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CMS announces innovation in behavioral health model

This week, our In Focus section highlights the Innovation in Behavioral Health (IBH) model, which the Centers for Medicare & Medicaid Services (CMS) announced January 18, 2023. It is the third state-based alternative payment model that the CMS Center for Medicare and Medicaid Innovation (Innovation Center) has released in recent months. HMA wrote about the Transforming Maternal Health (TMaH) Model here and States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model here.

IBH Model Overview

This model is designed to improve the quality of care and health outcomes for people with moderate to severe behavioral health conditions through person-centered care that integrates physical health, behavioral health, and health-related social needs (HRSN). Its objective is to improve care through healthcare integration, care management, health equity, and health information technology.

CMS will select up to eight state Medicaid agencies for participation in this eight-year model that will begin in fall 2024. Participating states must partner with the agencies that are responsible for mental health and/or substance use disorder treatment to ensure coordination and alignment of policies. Model participants will develop and implement the IBH model in partnership with at least one Medicaid managed care organization or another intermediary as applicable.

Community-based behavioral health organizations and providers in selected states can choose to engage as practice participants in the model. Community-based providers can include safety net providers, community mental health centers, public or private practices, and opioid treatment programs. Practice participants will be responsible for coordinating with other members of the care team to comprehensively address behavioral and physical health needs and HRSN, such as housing, food, and transportation for patients. Practice participants will conduct HRSN screenings, refer patients to specialists and community-based resources, and more. They will be compensated based on the quality of care provided and improved patient outcomes.

Opportunities and Considerations

The model will include three pre-implementation years during which states and practice participants will receive Medicaid and Medicare funding for development and capacity building. Medicare will provide practice participants with a per-beneficiary-per-month payment in pre-implementation years to support health IT, electronic health records (EHR), practice transformation, new workflows, and staffing investment necessary to implement the model. Starting in year four, the Medicaid alternative payment model must be implemented, and Medicare will begin making performance-based payments.

Notably, the announcement materials do not indicate the maximum funding amount selected state Medicaid agencies are eligible to receive in IBH. The cooperative agreement funding for selected states will support implementation preparations, such as statewide health IT infrastructure, supporting practice participants, stakeholder convening, and developing the Medicaid alternative payment model.

What鈥檚 Next

The Innovation Center expects to release a Notice of Funding Opportunity (NOFO) in spring 2024. More details on the requirements, including payment methodologies and funding, are expected to be included in the NOFO.

The HMA Behavioral Health and federal policy teams will continue to monitor developments in IBH and analyze the opportunities for states and providers in this model. HMA experts are also assessing the relative opportunities of the IBH model alongside other Innovation Center opportunities and initiatives already underway in states.

The core design elements and objectives of the IBH are illustrative of the issues that HMA鈥檚 experts and industry leaders plan to discuss at HMA鈥檚 Spring Workshop, .

For more information on the IBH model, contact聽our experts below.

CMS approves next phase of New York鈥檚 Medicaid 1115 waiver journey

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This week, our In Focus section describes New York State鈥檚 Medicaid Section 1115 waiver amendment authorizing at least $6.7 billion in funding for new programs and initiatives in the state鈥檚 Medicaid program. The Centers for Medicare & Medicaid Services (CMS) approved New York鈥檚 application for the amendment January 9, 2024, which is effective retrospectively to April 1, 2022, through March 31, 2027.

New programs and initiatives are intended to improve access to services for Medicaid enrollees and include:

Regional social care networks (SCNs) responsible for screening, referring, and providing new health-related social needs (HRSN) services to eligible Medicaid beneficiaries
A statewide health equity regional organization (HERO), which will provide data analysis, regional needs planning, stakeholder engagement, value-based payment recommendations; and program analyses
Workforce initiatives, including student loan repayment (SLR) and career pathways training (CPT) to recruit and retain healthcare professionals in high-need fields
A Medicaid hospital global budget initiative (MHGBI) to provide funding to safety-net hospitals with negative operating margins to support their participation in waiver-related services
An institution for mental diseases (IMD) waiver for substance use disorder (SUD) services
A commitment from the states to sustain and enhance Medicaid provider payment rates to ensure access to services

Funding

CMS authorized at least $6.7 billion in funding. Some waiver components are without specific monetary valuation (i.e., IMD waiver, payment rate increases).

	DY 25 (ends 3/31/24)	DY 26 (ends 3/31/25)	DY 27 (ends 3/31/26)	DY 28 (ends 3/31/27)	Total
HRSN Infrastructure	$0	$260,000,000	$190,000,000	$50,000,000	$500,000,000
HRSN Services					$3,173,000,000
HERO		$50,000,000	$40,000,000	$35,000,000	$125,000,000
Workforce: Student Loan Repayment		$12,080,000	$24,150,000	$12,080,000	$48,310,000
Workforce: Career Pathways Training		$175,770,000	$310,480,000	$159,500,000	$645,750,000
Medicaid Hospital Global Budget Initiative	$550,000,000	$550,000,000	$550,000,000	$550,000,000	$2,200,000,000
					$6,692,060,000

HRSN

NY will implement 13 SCNs in nine regions, which are expected to establish networks of community-based organizations (CBOs) that provide HRSN services.
Contracted SCNs, which will be awarded pursuant to a recently published request for applications, will receive infrastructure funding to invest in technology, business and/or operational practices, workforce development, and outreach and stakeholder engagement.
SCNs will be reimbursed according to a state-published fee schedule for delivering HRSN services on a fee-for-service basis.
SCNs are responsible for screening for HRSN and determining Medicaid beneficiaries鈥� eligibility level for enhanced HRSN services, spanning case management, nutrition supports, housing supports, and transportation.

