficiaries, and other stakeholders. Table 1 provides a snapshot of some of the issues that warrant further consideration.
Table 1. Other Notable Proposed Changes Impacting Health Care Providers and Stakeholders
Topic
Summary
Provider Transparency
CMS issues a request for information linked to the President鈥檚 July 2021 (E.O.) on Promoting Competition in the American Economy. CMS currently manages a database of nursing homeowners and operators, and the agency has begun to leverage that data to support hospital and nursing home patients and their families. The agency solicits feedback on whether it should release additional data that is already being collected 鈥渢o help identify the impact of provider mergers, acquisitions, consolidations, and changes in ownership on the affordability and availability of medical care.鈥� CMS also invites comments on whether the agency should release similar data for other types of providers. The solicitation represents the next phase in CMS鈥� expansive portfolio of work to address the impact of market consolidation on health care prices, consumer costs, and quality in the healthcare industry writ large. Medicare providers and stakeholders should be tracking how federal health care regulators, including CMS, are working to respond to the E.O. There is a strong likelihood that CMS will begin to include data on other types of providers and stakeholders will need to understand this shifting landscape and how it could impact their current and potential future business decisions.
SaaS
CMS discusses its desire to address the novel and evolving nature of Software as a medical Service (Saas) procedures. The agency is seeking comments on the specific payment approach we might use for these services under the OPPS as SaaS-type technology becomes more widespread. We are also concerned about the potential for bias in algorithms and predictive modeling, and are seeking comments on how we could encourage software developers to prevent or mitigate the possibility of bias in new applications of this technology.
Inpatient Only List
Removes ten services from the Inpatient Only (IPO) list.While the IPO list has previously been targeted for major reforms, this year鈥檚 narrower set of proposed changes signal CMS鈥� is deprioritizing IPO list reform.
Payment for surgical N95 Respirators
CMS recognizes that hospitals may incur additional costs when purchasing domestic NIOSH-approved surgical N95 respirators. CMS is proposing payment adjustments under the IPPS and OPPS that would reflect, and offset, the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators. Under this proposal, these payments would be provided biweekly as interim lump-sum payments to the hospital and would be reconciled at cost report settlement. The rule outlines the information providers need to include on the cost report to determine payments for cost reporting periods beginning on or after January 1, 2023.
Ambulatory Surgery Centers
CMS requests stakeholder feedback on methods that could be implemented to collect cost data from ASCs that minimize reporting burden.This could be the beginning of a process to implement cost reports for ASCs.
The HMA Medicare team will continue to analyze these proposed changes. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support the drafting of comment letters to this rule.
On June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation establishing the Conditions of Participation (CoPs) for a new hospital provider type, Rural Emergency Hospitals (REHs). The REH concept was first developed by the Medicare Payment Advisory Commission (MedPAC) and subsequently mandated by Congress through the Consolidated Appropriations Act (CAA) of 2021 to address the growing concern over closures of rural hospitals.
REHs provide an opportunity for Critical Access Hospitals (CAHs) and rural hospitals to improve the way care is delivered in their communities, maintain access, and avert potential closure by choosing to focus on the service offerings that are most essential to their communities, such as emergency services, observation care, and additional medical, behavioral, and maternal outpatient services. Importantly, the REH concept enables facilities to maintain a hospital designation absent inpatient capacity thereby ensuring that rural communities retain access to services. This proposed regulation is a significant milestone in CMS鈥� work to implement the REH designation and their novel payment methodology by their mandated start date of January 1, 2023.
The REH concept is expected to help address the observed health inequities that arise when rural communities lack access to hospitals and other providers. Obtaining an REH designation could be an opportunity for many independent hospitals and delivery systems to strategically reshape themselves in line with their community鈥檚 needs while receiving payments from Medicare for doing so.
Within CMS鈥� proposed regulation, the agency proposes to establish a novel set of REH CoPs which will define the parameters of the REH designation. The REH CoPs closely align with the current CAH CoPs in most cases, while considering the uniqueness of REHs and the statutory requirements. In some instances, the proposed REH policies closely align to the current hospital and ambulatory surgical center standards, such as the polices for outpatient services鈥� requirements and life safety code, respectively.
