COVID-19 Resources & Support

Should you put the PHE’s Medicaid unwinding at the top of your to-do list?

While the current federal COVID-19 Public Health Emergency (PHE) declaration could be in place through the winter months, HMA’s team of experts see many reasons to put the PHE’s Medicaid unwinding planning at the top of your list now.

Without an extension, the PHE declaration will expire on January 11, 2023. U.S. Department of Health and Human Services (HHS) officials pledged to provide 60-days’ notice before ending the PHE. As a result, since HHS did not announce an extension by November 12, we can assume that HHS Secretary Xavier Becerra will extend the PHE beyond January.

However, congressional leaders are again considering proposals that would impact the PHE’s Medicaid policies. Such a change could advance during the lame duck session of Congress. For a variety of reasons, lawmakers could seek a statutory change that would de-link Medicaid’s continuous enrollment requirement, the 6.2 percentage point increase in the federal Medicaid match, and other Medicaid maintenance of effort policies from the PHE declaration. Congress could set a specific date for ending these Medicaid policies. Doing so would provide more certainty for planning for the end of the continuous Medicaid enrollment policy and its downstream implications for health insurance programs.

What can Medicaid agencies, health plans, providers and other stakeholders do now?

The transition from Medicaid’s continuous enrollment requirement to normal eligibility operations involves a myriad of policy decisions and operational changes that will impact enrollees. In turn, the end of Medicaid’s continuous coverage policy will also have great bearing on the business and operational strategies of managed care plans, providers and other stakeholders participating in the Medicaid and Marketplace programs.

HMA’s experts are working with state agencies, health plans, hospitals and health systems, and other stakeholders to identify options and workable solutions to prepare for these major changes. This work touches policy, organizational workstreams, systems, and payment. There are issues specific to Medicaid as well as the intersection with Marketplace, the Supplemental Nutrition Program (SNAP), and other public programs.

Combining our collective on-the-ground experience in states with our federal policy insights, experts from across the HMA family of companies list below themes and immediate actions stakeholders can consider. These action steps are focused on ensuring states, managed care plans, providers and other stakeholders are prepared to immediately respond to the end of the Medicaid continuous enrollment policy and work with individuals to provide information and other support they may need to stay enrolled in a coverage program.

1. Monitor and prepare for federal activities, particularly during the lame duck session of Congress and into 2023. Healthcare policies are likely to feature prominently in Congress’ lame duck session in November and December. Decoupling the Medicaid continuous enrollment and enhanced Federal Medical Assistance Percentage (FMAP) policies from the PHE is one issue under consideration. Any statutory changes to these policies may also include new requirements for the unwinding process. Stakeholders will want to closely monitor these discussions.

If Congress sets a statutory end date for the PHE’s Medicaid eligibility policies, this will provide the certainty needed for states to finalize PHE unwinding action plans with target dates for resuming normal eligibility operations. Notably, this may also drive conversations during states’ 2023 legislative sessions.

Consider the impact to your state and your organization – and any decisions you’ll be faced with – if the enhanced FMAP is decoupled from the PHE.  For example, if your state had the option to maintain continuous eligibility without the enhanced FMAP, would it do so?  States and stakeholders will want to revisit their Medicaid unwinding plans, consider options for meeting any new requirements, and update existing plans accordingly. Also, stakeholders can offer to serve as a resource to your state Medicaid agency and/or Congressional delegation regarding lame duck legislative proposals pertaining to Medicaid and the PHE.

2. Stay informed about state-specific landscapes. With statewide elections largely decided and expectations for a PHE end date sometime in the first part of 2023, now is the time for stakeholders to revisit when and how to engage with state Medicaid and other state agencies to support Medicaid eligibility unwinding plans. Stakeholders will want to solidify strategies and timing for engaging with states as unwinding plans are further solidified and eventually implemented.