HERO

NY will contract with a single statewide Health Equity Regional Organization (HERO), which is independent of state or other government entities.
The HERO will be responsible for five activities:
Collect, aggregate, analyze, and report data
Conduct regional needs assessments and planning
Convene regional stakeholders
Make recommendations to support advanced VBP arrangements and develop options for incorporating HRSN into VBP methodologies
Conduct program analyses

Workforce

The waiver approval identifies two pathways for workforce investment:
SLR program for people who will serve in certain healthcare workforce shortage professions
CPT program to support recruitment and advancement in healthcare careers

Medicaid Hospital Global Budget Initiative

The MHGBI will be available to certain safety-net hospitals that meet governance, solvency, and geographic requirements.
The MHGBI provides incentive payments to these hospitals if they:
- Collect and report data
- Meet milestones for transitioning to alternative payment models
- Demonstrate improvement in healthcare quality and equity
As a condition of MHGBI, New York will apply for participation in the CMS Innovation Center鈥檚 AHEAD model.

IMD Waiver for SUD

CMS approved an IMD waiver for SUD services. As a result, NY will be eligible to receive federal financial participation for Medicaid members who are short-term residents in IMDs for services that would not otherwise be matchable
The state anticipates 50 providers will enroll within the first year

Curious 黑料网 What the Waiver Means for Your Organization?

HMA鈥檚 New York Team can assist organizations assessing opportunities and understanding implications tied to these new, significant waiver investments. They have been working with key stakeholders to help inform the design of foundational components of the new wavier initiatives. HMA鈥檚 team of experts anticipate that the terms and conditions agreed to in the New York amendment provide important policy insight and direction for other states pursuing similar initiatives. If you have any questions or are seeking a more detailed analysis of the state鈥檚 waiver amendment, please contact聽our experts below.

Driving change in healthcare delivery: HMA Spring Workshop dives into metrics, coordination, and partnerships for value-based care

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Within the healthcare sector, there is an imperative for a comprehensive understanding of the care delivery framework that will positively impact outcomes, equity, and the overall health of communities. Among the drivers for this imperative is renewed focus among Medicare officials and interest from states and employers to transition to alternative payment methods that focus on value for payers and patients. A variety of care delivery structures and metrics can be used, and all have a role in driving value-based care (VBC).

One critical element of VBC hinges on whether and how healthcare organizations focus their care delivery structures on patients. VBC also incorporates metrics that further validate the ability of the system to positively impact patient outcomes, reduce health disparities, and improve population health. Emphasizing technology, interdisciplinary collaboration, and streamlined communication can revolutionize the care delivery model.

The HMA workshop-style on March 5 and 6, is designed to delve deeply into the intricacies of these care delivery frameworks and metrics within the context of VBC. This unique workshop will challenge attendees to roll up their sleeves and actively engage to become part of the solution through an interactive conversation, allowing participants to discuss real-world scenarios, analyze data and metrics and, using small-group breakout sessions, engage in focused and in-depth knowledge sharing.

Break-out sessions facilitated and led by subject matter experts will challenge attendees to identify new solutions around care delivery structures and contractual metrics that improve outcomes, that may include:

Engaging providers around consistent approaches to enhance patient outcomes, optimize treatment plans, and ensure the delivery of evidence-based, high-quality care.
Developing approaches for patient engagement that improve care delivery and foster active involvement and collaboration between patients and healthcare providers.
Crafting strategies for seamless coordination among healthcare providers, spanning sectors, and involving non-traditional providers and community organizations.
Understanding components of effective provider network agreements and how they contribute to achieving healthcare goals through strong partnerships and collaborations.

The workshop promises to be a dynamic platform for professionals in the healthcare sector, offering valuable insights, practical strategies, and collaborative opportunities to secure a place for high-quality value-based care. By focusing on care delivery structures, patient engagement, care coordination services, and provider network agreements, attendees will be well-equipped to navigate the complexities of healthcare and contribute to a healthier, more equitable future.

To learn more about the HMA 2024 Spring Conference Workshop and to register, visit the .

Devising a framework for non-profit fundraising

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Money is always 鈥渢op-of-mind鈥� among non-profit leaders, from CEO鈥檚 at Federally Qualified Health Centers (FQHCs) to Executive Directors at Community-based Organizations. To supplement projects and retain the ability to further their missions, non-profit organizations (NPOs) need funding. When non-profits and funding sources are not well aligned, programs are cut, curtailed, or never launched. Assisting clients in pursuing alternative funding sources requires a creative yet methodical approach to promote success and boost organizational sustainability.

