Managed Care

Florida releases procurement for statewide Medicaid prepaid dental program

This week, our In Focus section reviews the Florida Statewide Medicaid Prepaid Dental Program invitation to negotiate (ITN) released October 6, 2023, by the Florida Agency for Health Care Administration (AHCA). Contracts will serve 4.4 million Statewide Medicaid Managed Care (SMMC) members.

Background

The Florida Statewide Medicaid Prepaid Dental Program is a full-risk capitated dental program, which began rolling out by groups of regions in December 2018. The incumbent statewide Medicaid dental plans are DentaQuest, Liberty, and MCNA Dental.

Florida also is reprocuring its traditional managed medical assistance (MMA) program and managed long-term care program under SMMC. Awards for Medicaid managed care organizations (MCOs) are expected in February 2024.

ITN

Florida intends to award contracts to at least two plans. One of AHCA’s goals is to contract with plans that will support the HOPE Florida: Pathways to Prosperity initiative, which focuses on community collaboration between the private sector, faith-based community, not-for-profits, and government entities to break down traditional community silos. Through this program, AHCA seeks to:

  • Improve oral health outcomes by implementing a quality continuum
  • Enable personalized oral healthcare, particularly for people with special needs
  • Strengthen the network of dental providers
  • Integrate medical and dental care

In addition to the services currently provided, dental plans will cover authorized hospital outpatient and ambulatory surgery center (ASC) services as part of the new contracts. Plans will cover ancillary medical services provided secondarily to dental care in an ASC or outpatient hospital setting when medically necessary.

Dental plans will continue to operate statewide across all regions. Capitation rates for Medicaid and dually eligible members, however, are set regionally. Rates for medically necessary procedures are set at a statewide level. The new contracts will consolidate the 11 regions into nine as shown in the table below.

Timeline

Responses are due January 5, 2024, and notification of intent to award is anticipated to be released on March 29, 2024. Contracts will run from the execution date in 2024 through 2030.

Evaluation

Technical proposals will be scored using a total weighted score of 6,600, as shown in the table below.

Link to RFP

Kansas releases KanCare, CHIP Medicaid managed care RFP

This week, our In Focus section reviews the KanCare Medicaid capitated managed care request for proposals (RFP), released October 2, 2023, by the Kansas Department of Health and Environment and Department for Aging and Disability Services. The program covers approximately 520,000 beneficiaries and is worth $4.1 billion. New contracts would begin January 2025.

KanCare Background

KanCare is the state’s Medicaid managed care program, covering both traditional Medicaid and Children’s Health Insurance Program (CHIP) members. In all, KanCare covers approximately 320,000 children, 79,000 parents and pregnant women, 59,000 individuals with disabilities, and 54,000 individuals ages 65 and older.

Managed care organizations (MCOs) provide statewide integrated physical health, behavioral health, and long-term services and supports. Covered services include nursing facility care and home and community-based services, as well as Medicaid-funded inpatient and outpatient mental health and substance use disorder services and seven Section 1915(c) HCBS waiver programs.

Kansas is not currently an expansion state. While the governor’s 2024 budget plan called for Medicaid expansion, lawmakers rejected the proposal during the last legislative session.

In 2022, the state legislature delayed the procurement until 2023 to ensure that it occurred after the gubernatorial election and extended current MCO contracts through 2024.

RFP

Kansas expects to select three MCOs. The RFP includes a renewed focus on integrated, whole-person care, workforce retention, and accountability measures for the MCOs. The state lists the main goals for the KanCare procurement as:

  • Improve member experience and satisfaction
  • Improve health outcomes by providing integrated, holistic care with a focus on the impacts of social determinants of health
  • Reduce healthcare disparities
  • Expand provider network and direct care workforce capacity and skill sets
  • Improve provider experience and encourage provider participation in Medicaid
  • Increase the use of cost-effective strategies to improve health outcomes and the service delivery system
  • Leverage data to promote continuous quality improvement

Timeline

A mandatory pre-bid conference will take place on October 16, 2023. Proposals are due January 4, 2024, with awards expected April 12, 2024. Contracts will be effective January 1, 2025, through December 31, 2027, with up to two one-year renewal options. Following is the timeline leading up to implementation.

