Long-Term Services and Supports

Massachusetts releases RFR for One Care and Senior Care Options

This week, our In Focus section reviews the request for responses (RFR) for the Massachusetts One Care and Senior Care Options (SCO) programs, released by the Massachusetts Executive Office of Health and Human Services (EOHHS) on November 30, 2023. The programs provide physical, behavioral, long-term services and supports (LTSS), and other community services to Medicare and Medicaid dual-eligible beneficiaries. Implementation is set to begin January 1, 2026.

One Care

One Care launched in 2013 as a Section 1115 Medicare-Medicaid Plan (MMP) program dual demonstration waiver. It operates under a financial alignment initiative (FAI) capitated model. The program provides integrated care to dual eligible adults ages 21 to 64. Individuals may remain enrolled in One Care when they turn 65 years old as long as they continue to meet all other requirements. Members can also access an independent LTSS coordinator.

As the Centers for Medicare & Medicaid Services (CMS) sunsets the FAI dual demonstrations, One Care will shift to a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) beginning in 2026, pending federal approval of the Section 1115 amendment request. Members will have exclusively aligned enrollment with the same plan for both Medicare and Medicaid coverage.

SCO

SCO launched in 2004 and is currently a FIDE SNP with exclusively aligned enrollment. Medicaid enrollees ages 65 and older with or without Medicare are eligible. Enrollment in this managed care program is voluntary. Individuals on the Frail Elder Waiver can only join SCO.

RFR

Massachusetts will award separate contracts for One Care and SCO but may prefer bids from plans seeking to operate both; however, plans may submit bids to operate one type of plan. The state seeks to offer both One Care and SCO coverage for eligible individuals in as many counties as possible, and ideally statewide. Plans must propose to cover people in at least six counties for each type of plan.

To be selected, plans will need to have a contract with CMS to operate a FIDE SNP in Massachusetts in 2026. Applications must be submitted to CMS by February 2025.

Timeline

Letters of intent are due February 15, 2024, and the deadline for responses is March 22, 2024. Plans will be selected by November 1, 2024. Implementation is set to begin January 1, 2026. Contracts will run an initial five-year term through December 31, 2030. Contracts may be renewed for up to five years in any increment.

Current Market

Commonwealth Care Alliance, Tufts, and UnitedHealthcare serve 43,000 One Care members.

SCO incumbents WellSense Senior Care Options (formerly BMC Healthnet), Commonwealth Care Alliance, Fallon Health, Molina/Senior Whole Health, Tufts, and UnitedHealthcare serve 77,000 members.

Link to RFP

Arizona releases Medicaid ALTCS-EPD Program RFP

This week, our In Focus section reviews the Arizona Long Term Care System (ALTCS) Elderly and Physically Disabled (EPD) Program request for proposals (RFP), which the Arizona Health Care Cost Containment System (AHCCCS) released on August 1, 2023. The ALTCS-EPD program covers 26,000 individuals, representing approximately 38 percent of the ALTCS managed care population. The remaining ALTCS members are covered under a state-run model through the Department of Economic Security, Division of Developmental Disabilities (DES/DDD) health plans, which provide long-term care (LTC) to individuals with intellectual/developmental disabilities. Contracts for ALTCS-EPD are worth approximately $1.6 billion and will take effect October 1, 2024.

Background

ALTCS is one of the oldest Medicaid managed long-term services and supports (MLTSS) programs in the country, providing integrated physical health, behavioral health, and LTSS to individuals who are 65 years of age or older or who have a disability and require nursing facility level care. Beneficiaries may live in assisted living facilities or receive in-home services. The ALTCS-EPD program covers nearly all Arizonans who are dually eligible for Medicaid and Medicare statewide. Winning managed care organizations (MCOs) also will be required to implement companion Medicare Advantage Fully Integrated D-SNPs (FIDE SNPs) effective January 1, 2025.

Market

Members receive coverage through Banner-University Family Care, Mercy Care Plan, and UnitedHealthcare, depending on their geographic service area (GSA). MCOs will bid on all three GSAs and indicate their order of preference to be awarded. AHCCCS will not award the South GSA only or the North GSA only. At present, in the South region, Mercy Care Plan serves Pima County only. Under the new RFP, AHCCCS will not make an award specific to Pima County; rather the MCO will serve all seven counties within the South GSA.

Together, the plans cover 25,973 individuals (see below).