Devising a framework for non-profit funding presents challenges. Funding models/strategies cannot be too general nor too specific. There is not a single approach, a one size fits all model or sourcing strategy for non-profits to pursue. Instead, non-profit leaders must clearly articulate the funding model or strategy that best supports the growth of their organization and use that insight to examine the potential funding opportunities preeminently associated with organization-specific success. For example, a community health center serving patients covered by Medicaid and a non-profit organization doing development work in housing for the homeless are both funded by the federal government, yet the type of funding each receives and the decision makers controlling that funding are very different. Utilizing the same funding methodology for the two would not be productive. Fortunately, there are multiple methods and strategies to acquire funds. Non-profits should be strategic in seeking approaches suitable to their needs and capabilities and be creative in pursuing more than one model to acquire supplemental funds.

The core success of NPOs is based on a range of funding options, private grants and government grants, corporate sponsorships, private funding, endowments, and community fundraising. There is also a considerable amount of money available from the public sector, businesses, charitable trusts, foundations, in-kind donations, and local and state legislative bodies. The goal of any successful fundraising campaign is to convey fully what the money is or will be supporting and clearly articulate the projected positive outcomes that will be derived from the funding. Once the project is fully clarified, the next step is research. Many funding avenues exist. The NPO must decide which funding sources are best suited for each project and pursue those options.

When choosing potential funding sources, NPOs must consider the size of their organization, their mission, and various other defining characteristics. Once this internal due diligence is completed, revenue needs should be clarified, and a tactical fundraising strategy outlined. Creating a 鈥渞atio鈥� with the end-result in mind allows for revenue diversification and avoids the too heavy reliance on one income source. For example, an NPO might project obtaining 50% of needed revenues from grants, 20% from a corporate sponsorship, and the remaining 30% from a foundation. Once the funding sources have been identified, the types of decision makers and the motivations of these decision makers must be evaluated. Then, a tactical roadmap designed to obtain the needed funding should be implemented.

As society looks to the non-profit sector to solve important problems, a realistic understanding of funding models is increasingly important to realizing these aspirations. As consultants whose mission is to turn challenges into triumph for our clients, championing efficacious, high-yielding funding models ensures long-term viability for the organizations we serve.

Success relies on planning. It is much better to be proactive than reactive. Consider your organization鈥檚 funding needs, do your research, and lay the groundwork before diving into any fundraising pursuit. An assessment of your organization鈥檚 current funding strategies is essential. What is working; what is not? Is the current funding source reflective of the organization鈥檚 mission and values? Use the answers to these questions to make decisions and recommendations on which fundraising strategies to source. Get creative! Brainstorm unconventional ways your organization will stand out to potential funders, but be analytical. Balance creativity with data, keeping in mind which funding strategy reflects the best return. Focus time and energy on the funding model that will be most reliable, profitable, and feasible.

The non-profit world rarely engages in a succinct conversation about an organization鈥檚 appropriate long-term funding strategy. That is because the different types of funding that fuel non-profits have never been clearly defined. More than a poverty of language, this represents and results in a poverty of understanding and clear thinking. As consultants, HMA can provide an outside perspective and sort through the minutia presenting a clear, methodical, appropriate path to fundraising success.

Potential links to aid in your fundraising endeavors:

HMA works with a wide variety of healthcare clients, including FQHCs, community-based organizations, hospitals, provider practices, behavioral health, and managed care organizations, and can help with:

Grant Writing
Technical Assistance
Strategic Planning
Financial planning, Implementation and Optimization

For more information about how HMA can help your organization鈥檚 grant and funding strategies, contact our experts below.

Rhode Island releases Medicaid managed care program RFP

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This week our In Focus section reviews the Rhode Island statewide, capitated risk-bearing Medicaid managed care program request for proposals (RFP), which the Rhode Island Executive Office of Health and Human Services (EOHHS) released December 15, 2023. New program changes will include carving in long-term services and supports (LTSS) as an in-plan benefit for all populations and expanding managed care to include people who are dually eligible for Medicare and Medicaid. Contracts are expected to be worth $2.3 billion.

Background

Rhode Island鈥檚 Medicaid managed care program, which operates under the authority of a Section 1115 waiver and Section 1932(a) state plan amendment, consists of the following programs:

RIteCare, which serves children and families, including children with special healthcare needs
Rhody Health Partners, which serves aged, blind, or disabled (ABD) adults
Medicaid expansion, which serves childless adults ages 19 to 64

At present, full-benefit dual eligible (FBDE) members are not covered through the Medicaid managed care organization (MCO) contracts.

RFP

New contracts will be implemented in three phases, starting with enrollment of core populations and the addition of LTSS in-plan benefits to Medicaid managed care for Medicaid-only enrollees beginning July 1, 2025. In the second phase, current fully dual eligible members will transition to Medicaid managed care plans on January 1, 2026. All bidders will be required to offer an integrated Dual Eligible Special Needs Plan (D-SNP) and managed LTSS (MLTSS) plan to dually eligible members, as Rhode Island transitions from the Financial Alignment Initiative (FAI) Medicare-Medicaid Plan (MMP) Demonstration, which sunsets December 31, 2025. In addition, beginning January 1, 2027, default enrollment will begin for Medicaid members who become newly eligible for Medicare.