As a part of this proposed regulation, CMS seeks input from the rural community on a few key aspects of the REH designation, including:
The specific proposed REH standards, including the ability of an REH to provide low-risk childbirth-related labor and delivery services and whether the agency should require REHs to provide outpatient surgical services in the event that surgical labor and delivery intervention is necessary.
Whether it is appropriate for an REH to allow a physician, physician associate, nurse practitioner, or clinical nurse specialist, with training or experience in emergency medicine, to be on call and immediately available by telephone or radio contact and available on site within specified timeframes.
Updates to CoPs for Critical Access Hospitals
Also within this draft regulation CMS proposes to update the CoPs for CAHs by: (1) adding a definition of primary roads to the location and distance requirements; (2) establishing a patient鈥檚 rights CoP; and (3) allowing CAHs that are a part of a larger health system (containing other hospitals and/or CAHs) to unify and integrate their infection control and prevention and antibiotic stewardship programs, medical staff, and quality assessment and performance improvement programs (known as QAPI) to ensure consistent and safe care.
What鈥檚 Next
CMS is accepting comments on this rule until August 29, 2022. CMS intends to propose additional policies related to Medicare enrollment, payment, and quality reporting in the upcoming Calendar Year 2023 Outpatient Prospective Payment System/Ambulatory Surgery Center proposed rule. CMS will develop final policies for this program later this year.
For more information about this proposed regulation including how to submit comments and how the REH concept may impact the hospital industry and patients in rural communities please contact our Medicare team who have knowledge in Congressional, MedPAC and CMS policy and operations featured below.
This week鈥檚 In Focus section delves into the Next Generation MyCare Ohio managed care program, spotlighting the request for applications (RFA) that the Ohio Department of Medicaid (ODM) released on May 31, 2024. The MyCare Ohio Program, which serves people who are dually eligible for both Medicaid and Medicare, is undergoing a substantial transformation. Transitioning from the financial alignment initiative (FAI) demonstration model used in 29 counties, it is evolving into a statewide, fully integrated dual eligible special needs plan (FIDE-SNP) model. This shift is more than procedural; it signifies a pivotal moment of transition to new federal D-SNP requirements.
Background
The MyCare Ohio Program launched in May 2014 as a Centers for Medicare & Medicaid Services (CMS) FAI demonstration. MyCare Ohio integrates Medicare and Medicaid benefits for dually eligible members enrolled in competitively selected MyCare Ohio managed care plans, providing one care coordinator and streamlined communication and services. It serves 150,000 individuals in 29 counties.
CMS is sunsetting all FAI demonstration programs on December 31, 2025, prompting ODM to convert to the FIDE-SNP model.
Next Generation RFA
The MyCare Ohio Program will convert to the Next Generation MyCare Ohio Program in January 2026. ODM is modeling portions of the program after the state鈥檚 Next Generation Medicaid managed care program. The Next Generation MyCare Ohio Program initially will be implemented in the 29 currently participating counties and then expand statewide, covering a total of 250,000 eligible individuals. Medicaid managed care organizations (MCOs) that serve the program will need to become CMS-approved FIDE-SNPs. MCOs awarded a Next Generation MyCare Ohio contract will need to notify CMS of their intent to establish a statewide FIDE-SNP in Ohio by fall 2024 to begin operations in January 2026.
ODM anticipates selecting up to four Next Generation MyCare Ohio MCOs to serve enrollees statewide, though a decision on the number of plans will be finalized as awards are made and based on what is most advantageous to the state.
MCOs will need to develop a member-focused strategy with care coordination as a priority. MCOs will also increase focus on behavioral health coordination. According to ODM, goals for the Next Generation program include:
Focusing on the individual
Improving individual and population wellness and health outcomes
Creating a personalized care experience
Supporting providers in continuously improving care
Improving care for people with complex needs to promote independence in the community
Increasing program transparency and accountability
Next Generation MyCare will advance these goals through a population health approach, designed to address inequities and disparities in care.
The program will enroll dually eligible individuals ages 21 and older. This is a change from the current program, which enrolls dual eligibles who are 18 years old and older. The eligible age increase is being made to align with the Medicaid early and periodic screening, diagnostic, and treatment (EPSDT) benefit.
The new program also will continue to offer all the same services available through Ohio鈥檚 home care, PASSPORT (long-term services and supports), and assisted living waivers.