(United and Mercy administer DDD plans.)

Timeline

Intent to bid forms are due by August 31. Proposals are due October 2, and awards are expected to be announced December 13. As noted previously, implementation is scheduled to begin October 1, 2024.

RFP Link

New CMS dementia care model emphasizes role of caregivers

This week, our In Focus section reviews the new Guiding an Improved Dementia Experience (GUIDE) Model, announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) on July 31, 2023.

In addition to announcing the Innovation Center’s GUIDE Model, CMS released five final fiscal year (FY) 2024 payment rules this past week. Of note, these regulations set higher than anticipated reimbursement rates for many providers:

CMS also released the 2024 projected Medicare Part D premium and bid information, which may provide early indications on the effects of the Inflation Reduction Act’s drug pricing policies.

GUIDE Model: Parameters and Opportunities

President Biden signed an Executive Order in April 2023 on Increasing Access to High-Quality Care and Supporting Caregivers. The order directed the Innovation Center to develop a payment and delivery system model for dementia care. The program is intended to improve the quality of life for people living with dementia, reduce strain on unpaid caregivers, and help people remain in their homes and communities through improved care coordination and management, caregiver education and support, and respite services.

The announcement this week outlines the basic parameters of the model, which track with CMS’s focus on reducing health disparities, supporting innovation, and addressing affordability. CMS expects that the model’s additional support for caregivers will reduce federal spending on hospitalizations and post-acute care. Notably, CMS projects savings will come from reduced long-term nursing facility placement through a decrease in Medicaid spending on the federal medical assistance percentage (FMAP). Helping Medicare enrollees stay in their homes may also lower state spending on long-term care.

Additional information, including the application to participate, will be available this fall. In the meantime, CMS is accepting letters of interest through September 15, 2023. The model will begin on July 1, 2024, and run for eight years.

HMA’s experts identified the below list of policies that will be important for provider organizations, caregivers, and other stakeholders considering participation in the model:

  • GUIDE Model participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, that are eligible to bill for Medicare physician fee schedule services and agree to meet the care delivery requirements.
  • The GUIDE Model comprises two tracks for participation—one for established programs and another for new programs.
    • Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record (EHR) platform that meets the standards for certified EHR technology, and meet other care delivery requirements as outlined in the request for applications.
  • If a participant cannot meet the GUIDE healthcare delivery requirements alone, CMS will allow the provider or supplier to partner with other Medicare organizations, to meet the mandates.
  • The model also includes policies designed to reduce disparities in dementia care. For example, CMS plans to conduct outreach with organizations that do not yet offer comprehensive dementia care or lack prior experience with alternative payment models such as safety net providers. Participants also will need to develop health equity plans, and a “health equity adjustment” will be made to payments for providers that serve disadvantaged beneficiaries.
    • CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for participation.
  • CMS will test an alternative payment methodology for participants that deliver key care management and coordination services to people with dementia and their family caregivers, including comprehensive, person-centered assessments and care plans; 24/7 access to a helpline; and caregiver support and education, such as training on how to best care for a relative with dementia. CMS clarifies that GUIDE is not a shared savings or total cost of care model and does not address coverage of novel Alzheimer’s drugs.
  • Participants will assign Medicare fee-for-service beneficiaries, including people who are dually eligible for Medicare and Medicaid, living with dementia and their caregivers to a care navigator. This individual will help people access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants will also help caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities. Evidence demonstrates that respite enables caregivers to care for individuals with dementia at home for a longer period, thereby forestalling institutional placement.

CMS will host a webinar with more details about the model on Thursday, August 10, from 2:00−3:00 pm.

The HMA team will continue to evaluate the GUIDE model and other Innovation Center opportunities. If you have any questions about the model, contact Amy Bassano, Barry Jacobs, or Maddy Shea.

We also can assist with questions about any of the new regulations. Contact Zach Gaumer, Andrea Maresca or Amy Bassano.

We also would like to remind our readers that the HMA team hosted a webinar last week on the Medicare Behavioral Health proposed changes. We previously discussed those changes in the July 19, 2023 In Focus. If you missed the webinar, you can find the recording and slides on the HMA website.

HMA annual conference on innovations in publicly sponsored healthcare

Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth

Pre-Conference Workshop: October 29, 2023
Conference: October 30−31, 2023
Location: Fairmont Chicago, Millennium Park

Health Management Associates has announced the preliminary lineup of speakers for its sixth annual conference, Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth.