EOHHS will award contracts to two or three MCOs.

Other changes in the RFP include increasing oversight and accountability for the use of pharmacy benefit managers (PBMs); requiring that EOHHS approve contracts for MCO major subcontractors; reducing unnecessary prior authorizations, particularly for behavioral health services; increasing financial sanctions for noncompliant MCOs; and increasing investments in population health and health equity with a focus on the identification of health disparities; and other changes.

Timeline

Proposals are due February 23, 2024. The new contracts will take effect July 1, 2025, and will run through June 30, 2030, with an option to extend the agreement for up to five additional years.

Current Market

Neighborhood Health Plan, Tufts Health, and UnitedHealthcare served approximately 313,000 members as of November 2023. These MCOs have signed contract extensions through June 30, 2025.

Evaluation

Rhode Island will not require cost proposals under this procurement, with capitation rates set by EOHHS actuaries. MCOs must meet the passing technical score of 85 points. Technical proposal requirements are shown below:

Driving change in healthcare delivery: payment models and risk management at HMA Spring Workshop on value-based care

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Is the concept of value-based care (VBC) still relevant in today鈥檚 healthcare landscape or just a buzzword? Some argue that the financial challenges brought about by the pandemic have steered our healthcare delivery systems away from prioritizing value. However, many experts remain optimistic that value-based care is the key to achieving our overarching objectives of a more equitable, sustainable, high-quality healthcare system.

Kelsey Stevens, a principal at Wakely, an HMA Company, led a session on value-based care at the HMA Fall Conference. Her panelists felt strongly that value is critical to a functional and patient-focused healthcare system because the alternative is out of control spending and poor health outcomes. In fact, value-based care is flourishing in new ways as we look to integrate behavioral health and address health related social needs. There are lessons to be learned from early experiments, new models being built, and new models to be designed. Both public and private payers are pursuing new ways to take financial risk to deliver improved healthcare outcomes, focusing on solutions for higher risk populations or circumstances where quality of outcomes are indefensibly poor (i.e., maternal outcomes).

This enthusiasm felt by the wide variety of executives present at that fall meeting has inspired HMA to focus an entire conference on value. But not just another conference on value. Our internal experts felt strongly about hosting a forum for healthcare organizations to truly tackle the end-to-end challenges of VBC鈥� so we are doing that.

Those who join us March 5-6 in Chicago will experience a workshop designed to 鈥済et real鈥� about transforming healthcare quality and value. We are convening participants from all parts of the healthcare industry who have the collective experience to pinpoint common challenges and to build a path forward.

The workshop is organized into four cohorts:

Payment and Risk Management Models,
Policy and Strategy Frameworks,
Data and Technology, and
Care Delivery Frameworks

Each will produce concrete recommendations for action, as well as building new relationships among peers to sustain this change. In the cohort on Payment and Risk management, discussion will be focused on existing and new models for payment, pricing and attribution methodologies, risk mitigation levers along the value continuum, and approaches to engage employees in focusing on patient-centered value in the care they provide.

One of our fall panelists, Eric Mattelson, chief actuary at Zing Health, said 鈥淚鈥檓 still convinced that value-based care is the future of healthcare and the Sisyphean struggle to get there will ultimately be worthwhile.鈥� We echo this sentiment wholeheartedly, and if you share this conviction, we encourage you to secure your spot today and become a part of this exciting and transformative event.

Our sessions and networking events offer an opportunity to delve into approaches to develop and manage risk-based contracting across sectors, establish effective partnerships with safety net providers and community-based organizations, apply a value lens to deployment of technology and data analytics, and develop health equity plans aligned with value principles and policies.

Future blogs in this series will touch on elements from the other 3 cohorts on VBC that make up the balance of the workshop. To learn more and register go to page.

Discover the challenges and opportunities of implementing value-based care at the HMA Spring 2024 workshop

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Policymakers have been working to move the U.S. healthcare system away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality. Financial pressures, government regulation, and improvements in managed care all contribute to the drive toward value-based care, and that creates challenges for providers, payers, manufacturers, government, and others supporting the industry. Though some stakeholders are hanging on to the old ways of doing things, others are rightly moving toward putting their emphasis on value, changing their payment and workforce structures, and improving quality.

黑料网 will host the spring workshop, Getting Real 黑料网 Transforming Healthcare Quality and Value, March 5鈭�6, 2024, at the Fairmont Chicago Millennium Park Hotel in Chicago. The workshop starts with a kickoff event the evening of March 5 designed to foster meaningful connections for attendees, regardless of their role as a government official, provider, health system representative, payer, or vendor in public or private healthcare markets.