Stakeholders can also monitor changes to states’ eligibility and enrollment rules – including initiatives designed to simplify eligibility rules, enhance eligibility and enrollment systems, and adjust managed care rate setting policies, among others. Many states are utilizing the temporary federal Medicaid flexibilities to alleviate the significant eligibility unwinding workload. Federal agencies also continue to regularly publish new information for states and stakeholders to consider. Some states are implementing policies designed to improve the transition from Medicaid to Marketplace. Understanding the implications of such policies will help stakeholders anticipate how ending Medicaid’s continuous coverage requirement will directly affect them.

3. Refresh strategies and messaging for outreach and assistance. While the PHE end date remains in flux, state plans for ending the Medicaid continuous coverage policy are still evolving. States are refining their beneficiary communication plans and may be developing updated guidance for stakeholders. Health plans, providers, and other stakeholders should align their messaging and outreach work accordingly and continue to build partnerships in communities across the state.

However, outreach alone will not be enough to reach all Medicaid enrollees. Many will need assistance in understanding and complying with changes that come with the end of the continuous enrollment policy. For example, stakeholder-provided redetermination assistance will be key to minimizing the number of enrollees who lose coverage for failure to complete the redetermination process and state requirements for stakeholder assistance will vary state by state.  

4. Update projected impact of enrollee transitions between Medicaid and Marketplace programs. For states and stakeholders, especially health plans, it is time to update projections about 2023 Medicaid and Marketplace enrollment. This may also require new analysis and strategies to address the changing population acuity and resulting impact on capitation revenue. For healthcare providers, health systems, and other healthcare facilities, the end of the Medicaid continuous enrollment policy is expected to drive significant changes in payer mix, and it could reduce revenue as well as impact qualifications for special payment programs, the 340B program, among others. Understanding these dynamics can help with budgeting and implementation of specific patient outreach and support strategies.

5. Develop strategies to translate experiences from Medicaid to Marketplace. Medicaid agencies, managed care plans, and providers have gained valuable insights about the needs of individuals who have remained continuously enrolled in Medicaid during the COVID-19 PHE. This is particularly true for Medicaid enrollees diagnosed with a mental illness, substance use disorder, or both. Medicaid providers and health plans have gained valuable insight on effective clinical care models, whole person care, partnerships with community-based organizations and reimbursement strategies that can better meet the needs of complex populations. Providers and plans can utilize these experiences to better support the millions of individuals who are expected to become eligible for Marketplace coverage after Medicaid’s continuous enrollment policy ends.

The HMA team continues to monitor the dynamic state and federal policy landscapes, including state planning documents and new federal guidance and informational tools. We have the ability to support stakeholders to prepare for the end of PHE and to support state and communities by modeling projected enrollment and payer mix changes across health coverage categories. Stakeholders should be using this time to address gaps in their plans for PHE unwinding and continue to identify and evaluate new options that may emerge to support beneficiaries in retaining health coverage.

This blog was written by Jane Longo, Andrea Maresca and Bill Snyder.

HMA Identifies Key Trends for Emerging Medicaid Section 1115 Demonstration Proposals

As the urgent needs of COVID-19 Public Health Emergency (PHE) continue to subside, state Medicaid agencies are exploring pathways and concepts to further address the historic inequities and health disparities laid bare by the pandemic. These efforts are closely aligned with the current Administration’s policy objectives for the Medicaid program, specifically:

  1. Addressing health equity
  2. Improving access and coverage
  3. Promoting whole person care

For several decades, Medicaid Section 1115 demonstration programs have provided a powerful lever for federal and state policymakers to design, implement, and evaluate transformative initiatives. All states administer at least one Section 1115 demonstration program. Some demonstrations are narrowly tailored to address services or populations while others capture broader features pertaining to coverage, benefits, and payment and delivery system innovations.

Notably, a new wave of comprehensive and transformative Medicaid Section 1115 demonstration proposals is emerging.

Working closely with the Centers for Medicare and Medicaid Services (CMS), states are developing proposals that place individuals at the center of health care in an entirely new way – by recognizing their medical needs as well as the complexity of circumstances and environmental factors that shape the individual’s medical, physical, and behavioral care needs and outcomes.