Current Market

Incumbents are Centene, CVS/Aetna, and UnitedHealthcare. A breakdown of market share by enrollment as of June 2023 can be seen in the table below. Other insurers have already cited their interest in bidding for the new contracts.

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

Focus on equitable access at 2023 HMA conference

Access to care is not as simple as obtaining an insurance card. Some people find access to care is limited by geography or distance, others are limited by their native language or cultural awareness. In other ways, care can be limited by who is in the insurance network. All of these inequities can cause gaps in care that undermine health outcomes. In a system that is increasingly paying for outcomes, elimination of inequities is a matter of financial performance, as well as a sign of clinical excellence. Finding and reducing inequities in access to care requires an operational commitment to change workflows, leverage technology, and train staff at all levels to align incentives and culture.

Providing equitable access to care is subject to ever-changing policy and regulatory requirements, and it is increasingly tied to funding, work force staffing and many other operational requirements. This topic will thread through several discussions and panels during the 2023 HMA fall conference with federal policy leaders, health system administrators, and other industry leaders all poised to address the pain points of achieving and maintaining equitable access.

Key sessions (full agenda here):

  • Leading the Charge on Value, Equity and Growth: The Future of Publicly Sponsored Health Care – A discussion on how these public programs came to be the industry standard bearers and what this shift means for outcomes, affordability, policy, and the overall direction of U.S. health care. (Monday 8:30am keynote by Alan Weil)
  • Understanding and Meeting New Health-Related Social Needs Requirements – An environmental overview, including a look at what’s driving these demands and how organizations are specifically working to address the new mandates. (Monday 1:30pm breakout session featuring Bryan Buckley of NCQA, Richard Ayoub of Project Angel Food, and Paul Leon of National Healthcare & Housing Advisors)
  • Practical Approaches to Ensuring Equity in Publicly Sponsored Healthcare Programs This session will provide practical approaches to addressing equity, including an overview of efforts by policymakers, health plans, and providers to make equity the central component of all initiatives to improve healthcare outcomes, access, and health-related social needs. (Tuesday 8:30am keynote by Karen Dale of Amerihealth Caritas)
  • Medicaid in a Post-Pandemic World: Challenges, Opportunities, and a Renewed Focus on Equity State Medicaid directors will provide a status report on all this and more, including a special emphasis on how equity plays into planning and policy decisions. (Tuesday 9:15am plenary featuring Jacey Cooper of the California Department of Health Care Services, Kelly Cunningham of the Illinois Department of Healthcare and Family Services, Drew Snyder of the Mississippi Division of Medicaid, and Stacie Weeks of the Nevada Department of Health and Human Services)

HMA consultants and our speakers look forward to engaging with participants as they delve into these topics to gain a better understanding of the gains we are making as industry leaders and where we still need to innovate. 

To learn more about our Equity work, please contact Leticia Reyes-Nash; to learn more about our Managed Care work, please contact Michael Engelhard or Patrick Tigue.

The CMS managed care proposed rule: three implications for local and regional MCOs

Previously, HMA reviewed the provisions of the Medicaid and Children’s Health Insurance Program (CHIP) managed care access, finance, and quality proposed rule published by the Centers for Medicare & Medicaid Services (CMS) on May 3, 2023. CMS is accepting comments on the proposed rule through July 3, 2023. While the proposed rule, if finalized as put forward, will have a significant impact across Medicaid stakeholders including enrollees, managed care organizations (MCOs), providers, and state Medicaid agencies, this blog post outlines three specific aspects of the proposed the rule and their implications for a subset of MCOs: regional and local MCOs.