Hundreds of executives from health plans, providers, state and federal government, investment firms, and community-based organizations will convene to enjoy top-notch content, make new connections, and garner fresh ideas and best practices.

A pre-conference workshop, Behavioral Health at the Intersection of General Health and Human Services, will take place Sunday, October 29.

Confirmed speakers to date include (in alphabetical order):

  • Jacey Cooper, State Medicaid Director, Chief Deputy Director, California Department of Health Care Services
  • Kelly Cunningham, Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services
  • Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas
  • Mitchell Evans, Market Vice-President, Policy & Strategy, Medicaid & Dual Eligibles, Humana
  • Peter Lee, Health Care Policy Catalyst and former Executive Director, Covered California
  • John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan
  • Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation
  • Anne Rote, President, Medicaid, Health Care Service Corp.
  • Drew Snyder, Executive Director, Mississippi Division of Medicaid
  • Tim Spilker, CEO, UnitedHealthcare Community & State
  • Stacie Weeks, Administrator/Medicaid Director, Division of Health Care Financing and Policy, Nevada Department of Health and Human Services
  • Lisa Wright, President and CEO, Community Health Choice

Publicly sponsored programs like Medicare, Medicaid, and the Marketplaces are leading the charge in driving value, equity, and growth in the U.S. healthcare system. This year’s event will highlight the innovations, initiatives, emerging models, and growth strategies designed to drive improved patient outcomes, increased affordability, and expanded access.

Conference Agenda

Early bird registration ends July 31. Questions may be directed to Carl Mercurio at [email protected]. Group rates, government discounts, and sponsorships are available.

Register Now

New experts join HMA in April 2023

HMA is pleased to welcome new experts to our family of companies in April 2023.

Jed Abell – Consulting Actuary
Wakely

Jed Abell is a professional health insurance actuary with over 20 years of experience focusing on Medicare Advantage, Part D, and commercial employer group plans.

Surah Alsawaf – Senior Consultant
HMA

Surah Alsawaf is a senior consultant with experience in creating and implementing regulatory strategies and workflows, conducting reviews and audits, and leading cross-functional teams to complete complex deliverables.

Elrycc Berkman – Consulting Actuary
Edrington

Elrycc Berkman is experienced in Medicaid managed care rate development including managed long-term services and supports (MLTSS) and program of all-inclusive care for the elderly (PACE) rate development.

Monica Bonds – Associate Principal
HMA

Monica Bonds is an experienced managed care professional with over 15 years of experience working in large and diverse organizations.

Yucheng Feng – Senior Consulting Actuary
Wakely

Yucheng Feng has over 15 years of experience providing actuarial support for Medicare Advantage clients, including bid preparation, reserve, actuarial analytics and providing strategic recommendations. Read more about Yucheng.

Melanie Hobbs – Associate Principal
HMA

Melanie Hobbs is an accomplished healthcare executive, consultant, and thought leader specializing in Medicare, Medicaid, and Special Needs Plans (SNPs).

Daniel Katzman – Consulting Actuary
Wakely

Daniel Katzman is experienced in Medicare Advantage bid pricing and modeling as well as claims trend analytics and affordability/cost-savings analysis. Read more about Daniel.

Supriya Laknidhi – Principal
HMA

Supriya Laknidhi has over 20 years of experience in the healthcare industry and a proven track record in driving growth and innovation for companies.

Donald Larsen – Principal
HMA

Dr. Donald Larsen is a C-suite physician executive with over 30 years of experience spanning complex academic medical centers, community health systems, acute care hospitals, and research institutes.

Ryan McEntee – Senior Consultant
Wakely

Ryan McEntee is an experienced managed care executive specializing in strategic leadership within Medicare Advantage plans. Read more about Ryan.

Nicole Oishi – Principal
HMA

Nicole Oishi has over 30 years of experience in senior leadership roles as a healthcare clinician and executive.

Read more about our new HMA colleagues

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Surah Alsawaf

Senior Consultant

Elrycc Berkman

Elrycc Berkman

Consulting Actuary II

Monica Bonds

Monica Bonds

Associate Principal

Melanie Hobbs

Associate Principal

Don Larsen

Donald Larsen

Principal

2022 Yearly Roundup: a year of successful partnerships

The holiday season is grounded in gratitude. At HMA, we are grateful for successful partnerships that have fueled change to improve lives.