Teams of experts from across the HMA family of companies are supporting state agencies, counties, health plans, providers, community and consumer organizations, and other stakeholders with translating federal goals and parameters into concrete proposals as these move through the stages of concept paper, application and negotiation, and implementation. Demonstrations will reflect each state’s unique political and policy landscapes, but the programs will be grounded in certain federal goals and expectations to enhance accountability and improve outcomes.

Our experts identified three trends in state 1115 demonstration programs. In this and subsequent In Focus posts we will share our team’s initial insights and considerations for stakeholders based on our collective “on the ground” expertise. We include illustrative examples from some states with approved and pending Section 1115 proposals.

Section 1115 Trend #1: States are advancing a new vision for Medicaid’s role in addressing health equity, influenced by social drivers and grounded in a community’s needs.

CMS is strongly encouraging states to consider initiatives that address health inequities and community specific social drivers of health. As evidenced by the current state initiatives, Section 1115 demonstration programs will be a primary — but not the only — pathway states utilize to design strategies to address health inequities driven by non-health systems and circumstances. Based on our work with states and stakeholders, it is critical that states ensure the services are directly linked to factors that impact health outcomes for Medicaid enrollees and that they have mechanisms to evaluate the impact of community and social care services.

Several state proposals already signal CMS’ current vision for using Section 1115 authority to test new types of assistance within service categories to include non-medical services, services tailored to populations, and assistance that is linked to desired outcomes. For example:

North Carolina’s Section 1115 pilot program will provide support to certain groups of consumers for an array of community supports ranging from housing related services and transportation access to interpersonal violence and access to food and nutrition services. The program includes help for consumers related to utility set up and moving costs, and support to connect with community services to address legal issues impacting housing and thereby impacting health.

In December 2021, CMS approved California’s Section 1115 demonstration program and linked this to a separate waiver approval allowing the state to further enhance services and accountability within its managed care program. As part of California’s implementation of its statewide whole person care initiative, the state will be able to pay for housing navigation and tenancy services and assistance with first month deposits for certain populations enrolled in its statewide managed care program. This proposal is grounded in the state’s commitment to ensure that the non-medical services were clearly defined and clinically oriented for the intended population.

CMS’ approval of the North Carolina and California programs is paving the way for conversations in other states, including New York, New Jersey, and Oregon among others. Negotiations on similar initiatives to address health equity in other states, include:

New York, like North Carolina, plans to seek CMS’ approval to offer a range of community services that would be provided through newly established networks of community-based organizations in all regions of the state. The state envisions that the CBO networks will include small neighborhood organizations familiar with their communities’ needs and the capacity to address multiple social risk factors as well as larger county or regionally focused entities. In addition, New York is asking CMS to support a health equity focused proposal which would provide certain “in-reach” services for incarcerated individuals before they are released.

Oregon submitted a request to use federal Medicaid spending authority to address community-based health inequities and to establish statewide health equity investments (HEIs). The state is especially focused on supporting consumers during disruptions in coverage, life transitions, or disruptions caused by climate events. Community-based investments will reflect empirical evidence and community assessments and may include efforts to improve building environments and expand culturally and linguistically. Addressing climate events may be of particular interest as it addresses multiple priorities for Administration.

Conclusion

North Carolina and California offer important insights into what may be possible and as importantly, what may be beyond the bounds of CMS’ Medicaid authority. Chief among the outstanding issues for states and stakeholders is whether additional innovative programs for addressing health disparities among justice-involved populations is possible under Medicaid’s demonstration authority.

CMS may use the experience with initial states to provide more concrete information on these general parameters and expectations. Formal guidance would prove helpful to states and stakeholders seeking to apply new knowledge and experiences with health inequities into practice within the Medicaid programs.

HMA’s interdisciplinary teams of Medicaid, human services, and actuarial experts are assisting states as well as stakeholders as they conceptualize, develop, and implement Section 1115 programs. To learn more about our work and the breadth of our services please contact HMA consultant Andrea Maresca, Principal.