Evaluation
Applications initially will be reviewed to confirm the applicant meets the mandatory requirements. Applicants who meet the mandatory requirements will proceed to review and evaluation of responses to application questions that fall into seven topic areas, with a total of 1,000 available points (see Table 1). Of note, if an applicant is not currently serving as either a Next Generation MCO or a MyCare Ohio MCO, the applicant will receive zero points for qualifications and experience. Organizations that have yet to participate in at least one of these programs should consider the effect on their total score.
Table 1
Current Market
Five MCOs鈥擟VS/Aetna, CareSource, Centene/Buckeye, Molina, and United鈥攑articipate in the current MCOP, with two or three of them participating in each of the seven regions.
Timeline
MCOs should submit a notice of intent to apply by June 21. Proposals are due August 2, and awards will be issued October 8. Implementation is scheduled for January 1, 2026.
Connect With Us
Ohio is one of several states transitioning from a FAI demonstration at the end of December 2025. Additionally, the 2025 Medicare Advantage Final Rule includes new policies affecting D-SNPs that could reshape the integrated care plan landscape in many states.
黑料网 (HMA) will host a webinar on June 20, 2024 titled “D-SNP growth and integration: key implications of the 2025 CMS final rule” to review the current landscape and federal changes that will affect D-SNPs in 2025 and beyond. The session will feature an analysis of the new regulations and a discussion of the critical strategic and product impacts on Medicare organizations that offer D-SNPs or are considering offering D-SNPs. Attendees also will have the opportunity to engage with the panelists during a Q&A session.聽Watch the replay now.
Contact our experts below聽for details about the nationwide D-SNP rules and landscape.聽聽
This week, our In Focus section considers the increasing emphasis on quality at all levels of our healthcare system, especially for work that affects federally funded health insurance programs.
The Universal Foundation Measure Set
The 2024 Centers for Medicare & Medicaid Services (CMS) Quality Conference, April 8鈭�10, in Baltimore, MD, continued to highlight the harmonizing of quality measures across CMS programs and promotion of CMS鈥檚 universal foundation measures. These metrics capture quality across six domains for adults and four domains for children. By promoting and integrating these well-established measures across all CMS programs, end users can align priorities across programs and help to reduce burden on providers and health plans being assessed.
Medicaid has long been a leader in incorporating the universal foundation measures, having used many of them in managed care contracts, health homes, and other arrangements that include a quality assessment component for the past 20 years. Earlier this year, many universal foundation measures, including those pertaining to behavioral health, became part of the mandatory core measure set that all states must report to CMS as required in the SUPPORT for Patients and Communities Act鈥攃omprehensive federal legislation that addresses the opioid epidemic. Mandatory reporting will allow Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC), and other stakeholders to better understand the impact of federal investments on quality of care for Medicaid and CHIP enrollees.
New Developments in Medicaid鈥檚 Approach to Quality
Forward momentum is evident in other areas of healthcare quality as well. A significant federal milestone in quality of care was included in the Medicaid Managed Care Rule released in April 2024, which required states to design a quality rating system (QRS) and submit their methodology to CMS for approval. The QRS is intended to be user-friendly and help Medicaid members to pick a plan and monitor its quality performance. States will be able to use the QRS as a monitoring and oversight tool to compare plan performance. Not only will a QRS help improve Medicaid鈥檚 accountability to states, enrollees, and policymakers, but it also promotes transparency for all end users and the public. At present, Medicaid quality measures are reported by state rather than by plan. Plan performance in Medicaid is typically captured in a state鈥檚 external quality review organization (EQRO) annual report, which may impede the ability of most users to extract, compare, and digest information.
Another federal initiative is the Medicaid Access Rule, also released in April 2024, to help state Medicaid programs move toward public reporting of quality and compliance measures in home and community-based services (HCBS). In 2022, CMS released more than 90 measures that could be used to assess quality of care in Medicaid HCBS waiver populations. Under the rule, CMS will identify a subset of HCBS quality measures in 2026 and the technical specifications for these measures will be made available publicly and updated as needed. Similar to the CMS Child and Adult Core Sets, states will have an opportunity to implement these measures and CMS can use those outcomes to create HCBS scorecards by state.