The full-day program on March 6 will feature a compelling keynote speaker and include multiple interactive workshop sessions focused on four key pillars of value-based care: Policy & Strategy Frameworks, Payment & Risk Management, Data & Technology, and Care Delivery Measures. HMA has expertise in working with commercial payers; primary, specialty, and behavioral healthcare providers; and publicly sponsored health plans at the local, state, and federal levels. Session discussions will help participants adapt to the new value-based market and are designed to provide a comprehensive exploration of the intricacies involved in healthcare transformation. Attendees will discuss what to expect during the early phases of transformation, as well as strategies, collaborations, and actions that have moved them closer to adding value on the ground.

Participants will be challenged to think critically about their organization鈥檚 cultural and operational readiness to create additional value for patients within the healthcare ecosystem. Drivers of policy, innovation, population health, risk management, IT, and data, as well as enablers and other stakeholders working in public and commercial markets, will meet in smaller groups to discuss and analyze scenarios, pose challenging questions, and identify tactical steps and solutions to thorny issues.

Other groups focusing on value will address multi-sector issues and perspectives that affect value-based care, including behavioral health, primary, and specialty care. From navigating the complexities of employee insurance plans for businesses to advocating for the needs of individual consumers, this workshop will address the formidable challenge of reshaping the healthcare landscape.

Don鈥檛 miss this opportunity to gain valuable insights and contribute to genuine and productive discussions that will shape the future of healthcare.

Whether you attend on behalf of your organization or with a team of colleagues whose roles touch upon different links in the value-based chain, you will bring back ideas and strategies that can be implemented upon your return. Register today!

HMA, Wakely, and The Focus Group Consultants available for meetings at the JPM Healthcare Conference in January 2024

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黑料网 consultants, including colleagues from Wakely and The Focus Group, will be attending the JP Morgan Healthcare Investor conference in San Francisco, January 8-10, 2024. In addition to meeting with clients, HMA will be cosponsoring a reception with Shepherd Mullin as well as participating on a panel hosted by KPMG.

鈥淲hile we鈥檝e acclimated to a more virtual business world, the JP Morgan conference represents a unique opportunity to get together in person with valued clients and partners to discuss healthcare policy dynamics, emerging investment themes, and the exciting capabilities HMA has added over the last year to support its investment clients,鈥� said Greg Nersessian, Managing Director of HMA Investment Services. 鈥淩ain or shine, we look forward to getting together and learning more about the trends that will shape healthcare investing in 2024.鈥�

, a former JPM analyst, and now a Principal and healthcare actuary at Wakely Consulting Group, an HMA Company, says 鈥淭he one inalienable truth about JPM鈥檚 annual event is that it sets the stage and tone for health care investing in the upcoming year…I鈥檒l be focused intensely on how investors see the myriad headwinds facing government-sponsored healthcare programs playing out in 鈥�24…they will surely inhibit growth but may also set the stage for opportunistic deal flow.鈥�

The Focus Group is a strategic consulting firm working on business transformation in healthcare and private equity portfolios, acquired by HMA in late 2021. Its Managing Director Alex Rich added 鈥渙ur team is eager to reflect on recent deals and provide perspectives on new theses. Based on our wide array of recent projects and experiences, we鈥檙e excited to share and prepare creative strategies for portfolio value creation in the year ahead.鈥�

Several HMA experts will be in attendance. To set up a meeting with any of our team, please click . For further information on HMA Investment Services, please contact Greg Nersessian.

HMA collaborates on technical assistance report through the Medicaid Business Transformation D.C. Initiative

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HMA was engaged by the Washington, District of Columbia Department of Health Care Finance (DHCF) to lead their Medicaid Business Transformation D.C. Initiative, assessing the technical assistance needs of Medicaid providers and organizations in the areas of legal analysis, budgeting, and business development as they move toward value-based care arrangements. HMA partnered with the D.C. Behavioral Health Association (BHA), Medical Society of the District of Columbia (MSDC), D.C. Primary Care Association (DCPCA), and DHCF to engage, recruit, and collaborate with organizations and stakeholders across the District.

The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the webpage.聽The report and other information about the program were published on the website.

Experts from HMA as well as Wakely Consulting Group and Lovell Communications, both HMA subsidiaries, contributed to this report. We offer our clients a wide range of deep technical, analytical, policy, and communications support to providers, state agencies, and recommendations on ways to improve value-based payment models.

Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner.

Link to Medicaid Business Transformation DC: Recommendations for Technical Assistance Report

To learn more about this effort, contact聽our experts below.

Be sure to block off March 5-6 for HMA鈥檚 Spring Workshop in Chicago, IL, where our experts will be continuing the dialogue about value-based care. Early bird registration ends January 26, 2024.

CMS transforming maternal health model offers states a chance to improve quality and outcomes

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This week, our In Focus section reviews the new , which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on December 15, 2023. TMaH is the fourth major model that the Innovation Center has introduced to its payment portfolio since July.

Pregnancy-related deaths have more than since 1987 to 17.6 deaths per 100,000 live births, with only worsening outcomes for different racial and ethnic groups. For example, the pregnancy-related mortality rates for Black and Native American and Alaska Native women are approximately two to three times higher than the rate for White women. In recent years, have extended post-partum coverage and now offer doula coverage for Medicaid enrollees. This initiative accelerates the focus on maternal outcomes and, with nearly of births paid for by Medicaid, has the potential to impact health across generations.