Which Medicare Changes Should Continue Beyond the COVID-19 Pandemic? Four Questions for Policymakers

In an issue brief prepared for The Commonwealth Fund and The SCAN Foundation, HMA consultant Jennifer Podulka and Vice President Jonathan Blum, analyze the temporary COVID-19-related changes to Medicare regulations, described the benefits and risks of the changes, and offered a framework to support policymakers’ decisions on the future of these temporary policies.

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A Short-Term Path to Avoid ACA Uncertainty as the Pandemic Continues

In this week’s In Focus section, Health Management Associates (HMA) Managing Director MMS Matt Powers, Senior Consultant Kaitlyn Feiock, and Regional Vice President Kathleen Nolan look at the future of the Patient Protection and Affordable Care Act (ACA). On November 10, 2020, the Supreme Court of the United States (SCOTUS) heard oral arguments for California v. Texas, challenging the constitutionality and severability of the ACA.  This challenge became possible after the 2017 Tax Cuts and Jobs Act, which zeroed out the individual mandate penalty for not purchasing health insurance.  While most experts agree that an entire invalidation of the ACA is the least likely outcome based on the oral arguments, some uncertainty remains and more than $100 billion federal funds are at risk. The ACA standardized insurance rules offset premium costs for many individual market consumers and provided authority and funding for Medicaid Expansions in the overwhelming majority of states. The ACA also included other provisions that may be at risk but are not the subject of this note, such as the creation of Center for Medicare and Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office, as well as demonstration authority that has led to the creation of numerous coverage models.  As states, Congress, and the federal executive branch face the possibility that the ACA may not survive in its present form, what mitigation strategies are available at the state and federal levels to stabilize uncertainties and protect against abrupt coverage changes?

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Regulatory Changes to Medicare in Response to COVID-19

This week, our In Focus section examines how the federal government implemented changes to the Medicare program in response to COVID-19.  As the COVID-19 pandemic began in the United States, Congress and the Administration responded with a series of legislative, regulatory, and sub-regulatory changes to the Medicare program that were designed to provide relief from certain Medicare rules to assist health care providers, Medicare Advantage organizations, and Part D plans in responding to the pandemic. Some of these changes waived conditions of Medicare participation to enable patients to be treated in alternative care settings. Others permitted physicians and other providers to receive Medicare reimbursements for telemedicine services.

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Impact of COVID-19 Federal Policy on Medicare Advantage

This week, our In Focus section examines the operational impacts of federal Medicare Advantage policy changes in response to the COVID-19 pandemic. On January 31, 2020, the Secretary of Health and Human Services declared a public health emergency. This was followed by a national emergency declared by President Trump on March 13, 2020. These declarations provide the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) authority to waive certain Medicare and Medicaid regulatory requirements to help health plans, providers, and other stakeholders respond to immediate needs of their members and communities. These waiver flexibilities, when combined with other legislative and regulatory changes issued by Congress and CMS have resulted in over 200 policy changes to Medicare alone. Many of these affect Medicare Advantage sponsors and have direct implications to current and future operations of plan responsibilities. We examine eight categories of requirements and flexibilities that have significant business relevance and exposure for Medicare Advantage plan sponsors:

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Medicare FY 2021 Hospital Inpatient Proposed Rule, Federal Flexibilities for COVID-19

This week, our In Focus section reviews recent announcements and actions by Congress and the Centers for Medicare & Medicaid Services (CMS) that have significant financial and operational implications for the hospital industry. This brief begins with the most recent of these actions by providing a summary of the key provisions of the CMS Fiscal Year (FY) 2021 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Proposed Rule (CMS-1735-P), which includes Medicare payment updates and policy changes for the upcoming FY, with a comment deadline of July 10, 2020.  Although somewhat limited in scope compared to previous proposals, this year’s proposed rule includes several disruptive proposals that the hospital industry should carefully consider.

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