Medicare Advantage Star Ratings Program
Finally, CMS is incorporating the health equity index (HEI) into the Medicare Advantage Star Rating system. The HEI contributes to a plan鈥檚 potential bonus and helps level the playing field for plans that enroll and provide services to underrepresented or at-risk populations. The HEI will account for enrollees who are dually eligible for Medicare and Medicaid, individuals with disabilities, or members with a low-income subsidy (LIS). The HEI also assesses plan-level performance for these specialized populations. Allowing plans to earn a better bonus for delivering high-quality services to these populations helps to mitigate adverse selection and reward plans for care that may be resource intensive.
What鈥檚 Next
Accountability for quality is beginning to emerge in the form of value-based contracting, incentive payments, and other forms of reimbursement focused on reducing disparities and improving outcomes. Health plans, providers, state agencies, vendors and other interested stakeholders need to have a strategy for quality improvement that reflects evolving federal and state quality priorities, reporting systems, and improvement processes.
HMA鈥檚 quality and accreditation team includes experts in the quality space from a variety of backgrounds, including National Committee for Quality Assurance (NCQA) surveyors, former HEDIS auditors, health plan and provider senior quality staff (vice presidents and chief quality officers), and former Medicare/Medicaid leaders. To learn more about implementing quality programs or to explore options for leveraging quality measures to maximize your organization鈥檚 value-based contracts, win requests for proposals, increase membership, and optimize member experience, contact聽our featured expert below.
The Center for Workforce Solutions (CWS) complied more than 400 recommendations for dealing with behavioral health workforce issues, from publicly available reports by federal and state policymakers, national associations, foundations and other partners and stakeholders. The summary of that report can be found below.
The is a partnership between the (National Council), 黑料网 (HMA) and (CBHL). The CWS is invested in creating a national platform that supports cross-sector partners working at multiple levels of the system to execute solutions in concert to tackle complex recommendations and achieve meaningful impact. They want to elevate workforce solutions that exist and can scale as well as build the pathways for overcoming barriers to implementation.
In an effort to understand what recommendations exist and what initiatives are suggested as solutions for the workforce crisis, the CWS reviewed recommendations and cross-walked them to the CWS levers of change as a way of building an actionable roadmap for addressing the behavioral health workforce crisis and to support cross-sector action towards creating a stronger, more equitable workforce.
Innovation is the source of progress, driving advancements across industries and shaping the way we live, work, and interact. However, the landscape of innovation is not static鈥攊t ebbs and flows, influenced by various factors including political leadership. This year鈥檚 presidential election may bring forth significant shifts in priorities, policies, and funding that directly impact innovation efforts like Center for Medicare & Medicaid Innovation (CMMI), state waivers and the Advanced Research Projects Agency for Health (ARPA-H).
CMMI serves as a catalyst for testing innovative payment and service delivery models within Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). With a new administration comes the potential for shifts in CMMI’s focus and funding priorities. For instance, a president (or his/her appointees) can direct CMMI to design payment models, reimbursement structures that can lead to higher quality outcomes and more cost-effective healthcare delivery. The policy priorities and values that undergird a president鈥檚 healthcare agenda can shape the kinds of innovation that CMMI drives. Current CMMI initiatives have prioritized value-based care approaches linking payment to outcomes, improving equity of care across race, gender, and geography, and patient-centered care models designed to support particularly high cost, complex conditions; the priorities of the previous administration included focus on substance abuse disorders, kidney disease, and diabetes.
CMS also grants waivers to states, such as Section 1115 waivers for Medicaid or 1332 waivers for insurance marketplaces, that offer flexibility to experiment with innovative healthcare solutions. The values and policy approaches of a new president will influence the degree of regulatory flexibility and the types of experimentation that will be approved. For example, several states have recently received approval on Medicaid waivers that encourage community-based approaches to whole person care, wrapping together healthcare coverage, benefits, delivery, with new support services that address upstream barriers to health.
ARPA-H, a new unit within the National Institutes of Health focuses on investments in 鈥渂reak-through technologies and broadly applicable platforms, capabilities, resources, and solutions that have the potential to transform important areas of medicine and health for the benefit of all patients,鈥� holds immense potential for driving breakthroughs in healthcare by funding innovation that 鈥渃annot readily be accomplished through traditional research or commercial activity.鈥� The types of projects funded by ARPA-H could be directly impacted by the policy and budget priorities of whomever is president in 2025 and their interest in promoting collaboration between government, academia, and industry to address complex health challenges. A prime example of a potentially impacted area is the emphasis on cancer research by the Biden Administration. This focus may shift drastically with a change in leadership.