This model is designed exclusively to improve maternal healthcare for people enrolled in Medicaid and the Children鈥檚 Health Insurance Program (CHIP). The last Innovation Center maternal health-focused model, ran from 2012 to 2016 with the goal of reducing preterm births and improving outcomes for newborns and pregnant women. The TMaH model takes a whole-person approach to pregnancy, childbirth, and postpartum care, addressing the physical, mental health, and social needs experienced during pregnancy.

Model Overview

Participating state Medicaid agencies (SMAs) will receive up to $17 million over the 10-year period to develop a value-based alternative payment model for maternity care services, with the intention of improving quality and health outcomes and promoting the long-term sustainability of services. TMaH will focus on three pillars, with a range of solutions outlined for each.

Pillar	Model Solutions
Access to care, infrastructure, and workforce capacity	Increase access to birth centers and midwives.Increase access to perinatal community health workers and doulasEnhance data collection, exchange, and linkage through improvements in electronic health records and health information exchanges
Quality improvement and safety	Implement patient safety bundles or specific protocols that promote the reduction of avoidable procedures and lead to improved outcomesPromote achieving 鈥渂irthing friendly鈥� designationIntroduce option to promote shared decision making between mothers and providers
Whole-person care delivery	Institute evidence-based medical and social risk assessment to drive risk-appropriate careDeliver care consistent with individual preferencesRoutinely screening and follow-up care for perinatal depression, anxiety, tobacco, and substance use during prenatal and postpartum periodsIncorporate home monitoring and telehealth technology for birthing people who have medical conditions, such as gestational diabetes and hypertension, that complicate pregnanciesRoutinely screening and follow-up care for health-related social needs (HSRNs)Establish reliable referral pathways to and from community-based organizations (CBOs) to address HSRNsDevelop and implement health equity plans as well as cultural competency technical assistance for providers

The TMaH model is designed to support birthing persons along their , expanding continuity, and improving outcomes.

The Model will have two phases for participating SMAs:

Pre-Implementation: A 3-year period during which states receive targeted technical assistance to achieve pre-implementation milestones prior to the implementation phase.
Implementation: A 7-year period where the SMAs (as the awardee) implement the program with critical partners, such as Managed Care Organizations (MCOs), Perinatal Quality Collaboratives, hospitals, birth centers, health centers and rural health clinics, maternity care providers and community-based organizations.

The model also requires a health equity plan, which has been a consistent requirement across models from the Innovation Center. Awardees must develop a plan that addresses disparities among underserved populations, such as racial and ethnic groups and people living in rural areas, who are at higher risk for poor maternal outcomes.

TMaH Opportunities and Considerations

The model offers states resources and technical assistance to develop value-based alternative payment model to support whole-person pregnancy, birth, and post-partum care and improved outcomes. Many SMAs are already working on programs to innovate care and payment, and the TMaH is an opportunity to expand and accelerate those programs.

The model offers an opportunity for states that have not expanded post-partum coverage or added doula benefits to adopt these policies with the funding and technical assistance to support their efforts.

SMAs interested in this opportunity may want to evaluate their application readiness and pre-plan for the application.

What鈥檚 next?

CMS is expected to release a Notice of Funding Opportunity (NOFO) in Spring 2024, and the application will be due in Summer 2024.

The HMA team will continue to evaluate the TMaH model as more information becomes available. For more information, please contact our experts below.

Opportunities for local and regional managed care organizations with justice-involved services

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Previously, HMA developed a comprehensive series of webinars reviewing the potential for using 1115 waivers to expand and improve health care services for the justice-involved population. With California becoming the first state earlier in 2023 to receive for the authority to provide a specific set of Medicaid services for up to 90 days in advance of release to youth and adults in state prisons, county jails, and youth correctional facilities, and many other states with pending waivers of a similar type, this blog post considers the implications of this emerging policy trend for local and regional managed care organizations (MCOs) in 2024.

The Opportunity

Delivering Medicaid services through MCOs has become the dominant strategy employed by states with using managed care for at least certain Medicaid populations. Local and regional MCOs represent a key component in this landscape across the country and often are deeply rooted in the states and communities they serve because of their specific focus on a single or limited number of markets.

With the precedent now in place for federal authority (and federal financial participation) to provide services such as reentry case management, behavioral health and physical health consultation services (in-person or via telehealth), laboratory and radiology services, medications as well as medication administration, medication assisted therapy inclusive of counseling, and community health worker services, states have a clear pathway toward pursuing the ability to provide services for the justice-involved population prior to release. Among the many important implementation questions states will need to consider as they continue to pursue the authority to provide these services is how the specific services will be delivered and financed. Given the dominance of Medicaid managed care, states will have to grapple with how MCOs can be leveraged to support a successful implementation of the delivery of services to the justice-involved population. The strong community presence of local and regional MCOs within the Medicaid managed care ecosystem makes these MCOs important entities for states to consider. Local and regional MCOs should consider what role they believe they can play as partners to states in these initiatives to serve justice-involved populations as successfully as they have served other Medicaid populations.