Medical Loss Ratio (MLR) Standards

In the proposed rule, CMS outlines three areas for revisions to its existing MLR standards which require MCOs to annually submit MLR reports to states and require states, in turn, to annually provide a summary of those reports to CMS. An MLR is calculated by adding the expenditures for incurred claims to the expenditures for activities that improve health care quality and fraud prevention activities (the numerator) and dividing this by adjusted premium revenue (the denominator). The three areas where CMS proposes revisions include: (1) requirements for clinical or quality improvement standards for provider incentive arrangements, (2) prohibited administrative costs in quality improvement activity (QIA) reporting, and (3) additional requirements for expense allocation methodology reporting.

Related to provider incentive arrangements (which are considered part of incurred claims), CMS proposes to require that contracts between MCOs and providers: (1) have a defined performance period that can be tied to the applicable MLR reporting period(s), (2) include well-defined quality improvement or performance metrics that the provider must meet to receive the incentive payment, and (3) specify a dollar amount that can be clearly linked to successful completion of these metrics as well as a date of payment. Furthermore, MCOs would be required to maintain documentation to support these arrangements and cannot rely upon attestations as documentation of compliance.

Related to QIA reporting, CMS proposes to explicitly prohibit MCOs from including indirect or overhead expenses when reporting QIA costs in the MLR. CMS notes that today, for example, expenditures for facility maintenance, marketing, or utilities may be included in the MLR even though such expenses do not directly improve health care quality. From the perspective of CMS, the inclusion of such expenditures in the MLR numerator may be resulting an inflated MLRs that then provide a distorted view of MCO performance.

Related to expense allocating reporting, CMS proposes to add requirements regarding how MCOs can allocate expenses for the purpose of calculating the MLR. Specifically, MCOs would need to describe in their methodology a detailed description of the methods used to allocate expenses, including incurred claims, quality improvement expenses, federal and state taxes and licensing or regulatory fees, and other non-claims costs. The goal of requiring this additional detail is to give state Medicaid agencies the ability to assess whether MLRs are accurately represented as a result of the methodology employed by an MCO to allocate expenses across lines of business (e.g., Marketplace, Medicaid, and Medicare).

For local and regional MCOs, the changes to MLR standards proposed by CMS will require meaningful efforts to ensure compliance. Provider incentive arrangements, most expansively, may need to be renegotiated to conform to the requirements and, at a minimum, may need to be documented in a more robust fashion to ensure evidence of compliance can be furnished upon request. The impact of QIA expenditures that are no longer able to be included in the MLR numerator will need to be modeled to ensure that a resulting failure to meet any minimum MLR requirements does not occur and, if this is projected to occur, a strategy will need to be developed and executed to ensure it does not. Expense allocation methodologies will need to be documented more extensively and evaluated for reasonability to ensure that they can withstand regulatory scrutiny when additional detail is provided to state Medicaid agencies.

Medicaid and CHIP Quality Rating System (MAC QRS)

In the proposed rule, CMS outlines a MAC QRS framework that includes: (1) mandatory quality measures, (2) a quality rating methodology, and (3) a mandatory website display format. State Medicaid agencies and MCOs will be required to adopt and implement the MAC QRS framework developed by CMS or adopt and implement an alternative managed care quality rating system. CMS will update the mandatory measure set at least every other year. Measures will have public notice through a call letter (or similar guidance) on any planned modifications with measures being based on: (1) value in choosing an MCO, (2) alignment with other CMS programs, (3) the relationship to enrollee experience, access, health outcomes, quality of care, MCO administration, or health equity, (4) MCO performance, (5) data availability, and (6) scientific acceptability.

