Managed Care

Highlights from this Week’s HMA Conference on The Next Wave of Medicaid Growth and Opportunity

This week, our In Focus section provides a recap of the fourth annual HMA Conference, The Next Wave of Medicaid Growth and Opportunity: How Payers, Providers, and States are Positioning Themselves for Success, held this Monday, September 9, and Tuesday, September 10, in Chicago, Illinois. Nearly 500 leading executives representing managed care organizations, providers, state and federal government, community-based organizations, and other stakeholders in the health care field gathered to address the challenges and opportunities for organizations serving Medicaid and other vulnerable populations. Conference participants heard from keynote speakers, engaged in panel discussions, and connected during informal networking opportunities. Below is a summary of highlights from this year’s conference.

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Hawaii Releases Quest Integration Medicaid Managed Care RFP

This week, our In Focus section reviews the Hawaii QUEST Integration (QI) Medicaid Managed Care request for proposals (RFP), issued by the Hawaii Department of Human Services (DHS) on August 26, 2019. DHS intends to contract with four health plans. All four will serve Medicaid and Children’s Health Insurance Program (CHIP) members in Oahu, while two will also operate statewide. The two plans with the highest scoring technical proposals will serve beneficiaries statewide. The Quest Integration program is worth $2.2 billion annually.

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CMS Medicare Fee-For-Service FY2020 Proposed Rules: Hospital Outpatient Department and End-Stage Renal Disease

This week, our In Focus section reviews the new Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service FY 2020 proposed rules. On July 29, 2019, CMS issued the Calendar Year (CY) 2020 proposed rules for the Physician Fee Schedule (PFS), the hospital outpatient department (HOPD) and ambulatory surgical center (ASC) prospective payment systems (PPS), and the End-Stage Renal Disease (ESRD) PPS. These proposed regulations include payment rate and policy changes for the upcoming calendar year. The comment deadline for all three of these proposed rules is September 27, 2019.

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California 2019-20 Budget Overview

This week, our In Focus section reviews the California fiscal 2019-20 budget. California Governor Gavin Newsom signed his first budget, and much of its related legislation on June 27, 2019. The budget appropriates $214.8 billion ($147.8 billion General Fund) in total spending with $19.2 billion in reserves. The total reserves includes $16.5 billion in the Rainy Day Fund, $1.4 billion in the Special Fund for Economic Uncertainties, $900 million in the Safety Net Reserve, and nearly $400 million in the Public School System Stabilization Account.

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Dual Eligible Financial Alignment Demonstration Enrollment Update

This week, our In Focus section reviews publicly available data on enrollment in capitated financial and administrative alignment demonstrations (“Duals Demonstrations”) for beneficiaries dually eligible for Medicare and Medicaid (duals) in nine states: California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, and Texas. Each of these states has begun either voluntary or passive enrollment of duals into fully integrated plans providing both Medicaid and Medicare benefits (“Medicare-Medicaid Plans,” or “MMPs”) under three-way contracts between the state, the Centers for Medicare & Medicaid Services (CMS), and the MMP. As of May 2019, approximately 372,600 duals were enrolled in an MMP. Enrollment was flat from May of the previous year.

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New Opportunities and Requirements for Integrated Managed Care Models for Medicare-Medicaid Dually Eligible Individuals Served by Health Plans

This week, our In Focus section provides a high-level overview and an analysis for how health plans should consider two related and significant policy statements from the Centers for Medicare & Medicaid Services (CMS) about opportunities to further integrate care for dually eligible individuals.  Specifically, the CMS April 24, 2019, State Medicaid Director letter (SMDL) outlines new opportunities for states, largely working with health plans, to test models of integrated care, including opportunities to continue current financial alignment initiatives (FAIs).[i] CMS also issued final rules related to Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) definitions and requirements for Medicare-Medicaid integration activities and unified grievances and appeals for calendar year 2021.[ii] Together, these guidance documents should present greater opportunities for health plans to partner with CMS and states to integrate care for dual eligible beneficiaries.[iii]

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HMA Collaborates on Connecticut HEC Initiative

The Connecticut Office of Health Strategy and Department of Public Health recently announced that the State Innovation Model (SIM) Healthcare Innovation Steering Committee has approved the Health Enhancement Community (HEC) initiative proposed framework. This blueprint is designed to build or expand collaborations across the state to improve healthy weight and physical fitness, advance child well-being, and strengthen health equity. The HEC initiative will further residents’ health and well-being by addressing both clinical need and the social determinants that impact overall health.

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HMA Analysis of Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses Final Rule

On May 16, 2019, the Centers for Medicare & Medicaid Services (CMS) issued its final rule, Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses (Final Rule). The proposed rule, which was issued in November 2018, included a number of provisions intended to improve drug price transparency and expand use of utilization management tools to further Medicare Advantage and Part D cost-cutting efforts. However, in response to significant pushback from beneficiary advocates, physician groups, insurers, and pharmaceutical stakeholders, CMS elected not to implement key provisions. These include proposals to allow Part D plans to exclude protected class drugs from formularies as a result of price increases or if the drug is a new formulation of an existing single-source drug as well as proposed reforms to pharmacy price concessions that would require discounts be passed on to beneficiaries at the point of sale. Commenters in opposition to the pharmacy price concession proposal contend that these reforms would result in higher Part D premiums. While CMS has postponed addressing this provision in this Final Rule, the recently issued Department of Health and Human Services (HHS) Office of Inspector General (OIG) proposed rule, if finalized, may include fundamental changes to these pricing arrangements and other federal safe harbors to the anti-kickback statute. 

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Kentucky Releases Medicaid MCO RFP

This week, our In Focus section reviews the Kentucky Medicaid managed care organizations (MCOs) request for proposals (RFP), issued by the Kentucky Finance and Administration Cabinet on May 16, 2019. The Kentucky Cabinet for Health and Family Services (CHFS), Department for Medicaid Services (DMS) will select up to five Medicaid MCOs to manage health care services for more than 1.2 million people, starting July 2020. Contracts are estimated at more than $7 billion.

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