While the opportunities for local and regional MCOs will evolve over time, initial opportunities to contemplate are as follows:

Serving as a Thought Partner: There is already significant interest across states in pursuing the ability to deliver services in advance of release but local and regional MCOs can support state officials looking to develop in greater detail the most viable path forward to do so. Local and regional MCOs can be well positioned serve as thought partners to states by educating themselves about California鈥檚 1115 waiver approval and engaging state officials in their markets as partners to think through how the approach taken by California can be adapted to a given state鈥檚 goals and environment.
Serving as the Lead Case Manager: Providing reentry case management to coordinate the reentry process for the justice-involved population is likely to be a key service in any service array from this population. To ensure the complex coordination related to this process occurs successfully across multiple organizations, local and regional MCOs can explore working with states to serve as the lead entity for case management as individuals are enrolled (or reenrolled) in managed care.
Facilitating Enrollment Continuity and Continuity of Care: The process for transitioning to Medicaid coverage and care after these have been interrupted as a result of incarceration can be daunting for both the justice-involved population and well as state administrators and providers. Local and regional MCOs can play an intervening role here to provide support to all parties involved to produce a result where the enrollment process is as seamless as possible and critical care delivery is maintained specific to an individual鈥檚 health and social needs.
Providing Infrastructure Funding: In partnership with states, local and regional MCOs can infrastructure funding to build capacity to support many of these entities who will be involved with the reentry process. Such entities can include, for example, behavioral health providers, community-based organizations, primary care providers, and social service providers. The type of capacity needed will likely include data sharing, technology changes, and workforce development.
Providing Technical Assistance: In addition to supporting capacity-building, local and regional MCOs can provide technical assistance to entities involved with the reentry process. Complex operational, policy, and technology issues will arise during the reentry process that are specific to a given entity. Local and regional MCOs, because of their focused knowledge and experience in specific markets, are well positioned to provide expertise and guidance on issues ranging from care management to claims submission.

What’s Next?

As more states with pending 1115 waivers for reentry services for the justice-involved population gain approval, local and regional MCOs should anticipate engagement from states on planning and implementation in in 2024. Given this, taking action early to engage state partners and prepare your organization to serve this population is a prudent step to consider now.

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If you have questions about how HMA can support your efforts related to the Medicaid services for justice-involved populations and local and regional MCOs, please contact our experts below.

Future-ready: is your MCO equipped for change?

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Government Funded Programs and Readiness

As a local or regional managed care organization (LRMCO), being 鈥渞eady鈥� means proactively addressing all the areas where your organization can get tripped up, or worse, lose your contract with a state Medicaid agency. LRMCOs are heavily reliant upon government funded programs. These include Medicaid, Medicare, and Marketplace business. Most LRMCOs are not as heavily involved in the commercial market, either on a fully insured or self-insured basis, and even when they are, these areas comprise smaller parts of their overall product offerings. National MCOs have looked to Medicaid managed care to fuel growth, strengthen relationships with government partners, and leverage infrastructure.

In any government program, 鈥渞eadiness鈥� is a critical capability that often gets overlooked due to the daily pressures of running the organization. It鈥檚 often said that 鈥測ou should always be audit ready.鈥� The meaning of this is that you and your organization should always be prepared to undergo an outside audit from your regulator, financial auditor, or other entity such as the National Committee for Quality Assurance. Having a well-run organization allows you to not only be ready to respond to regulators or auditors but also to be able to demonstrate stable financial, operational, and compliance performance. Having this stable base of performance allows for more meaningful strategic planning, innovation, and state and federal partnership.

In Medicaid and other government programs, where public purchasers follow stringent purchasing rules, perhaps another way to think of your MCO鈥檚 operations is to always be 鈥減rocurement ready.鈥� But what does it mean to be 鈥減rocurement ready鈥� for your MCO? Today, managed care is the primary Medicaid delivery system vehicle for most states across the country. While some states procure all Medicaid managed care services in single, comprehensive contracts, many states procure for services via specific programs. Managed long-term services and supports, behavioral health, dental, and other programs are examples of specific programs that states procure alongside those that states have procured historically including low-income children and their parents, pregnant women, people with disabilities, people aged 65 and older, and, with advent of the Affordable Care Act, low-income adults without dependent children. State Medicaid managed care contracts are typically three to five years in duration, often with single or multiple year optional extensions. What this means is that in any given year there are approximately 10 Medicaid managed care program procurements. Moreover, these procurements are now among the largest contracts awarded by states, often exceeding billions of dollars per year. As a result, the importance of being ready for these events has grown substantially over the years.

Being 鈥淩eady鈥� Means Being Prepared and Planning in Advance

A critical element of being 鈥減rocurement ready鈥� is not to rely upon fixing issues when a Medicaid request for proposal (RFP) appears likely; it is to be on top of requirements on an ongoing basis, address issues quickly, and capture success stories as they happen. Too often, LRMCOs don’t look to begin this process until it is too late鈥攁 small issue has become a big problem and remediation is expensive, time-consuming, and painful. Even the best proposal will struggle to win in the face of a record of real or perceived suboptimal performance.