For healthcare innovators looking to stay informed and adaptable amidst these potential policy changes, HMA has two opportunities of interest: The HMA Fall conference, and a DC Direct subscription. 聽On October 7-9, healthcare leaders and HMA experts will gather for the , focused on innovation in public programs. Our keynote speaker Darshak Sanghavi, MD is, a foundational leader at ARPA-H tasked with developing health programs that challenge how we think about healthcare innovation inside and outside government. Conference registration is now open – register today.
Leavitt Partners (LP), an HMA Company, guides clients who need to more closely track federal policy and regulatory activity and know when and how to influence the process. , an exclusive offering from LP, provides timely information and insights to elevate your knowledge from simply scratching the surface of understanding to becoming part of the fabric of change.
This week鈥檚 second In Focus reviews the , which the Texas Health and Human Services Commission released on May 10, 2024. The STAR Kids Medicaid managed care program provides coverage to children and youth ages 20 and younger with disabilities. currently participate in the program, with contracts worth approximately $4 billion annually.
STAR Kids Overview
The STAR Kids program operates under the Texas Healthcare Transformation and Quality Improvement Program 1115 demonstration project. To be eligible, individuals must receive Supplemental Security Income (SSI) and SSI-related Medicaid, participate in the Medically Dependent Children Program (MDCP) Section 1915(c) waiver, live in a community-based intermediate care facility, or participate in an intellectual or developmental disability (I/DD) waiver program.
Medicaid managed care organizations (MCOs) provide acute, behavioral, and long-term services and supports (LTSS) to children in the MDCP program and acute services only to children covered under the other home and community-based services/IDD waivers.
RFP
Texas plans to award contracts to at least two MCOs for each of the 13 service areas (SAs). Each MCO can be awarded up to six SAs.
MCOs will need to describe reimbursement strategies that incentivize high-quality and cost-effective healthcare while controlling spending and reducing ineffective service utilization in their proposals.
MCOs must demonstrate progress toward advancing alternative payment model (APM) initiatives within an APM performance framework. MCOs will need to provide a proposed APM and a means of tracking its effectiveness, including implementation of processes that support and incentivize providers to apply value-based care models and reward high performers.
Evaluation
Technical questions in the proposals are divided into five broad categories, representing a total of 1,800 points. Plans can score up to 2,000 points, including oral presentations (see table below).
Timeline
Proposals are due July 11, with awards expected to be made between December 2025 and February 2026. The contract start date is anticipated to begin between December 2026 and February 2027. Contracts will run for six years with three two-year renewal options.
Current Market
Incumbents CVS/Aetna, Elevance/WellPoint, Blue Cross Blue Shield of Texas, Centene/Superior Health Plan, Community First Health Plan, Cook Children鈥檚 Health Plan, Driscoll Children鈥檚 Health Plan, Texas Children鈥檚 Health Plan, and UnitedHealthcare served 150,000 beneficiaries as of November 2023.
Connect With Us
Texas has an active Medicaid procurement schedule, with key deadlines and additional developments expected in the coming months. HMA experts in Texas are monitoring these activities as the state works to reprocure all its Medicaid managed care contracts. These programs include the State of Texas Access Reform (STAR) and CHIP for traditional Medicaid members, STAR+PLUS for members who are aged and disabled, and STAR Kids for individuals younger than 20 years old with disabilities.
Through HMA鈥檚 Information Services, subscribers gain access to detailed information about the Texas and other state RFP landscapes and procurement documents, as well as historical data about plan contracts, enrollment, and financials.
For more information about HMA鈥檚 work in Texas and our HMAIS resources, contact聽our featured experts.
This week, our In Focus section spotlights Minnesota鈥檚 innovative efforts to develop a comprehensive ecosystem that addresses substance use disorder (SUD).
Overview
Like many states, Minnesota experienced a significant surge in overdose deaths between 2018 and 2021, magnifying disparities in health outcomes linked to SUD and fatalities. For example, in 2021, Native American Minnesotans were 10 times more likely to succumb to a drug overdose than their white counterparts. Similarly, Black Minnesotans faced over three times the risk of dying from a drug overdose compared with White Minnesotans.