State Medicaid agencies will be required to collect from MCOs the data necessary to calculate ratings for each measure and ensure that all data collected are validated. Additionally, state Medicaid agencies must calculate each measure and issue ratings to each MCO for each measure. Finally, the mandatory state website will be required to contain the following elements: (1) clear information that is understandable and usable for navigating the website itself, (2) interactive features that allow users to tailor specific information, such as formulary, provider directory, and ratings based on their entered data, (3) standardized information so that users can compare MCOs, (4) information that promotes beneficiary understanding of and trust in the displayed ratings, such as data collection timeframes and validation confirmation, and (5) access to Medicaid and CHIP enrollment and eligibility information, either directly on the website or through external resources.

For local and regional MCOs, the MAC QRS framework proposed by CMS will require assessing their capability to produce the mandated data upon request by state Medicaid agencies. It will also then require ensuring that all mandated data is available to be provided on an annual basis. To the extent possible, at the appropriate time, assessing baseline performance on measures and proactively developing and implementing strategies to improve performance will be prudent. Assessing the impact of the greater transparency around quality performance that the proposed MAC QRS will bring in order to understand the potential impact on competitive position will also be important.

Network Adequacy Requirements

In the proposed rule, CMS outlines important network adequacy requirements meant to further timely access to care for Medicaid and CHIP managed care enrollees. Two of these are focused upon here: (1) appointment wait time standards and (2) secret shopper surveys. Other policies to enhance access are also included in the proposed rule including, for example, a requirement that state Medicaid agencies conduct an annual enrollee experience for each MCO.

For appointment wait time standards, CMS proposes that state Medicaid agencies develop and enforce wait time standards for routine appointments for four types of services: (1) outpatient mental health and substance use disorder (SUD) for adults and children, (2) primary care for adults and children, (3) obstetrics and gynecology (OB/GYN), and (4) an additional service type determined by the state Medicaid agencies in an evidence-based manner (in addition to the previous three noted). The maximum wait times must be no longer than 10 business days for routine outpatient mental health and SUD appointments and no longer than 15 business days for routine primary care and OB/GYN appointments. State Medicaid agencies could impose stricter wait time standards but not more lax ones. The wait time standard for the fourth service type selected by state Medicaid agencies will be determined at the state level.

For secret shopper surveys, state Medicaid agencies will be required to utilize an independent entity to conduct annual secret shopper surveys to validate MCO compliance with appointment wait time standards and the accuracy of provider directories to identify errors as well as providers that do not offer appointments. For an MCO to be compliant with the wait time standards, as assessed through the secret shopper surveys, it would need to demonstrate a rate of appointment availability that meets the wait time standards at least 90% of the time. State Medicaid agencies would be required to develop remedy plans when MCO compliance issues are identified which designate the party responsible for taking action, outline the appropriate steps to be taken to address the issue, and document the intended implementation timeline.

For local and regional MCOs, the wait time standards and secret shopper surveys present opportunities to prepare to ensure compliance and to collaborate with state Medicaid agencies. For preparation, undertaking secret shopper surveys ahead of implementation to determine the current performance relative to maximum wait times may be advisable. Additionally, there is an opportunity to collaborate with state Medicaid agencies regarding the selection of the fourth service type for which wait time standards will be established.

For More Information

If you have questions about how HMA can support your efforts related to the proposed rule’s implications for local and regional MCOs, please contact Michael Engelhard, managing director, Patrick Tigue, managing director, or Sarah Owens, principal.

Takeaways from the early Medicaid unwinding actions

This week, our In Focus checks in on the Medicaid unwinding work and key issues HMA experts are watching as more states resume their normal policies and processes for determining eligibility. A total of 19 states started disenrollments effective for April or May coverage, and 22 additional states plan to start ending coverage this month. States are scheduled to submit the next monthly report by June 8, 2023.

Background

As explained in earlier In Focus articles, (herehere and here) federal COVID-19 relief laws allowed states to receive higher federal funding for Medicaid as long as the state did not terminate Medicaid coverage for anyone enrolled in Medicaid during the public health emergency (PHE). One result of the continuous coverage policy was sustained growth in Medicaid enrollment; more than 21 million additional individuals were continuously enrolled in Medicaid for up to three years between February 2020 and March 2023. In December 2022, Congress ended the Medicaid continuous coverage policy after March 31, 2023. States were allowed to begin processing redeterminations as early as February 2023 and start disenrolling ineligible individuals as early as April 2023.