The reality is that states are asking for MCO results (Healthcare Effectiveness Data and Information Set scores, state audit findings, Health Insurance Portability and Accountability Act breaches, etc.) as part of RFPs. These data points are hard to hide even with great writing and presentation. States are also more frequently including member or case 鈥渟cenarios鈥� in RFPs, which are specific in nature and are designed to have the MCO describe exact steps, processes, and outcomes. It is therefore important to monitor and measure for performance year-round.

For incumbent LRMCOs, the best way to maximize your chances of winning a renewal is to deliver effectively鈥攁nd to be seen as delivering effectively鈥攐n your existing contract. A well performing incumbent LRMCO has tremendous advantages because:

Switching vendors is risky and painful for states, even under the best of circumstances.
Competitors are less likely to bid when they know the incumbent is well-regarded by the state.
The key to delivering effectively is continuous assessment and adjustment, so LRMCOs identify potential issues early and can address them before they mushroom into bigger problems.

The time to begin preparing for your next procurement is while you begin to deliver under the existing procurement, not three months before a new procurement.

Best practice is to begin RFP planning 18 months to 24 months in advance of the anticipated issuance date. That planning should include developing 鈥渨in strategies,鈥� competitive assessments, and proposal logistics. Putting remediation initiatives on top of these areas adds unnecessary stress and strain on the LRMCO and the teams responsible for delivering a winning proposal. Therefore, being 鈥減rocurement ready鈥� is an important and often critical element in ultimately preparing winning proposals.

States look for 鈥減artners鈥� not just contractors. LRMCOs can serve as invaluable thought partners to help inform how states can meet their stated policy aims. This not only puts LRMCOs in good standing with state leaders, but it also means they are well informed about state thinking so they won鈥檛 be caught by surprise if new requirements appear in the next RFP.

States frequently provide vague guidance on when RFPs will be released (鈥渆arly next year,鈥� 鈥渋n the second quarter鈥�, etc.) Some states have published concrete schedules for their multiple RFPs, but this is the exception. The implication for LRMCOs is that it is very difficult to 鈥渢ime鈥� when to get your operations optimally ready for a forthcoming RFP. A wiser approach is to always be ready for an RFP to drop (again, like being audit ready). Some operational, performance, or compliance issues can be addressed in fairly short time frames. Other areas, such as quality reporting, require about a two-year lead time to fix any problems, gather the data, and exhibit optimal performance due to data/reporting lag. Other areas that require longer lead times are claims, encounter data reporting, risk adjustment, delegation oversight, and many others. Due to the lead times required, to be always 鈥減rocurement ready,鈥� LRMCOs need to have robust operational readiness and monitoring programs established as part of daily operations.

Strategies for Achieving and Maintaining Audit Readiness and Contract Compliance

As noted earlier, strong performance on audits and a consistent record of impressive compliance is an advantage when participating in RFP processes. States prefer to contract with MCOs that have a robust track record of compliance and can persuasively demonstrate their ability to consistently meet the needs of members. Strategies that LRMCOs can employ to develop such a track record include:

Develop Robust Compliance Programs: LRMCOs should establish comprehensive compliance programs that include policies and procedures, training, monitoring, and auditing. These programs should address all aspects of contract compliance and the specific requirements of the state鈥檚 program.
Internal Controls and Documentation: LRMCOs should implement internal controls to monitor and measure contract compliance regularly. In addition, organizations should maintain thorough documentation of all activities, decisions, and communication. This documentation serves as evidence during audits and demonstrates a commitment to compliance.
Regular Audits and Self-Assessments: LRMCOs should conduct regular self-assessments and internal audits to identify and rectify potential compliance issues before external audits occur. This proactive approach helps mitigate risks and ensures continuous improvement.
Data Management and Reporting: LRMCOs should develop robust data management systems to collect, store, and report the necessary data. Accurate and timely reporting is essential for demonstrating compliance with performance measures and outcomes.
Staff Training and Awareness: LRMCOs should ensure that staff members are well-trained and aware of their roles in maintaining contract compliance. Regular training sessions can keep employees updated on changing regulations and requirements.
External Auditors and Consultants: LRMCOs should consider engaging external auditors and consultants with expertise in compliance to conduct independent reviews and provide recommendations for improvement.
Continuous Quality Improvement: LRMCOs should implement continuous quality improvement processes to enhance the quality of care delivered to members. This demonstrates a commitment to improving health outcomes and can positively influence contract awards.

The Value of a Proactive Approach

To be continuously “procurement ready,” LRMCOs must be forward-thinking and adaptive. Embracing change, data-driven decision making, quality improvement, building strong provider networks, investing in technology, engaging stakeholders, and maintaining financial stability are all essential steps to ensure the sustainability and success of these organizations in the intervening years between state-issued RFPs. By taking a proactive approach to addressing these needs, LRMCOs can position themselves as leaders in providing high-quality health care services for the members they serve.

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Government Funded Programs and Readiness

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The Value of a Proactive Approach

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