We are proud to be trusted advisors to our clients and partners. Their success is our success. In 2022 our clients and partners made significant strides tackling the biggest healthcare challenges, seizing opportunities for growth and innovation, and shaping the healthcare landscape in a way that improves the health and wellness of individuals and communities.

Reforming Colorado’s Behavioral Health System

HMA partnered with the Colorado Department of Human Services to support the planning and implementation of a new Behavioral Health Administration (BHA). HMA provided technical research and extensive stakeholder engagement, drafted models for forming and implementing the BHA, employed an extensive change management approach, and created a detailed implementation plan with ongoing support. Today the BHA is a cabinet member-led agency that collaborates across agencies and sectors to drive a comprehensive and coordinated strategic approach to behavioral health.

From Bid to Trusted Advisor

Wakely Consulting Group, an HMA Company, was engaged to support the launch of a Medicare Advantage (MA) joint venture partnership between a health plan and a provider system. Wakely was responsible for preparing and certifying MA and Medicare Part D (PD) bids, a highly complex, exacting, and iterative effort. The Wakely team quickly became a trusted advisor and go-to resource for the joint venture decision makers. The joint venture has driven significant market growth over its initial years, fueled by a competitive benefit package determined by the client product team.

Laying the Foundation for Modernizing Indiana’s Public Health System

In 2021 Indiana Governor Eric Holcomb appointed a 15-member commission to assess Indiana’s public health system and make recommendations for improvements. The Indiana Department of Health (IDOH) engaged HMA to provide extensive project management and support for six workstreams. HMA prepared a draft report summarizing public input as well as research findings and recommendations. The commission’s final report will form the basis of proposed 2023 legislation, including proposals to substantially increase public health service and funding across the state.

Multiple Clients Accepted into ACO REACH Model

In early 2022 HMA and Wakely Consulting Group, an HMA Company, assisted multiple clients with their applications to participate in the new CMS ACO REACH model. The purpose of this model is to improve quality of care for Medicare beneficiaries through better care coordination and increased engagement between providers and patients including those who are underserved. The team tailored their support depending on each client’s needs. The application selection process was highly competitive. Of the 271 applications received, CMS accepted just under 50 percent. Notably, nine out of the 10 organizations HMA and Wakely supported were accepted into the model.

Pipeline Research and Policy Recommendations to Address New Innovative Therapies

HMA, and subsidiaries The Moran Company and Leavitt Partners, were selected by a large pharmaceutical manufacturer to analyze the current pipeline of innovative therapies, examine reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process. The project equipped the client with a holistic understanding of future potential impacts and actions to address challenges in a detailed pipeline analysis of innovative therapies.

Early bird registration discount expires July 11 for HMA conference on the future of publicly sponsored healthcare, October 10-11 in Chicago

Be sure to register for HMA’s 2022 Conference by Monday, July 11, to get the special early bird rate of $1,695 per person. After July 11, the rate is $1,895.

Nearly 40 industry speakers, including health plan executives, state Medicaid directors, and providers, are confirmed for HMA’s The New Normal: How Medicaid, Medicare, and Other Publicly Sponsored Programs Are Shaping the Future of Healthcare in a Time of Crisis conference, October 10-11, at the Fairmont Chicago, Millennium Park.

In addition to keynote sessions featuring some of the nation’s top Medicaid and Medicaid executives, attendees can choose from multiple breakout and plenary sessions on behavioral health, dual eligibles, healthcare investing, technology-enabled integrated care, social determinants of health, eligibility redeterminations, staffing, senior care, and more.

There will also be a Pre-Conference Workshop on The Future of Payment Reform: Delivering Value, Managing Risk in Medicare and Medicaid, on Sunday, October 9.

Visit our website for complete details: https://conference.healthmanagement.com/ or contact Carl Mercurio at [email protected].  Group rates and sponsorships are available. The last HMA conference attracted 500 attendees.