Preparations for the Medicaid unwinding have been under way for well over two years. The Centers for Medicare & Medicaid Services (CMS), states, Medicaid health plans, providers, beneficiary advocates, and other interested stakeholders have been working to ensure that the policies, outreach, and assistance are in place to support this massive eligibility renewal and redetermination initiative.

What Do We Know… Or Not Know?

Most of the available forecasts project between 10-15 million enrollees will lose Medicaid coverage. The Health Management Associates (HMA) insurance mix model projects that more than 10 million of the approximately 90 million Medicaid enrollees are at risk for disenrollment. HMA’s model illustrates the variety in state approaches to managing the resumption of eligibility redeterminations as well as key insights related to the differential impact by Medicaid eligibility categories.

  • Based on published information, the number of individuals who were disenrolled from Medicaid in April through May is likely to approach 500,000. In these early days of the unwinding period, HMA experts are closely reviewing the reports and engaging with key stakeholders in individual states. Several issues already are garnering more attention, such as the impact on child enrollment, churn and experiences in states using the extended reconsideration period flexibility, among others. Stakeholders will want to monitor how these and other program nuances evolve over the next year.
  • We do not yet have robust or consistent data from the states that have resumed their normal processes for determining eligibility. States must submit disenrollment reports to CMS each month, and CMS must publish this information. The states are not, however, required to publish this information on their website. While some states have chosen to publish the data or plan to do so, there is no consistent approach to the specific data states post. For example, while most states publishing a state data dashboard are sharing the number of renewals they are processing each month, only slightly more than half also are sharing the number of renewals resulting in coverage terminations.
    CMS is not expected to publish the state data before the end of June. Once this information is available, the state unwinding reports may provide a more comprehensive and consistent picture of enrollment over the next year.

In addition, the total number of “procedural terminations” currently is difficult to determine. Lack of consistent public reporting creates gaps in the data about the number of individuals disenrolled because they did not provide a timely response to the state’s request for more information (or for other procedural reasons). As Medicaid stakeholders know, the procedural disenrollment number is critical because these individuals could still be eligible for the program.

  • Early disenrollment numbers should be analyzed carefully and in the context of the state. As noted earlier, the full eligibility renewal and disenrollment reports are unavailable at this time. We do know, however, that the available data is best analyzed in the context of the state’s unwinding plan (e.g., how the state is sequencing its eligibility reviews). The sequencing, pace, staffing, messaging consistency, partner outreach and assistance, and other factors will result in variation in state experiences. States are actively analyzing the data as the information is released and considering course corrections that may be needed, which could affect enrollment.
  • Ongoing federal and state collaboration is improving preparations and allowing partners to address concerns as they arise. CMS and states have been transparent about the magnitude of the Medicaid unwinding and the fact that challenges will be inevitable throughout this process. The experiences reported by the first tranche of states to begin their unwinding period reinforce those points. They also provide important lessons for states that are or will shortly resume normal eligibility operations.

What to Watch

HMA’s experts are working with states, Medicaid health plans and their partners, providers, and advocacy organizations to identify and implement solutions to some of the known challenges. We also are looking ahead to forthcoming data, qualitative input, and other important developments that may inform federal and state policies and operations beyond the unwinding period.