How do you create a more effective SUD prevention and treatment system? By fostering collaboration among the people who are directly affected, service providers, advocates, policymakers, and payors so they can learn from one another, offer support, and collectively commit to advancing change.
The Minnesota Department of Human Services (DHS) Behavioral Health Division has enlisted 黑料网, Inc. (HMA), to facilitate the , with the goal of creating a culturally responsive system of care. A CoP has three primary elements:
A common identity, purpose, or value that encourages engagement and mutual exploration
A community that establishes a culture of learning and willingness to share, ask, and listen
The cultivation of practices where the community develops, shares, and maintains frameworks, tools, and ideas that are evidence-based and usedii
HMA understands that a well-established CoP, supported by solid processes, tools, resources, and expertise, is essential to realize and sustain a strong CoP foundation for translating knowledge into action.
Many states, including Minnesota, are using the American Society of Addiction Medicine (ASAM) criteria as the guidepost of their efforts to improve the addiction treatment system. To develop a road map on how to implement the ASAM Fourth Edition Levels of Care in Minnesota, HMA convened workgroups to collect firsthand information about services available in participants鈥� communities, whether they can deliver services at the ASAM level, and the barriers to providing this level of care.
The Approach
To authentically engage the community, HMA has partnered with three community advisors, each representing communities with the most significant disparities. The community advisors are integral to ensuring all CoP efforts incorporate a cultural lens that is responsive to the needs of communities facing health inequities. They do so by amplifying the voices and experiences of individuals in populations disproportionately affected by SUDs. In addition, the community advisors provide tailored facilitation, training, and resources within their respective CoPs to promote culturally specific and responsive practices. This approach seeks to increase treatment engagement and reduce disparities in treatment outcomes.
HMA is working with the CoP to create a report on SUD treatment gaps, a strategic planning and implementation summary, an ASAM implementation road map, a community advocacy capacity-building report, and an overview of culturally specific and responsive models of care.
Connect with Us
HMA brings experience in helping to build systems of care and expertise in assisting states with assessing ASAM levels of care and developing strategies, plans, and training to bolster these efforts. HMA is committed to empowering individuals with lived experience and people underserved by existing systems to play key roles in shaping new systems aimed at fostering equitable care.
The May 2024 edition of HMA鈥檚 Podcast, Vital Viewpoints, features a discussion with HMA Principal Debbi Witham about her insights on the ASAM levels and the impact on systems of care. She shares her in-depth understanding of the complexities of SUD and underscores the crucial need for quality measures and sustainable healthcare funding while warning against investing in ineffective systems. Ms. Witham further emphasizes how states might correct course now to ensure equitable distribution of funding and offers insights into the essential steps for coordinating a community response that enhances outcomes.
For more information about聽HMA鈥檚聽work in Minnesota聽and similar projects in other states,聽contact聽our featured experts.
The prospect of new leadership due to a presidential election brings with it the potential for significant shifts in priorities, policies, and programs within federal agencies. The Substance Abuse and Mental Health Services Administration (SAMHSA) plays an increasingly critical role in shaping the nation鈥檚 mental health and substance use disorder services in the United States. Mental health and the opioid crisis are a salient political issue that will receive some attention on the campaign trail, but candidates are unlikely to detail the specifics on how the rhetoric becomes reality.
SAMHSA’s budget could see adjustments, channeling resources toward initiatives that align with the new administration’s vision. This could mean increased funding for specific programs deemed critical under the new leadership and decreases for other programs. Any major shifts in funding will require the support of Congress. Also possible with new leadership are changes to programmatic approaches that revolve around the introduction of novel interventions, expansion of access to treatments, and addressing emerging challenges such as the opioid crisis with renewed vigor.
The intersection of technology and mental health is likely to receive heightened attention. Telehealth expansions, digital tools for prevention and intervention, and data-driven innovations may become focal points of SAMHSA’s strategy.
As SAMHSA adapts to new leadership, the opportunity arises to forge innovative pathways toward improved mental health outcomes and enhanced support for individuals and communities affected by substance use disorders. By embracing whatever change may come, SAMHSA can continue its vital mission of promoting behavioral health and resilience across the nation. The results of the 2024 election will have a significant impact on federal mental health policy in the coming years; subscribers get a steady stream of insight to stay on top of what鈥檚 coming next.