State Medicaid Speakers to Date (In alphabetical order)

  • Cristen Bates, Interim Medicaid Director, CO Department of Healthcare Policy & Financing
  • Jacey Cooper, Medicaid Director, Chief Deputy Director, California Department of Health Care Services
  • Kody Kinsley, Secretary, North Carolina Department of Health and Human Services
  • Allison Matters Taylor, Medicaid Director, Indiana
  • Dave Richard, Deputy Secretary, North Carolina Medicaid
  • Debra Sanchez-Torres, Senior Advisor, Centers for Disease Control and Prevention
  • Jami Snyder, Director, Arizona Health Care Cost Containment System
  • Amanda Van Vleet, Associate Director, Innovation, NC Medicaid Strategy Office, North Carolina Department of Health & Human Services

Medicaid Managed Care Speakers to Date (In alphabetical order)

  • John Barger, National VP, Dual Eligible and Medicaid Programs, Humana, Inc.
  • Michael Brodsky, MD, Medical Director, Behavioral Health and Social Services, L.A. Care Health Plan
  • Aimee Dailey, President, Medicaid, Anthem, Inc.
  • Rebecca Engelman, EVP, Medicaid Markets, AmeriHealth Caritas
  • Brent Layton, President, COO, Centene Corporation
  • Andrew Martin, National Director of Business Development (Housing+Health), UnitedHealth Group
  • Kelly Munson, President, Aetna Medicaid
  • Thomas Rim, VP, Product Development, AmeriHealth Caritas
  • Timothy Spilker, CEO, UnitedHealthcare Community & State
  • Courtnay Thompson, Market President, Select Health of SC, an AmeriHealth Caritas Company
  • Ghita Worcester, SVP, Public Affairs & Chief Marketing Officer, UCare
  • Mary Zavala, Director, Enhanced Care Management, L.A. Care Health Plan

Provider Speakers to Date (In alphabetical order)

  • Daniel Elliott, MD, Medical Director, Christiana Care Quality Partners, eBrightHealth ACO, ChristianaCare Health System
  • Taylor Nichols, Director of Social Services, Los Angeles Christian Health Centers
  • Abby Riddle, President, Florida Complete Care; SVP, Medicare Operations, Independent Living Systems
  • David Rogers, President, Independent Living Systems
  • Mark Sasvary, Chief Clinical Officer, CBHS, IPA, LLC
  • Jim Sinkoff, Deputy Executive Officer, CFO, SunRiver Health
  • Tim Skeen, Senior Corporate VP, CIO, Sentara Healthcare
  • Efrain Talamantes, SVP & COO, Health Services, AltaMed Health Services Corporation

Featured Speakers to Date (In alphabetical order)

  • Drew Altman, President and CEO, Kaiser Family Foundation
  • Cindy Cota, Director of Managed Medicaid Growth and Innovation, Volunteers of America
  • Jesse Hunter, Operating Partner, Welsh, Carson, Anderson & Stowe
  • Bryant Hutson, VP, Business Development, MedArrive
  • Martin Lupinetti, President, CEO, HealthShare Exchange (HSX)
  • Todd Rogow, President, CEO, Healthix
  • Joshua Traylor, Senior Director, Health Care Transformation Task Force
  • James Whittenburg, CEO, TenderHeart Health Outcomes
  • Shannon Wilson, VP, Population Health & Health Equity, Priority Health; Executive Director, Total Health Care Foundation

CMS’s hospital inpatient regulation proposes the use of novel methods to calculate 2023 payment rates

This week, our In Focus section reviews the policy changes included in the Centers for Medicare & Medicaid Services’ (CMS) Fiscal Year (FY) 2023 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Proposed Rule (CMS-1771-P). This year’s IPPS Proposed Rule includes several important policy changes that will alter hospital margins and change administrative procedures, beginning as soon as October 1, 2022.

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Texas Releases STAR+PLUS RFP

This week, our In Focus section reviews the Texas STAR+PLUS managed care services request for proposals (RFP) released on March 31, 2022, by the Texas Health and Human Services Commission (HHSC). The STAR+PLUS program, including the STAR+PLUS Home and Community-based Services (HCBS) program, provides acute care services and Long-Term Services and Supports (LTSS) to the aged and disabled.

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Minnesota Releases Senior Health Options, Special Needs Basic Care RFPs

This week our In Focus reviews Minnesota Department of Human Services (DHS) requests for proposals (RFPs) for two of the state’s Medicaid managed care programs: Minnesota Senior Health Options/Minnesota Senior Care Plus and Special Needs BasicCare/Integrated Special Needs BasicCare. Both RFPs, released on October 25, 2021, cover health care services in all 87 Minnesota counties.

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