  • Unwinding trends. Though it is too early to definitively identify trends, HMA experts are monitoring the early state data, and we are prepared to analyze the CMS reports once they are published. We anticipate the CMS published data could be more instructive regarding the impact of the unwinding on enrollment, including states or regions that could benefit from additional outreach and assistance strategies, disproportionate impacts on certain demographic groups, new flexibilities that states may want to consider, and steps that health plans, hospitals and health systems, providers, and other partners could advance.
  • State operational plans. As of late May, CMS officials reported they have not asked any state Medicaid agency to develop a corrective action plan related to the unwinding; however, this does not mean that federal officials do not have concerns about the experiences and data being reported out of certain states. States, their business partners, and advocates will all benefit from monitoring shifts in state plans, potential future CMS resources and direction to states such as additional reporting or modifying eligibility processes.
  • Coverage Program Transitions. Significant attention has been appropriately placed on the Medicaid disenrollment numbers. HMA experts also are closely watching for new data on the number of individuals who successfully transition and enroll in qualified health plans offered in the Health Insurance Marketplaces. In the short term, the Medicaid unwinding could have a notable impact on total enrollment in Marketplace plans as well as provider payer mix. This could affect longer-term policy, strategy, and operational decisions for officials at the federal and state levels, managed care organizations, providers, and other stakeholders. For example:
    • Health insurers should assess the opportunity to participate in the Marketplace program. Other insurers may need to develop new strategies to remain competitive in the Marketplace.
    • Providers have similar assessments to conduct related to changes in the number of uninsured people to whom they deliver care, as well as their payer mix and the Marketplace plan networks in which they participate.
    • Policymakers may revisit Marketplace regulations and standards in response to enrollment growth, enrollee demographics, and acuity of enrollees in Marketplace plans.

Medicaid agencies, health plans, all types of Medicaid providers, and advocacy organizations should continue to analyze their immediate needs during the Medicaid unwinding. They should also be planning to identify and incorporate lessons from this transition period, as well as preparing for policy and operations changes in the post-unwinding environment.

Please contact HMA experts Jane LongoAndrea Maresca, and Lora Saunders.

HMA: What We’re Watching

On June 8, 2023, the Health Care Payment Learning & Action Network (LAN) will hold a virtual meeting focused on accountable primary care. The LAN — an initiative supported by the Centers for Medicare & Medicaid Services (CMS) Innovation Center — is a group of public and private health care leaders that provide thought leadership, strategic direction, and ongoing support to accelerate our care system’s adoption of alternative payment models (APMs). During the session, CMS Administrator Chiquita Brooks-LaSure and the Innovation Center’s Deputy Administrator and Director Liz Fowler will share their vision for accountable primary care.

Over the past several months CMS leaders have discussed their intent to accelerate the transition to value-based care and more accountable primary care. They have identified key principals and hinted at certain components of a potential new primary care model. Additionally, the Innovation Centers’ earlier strategy documents have highlighted the imperative to include payers beyond Medicare, importantly Medicaid and commercial insurers, in models to achieve person-centered accountable and equitable care.

This meeting is notable because the Innovation Center’s models can drive transformational shifts in health care delivery and payment across public and private payers at the system and practice levels. Providers, health systems, insurers, and other interested stakeholders will want to closely monitor the LAN discussion for more information about CMS’ evolving thinking and future opportunities related to a potential model for accountable primary care. HMA experts are available to work with health care organizations and stakeholders to interpret and respond to developments flowing from the LAN session.

LAN meeting registration and information is available here.

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.

Early bird registration ends July 31. Questions may be directed to Carl Mercurio. 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

Illinois requests Section 1115 waiver extension to respond to HRSNs and eliminate inequities

This week our In Focus section reviews the Illinois Healthcare Transformation 1115 Waiver Extension request, posted for review on May 12, 2023.

In pursuing this waiver extension, Illinois joins a growing list of states taking advantage of new Centers for Medicare & Medicaid Services (CMS) policy flexibilities to address health-related social needs (HRSNs) through Medicaid and test community-driven initiatives that are focused on improving health equity, improving access to care, and promoting whole-person care.

The Illinois waiver incorporates two of the most significant new opportunities in the CMS demonstration waiver flexibilities by proposing to incorporate housing supports for people who are experiencing or at risk of homelessness. The waiver also would extend community reintegration services for justice-involved adults and youths for up to 90 days before their release from incarceration. For a full list of proposed benefits and demonstrations, see Table 1.

Table 1. Summary of Illinois Medicaid 1115 Waiver Extension 

Source: Illinois Department of Health and Family Services. Illinois Healthcare Transformation Section 1115 Demonstration Extension Overview. Available at: https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/1115demonstrationoverview05122023.pdf.

The Illinois waiver represents an unprecedented opportunity to demonstrate the long-term, positive impact of providing HRSN services to achieve health equity and create a sustainable, community-driven system for delivering those services. The demonstration proposes to offer a range of HRSN services that are focused on the unmet needs of people who are homeless and housing insecure, are justice-involved, have behavioral health conditions, are pregnant, are unemployed, are food insecure, and/or have been exposed to violence or are at risk of violence with the goal of eliminating health disparities.

The waiver projects a five-year total of $4.4 billion in HRSN services expenditures and another $800 million in HRSN-related infrastructure, indicating Illinois’ long-term commitment to healthcare transformation and to building an equitable, accessible, and high-quality delivery system.

For additional information, please email [email protected].

How will CMS’s proposed rule shift standards for Medicaid enrollee access to services?

This week’s In Focus is the second in a two-part look at the Centers for Medicare & Medicaid Services’ (CMS’s) recently proposed changes to the Medicaid program. Last week we covered CMS’s proposed changes to the federal Medicaid managed care regulations (CMS-2439-P). This week we review the Medicaid Access to Care proposed rule (CMS-2442-P).

As we discussed last week, the managed care and access to care rules include significant changes to core structural and financing aspects of the Medicaid program. Though state agencies, providers, health plans, consumer groups, and other stakeholders will want to understand the distinct requirements and expectations in each rule that apply to them, the proposed changes cannot be viewed in isolation.

The Access to Care rule addresses a range of challenges that shape the experience of Medicaid enrollees, regardless of whether they are in managed care programs or traditional fee-for-service (FFS). The proposed policy changes also are designed to create an updated federal framework for Medicaid’s home and community-based services (HCBS) programs. These proposals come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs).

The remainder of this In Focus delves into notable components of the proposed changes and includes analysis of the implications of these policies for stakeholders. CMS will benefit from stakeholder input; the deadline for submitting comments is July 3, 2023.

Table 1. Access to Care Regulations: Overview of Proposed Changes

Key Themes and Considerations

Ensuring Payment Adequacy for Key HCBS Services Experiencing Workforce Shortages. One of the most notable proposed changes that would directly impact DCWs is a requirement that at least 80 percent of Medicaid payments be spent on compensation. The proposed rule would apply to homemaker, home health aide, and personal care services, as they represent a large portion of HCBS services that DCWs provide. The proposal is based on feedback from states that have implemented similar provisions, which have ranged from 75 to 90 percent compensation requirements.

CMS specifically seeks stakeholder feedback on the percentage that should be adopted. This policy provision also is important from an equity perspective, given that 90 percent of DCWs are women and 60 percent are members of racial or ethnic minority populations. However, increased or mandated DCW rates may make it difficult for HCBS providers to sustain their businesses as they manage the increased administrative pressures of electronic visit verification, the complexity of filing claims for managed long-term services and supports (MLTSS), and the additional work that HCBS quality measurement may create. Smaller HCBS providers, some of which may have deep cultural expertise, may struggle to sustain themselves and meet these requirements.

Table 2. Access to Care Regulations: Snapshot of Proposed Rate, Access, and Payment Changes

Payment Alignment. CMS is seeking to align access to care strategies and payment rate transparency more closely across the FFS and managed care delivery systems. The proposed rule includes several changes that CMS has developed achieve this goal. For example:

  • CMS plans to require that states publish more detailed rate information in a consistent format. States, health plans, providers, and other interested stakeholders will want to consider the implications by delivery system. Additional transparency requirements could create a new opportunity to understand rates across payers and states and use this information in addressing access challenges for services.
  • The proposed rule also would require extensive comparative analysis of Medicaid FFS rates and Medicare rates. CMS proposes to use Medicare non-facility payment rates as a benchmark to determine if states are meeting federal Medicaid access State analyses will be vital to CMS oversight as well as advocacy efforts within states to monitor and update FFS rates as needed.

Strengthening the Focus on Quality in State HCBS Programs. Over the last several decades, states and Medicaid stakeholders have made significant progress toward increasing participation in HCBS programs and community integration initiatives to counter Medicaid’s institutional bias. CMS is proposing more consistency in the expectations and reporting for HCBS quality measures to further the impact and create a consistent foundation for the recently mandated HCBS quality initiatives starting to take root.

In the short-term, the proposed changes will require states, and likely downstream providers and Medicaid agencies, to immediately change their quality reporting policies and systems. States and their stakeholders will want to map out processes for cyclical updates to HCBS quality measures, including cross-walking the future measures with existing ones, making systems changes, and updating dashboards. Targeted attention and focus will be needed to identify realistic HCBS performance targets that yield successful improvement strategies in the midst of a workforce crisis. Longer term, it will be necessary to map out when updates and reporting will be required to strengthen the rigor and accountability for state performance in the HCBS quality measure set, as well as reinforce the information available to make policy, clinical, and operational improvements to Medicaid programs.

HCBS Access Measurement. CMS is proposing new FFS HCBS payment and access transparency requirements to ensure compliance with Medicaid provider payment rules that require payments to be adequate to enlist at least the same number of providers that the overall geographic population can access. Because the targeted HCBS services do not have a comparable Medicare rate, CMS proposes implementation of a payment rate disclosure approach that would standardize data and monitoring across service delivery systems, with the goal of improving access. In addition to proposed payment transparency changes, CMS proposed new reporting on HCBS waiver waiting lists and timelines for the start of related services once authorized.

These new reporting requirements will provide stakeholders with more information to benchmark their state’s experience with other providers across the nation. This information could be influential to policymakers and legislators and help uncover some of the core contributors to our nation’s HCBS workforce shortage.

Improving Health Equity with Medicaid Beneficiary Input. CMS proposes overhauling the scope and membership of the state Medical Care Advisory Committee. The new Medicaid Advisory Committee (MAC) would continue to advise the state on health and medical matters and play an expanded advisory role on matters of policy development and effective administration of the program. CMS also plans to require that states establish a Beneficiary Advisory Group (BAG) composed of current or past Medicaid beneficiaries. A subset of BAG members would serve on the MAC to ensure their perspectives are integrated into the committee’s recommendations to states.

Under the new federal requirements, MAC representatives could have greater relative input and influence on policies and actions each state Medicaid agency advances. Medicaid stakeholders will want to ensure the MAC’s minimum federal requirements support effective structures and processes in states.

What’s Next

CMS plans to reframe Medicaid access as one of three parts of the continuum of care, along with enrollment and maintenance of coverage. The proposals in the Access to Care rule would have a meaningful impact on the volume and type of data available to evaluate the relationship between Medicaid payment rates and access across all delivery systems.

States, managed care organizations, providers, Medicaid enrollee advocacy organizations, and other interested stakeholders should analyze the proposals and consider submitting comments to CMS on the feasibility, potential impact, and, where applicable, alternatives to the proposed changes. They also can use this time to begin planning and determine which resources and tools they may need to prepare for implementation of changes across delivery systems in the Medicaid program.

HMA’s experts are taking a wholistic approach to reviewing the Access to Care and Managed Care proposed rules in tandem and identifying key points of intersection.

For more information on the access to care proposed rule, contact HMA’s team of experts, Susan McGeehan and Andrea Maresca.