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Blog

North Carolina releases foster care specialty plan program RFP

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This week, our In Focus section reviews the statewide North Carolina request for proposals (RFP) for the new Children and Families Specialty Plan (CFSP), which the North Carolina Department of Health and Human Services (DHHS) released on February 7, 2024. The plan will provide physical health, behavioral health, intellectual and developmental disability, long-term care, and pharmacy services to children, youth, and families that the child welfare system serves. Implementation is scheduled for December 1. 

Background 

North Carolina implemented Medicaid managed care on July 1, 2021, after working on a plan to transition individuals from fee-for-service to managed care since 2015. CFSP is one of the four types of integrated Medicaid managed care plans the state will contract with to serve Medicaid beneficiaries. The other three are Standard Plans, the Behavioral Health and Intellectual/Developmental Disability (BH IDD) Tailored Plans, and the Eastern Band of Cherokee Indians Tribal Option.  

Standard Plans are operated by one of two types of Medicaid managed care organizations (MCOs): statewide commercial plans (CPs) or regional provider-led entities (PLEs). The state awarded contracts to four CPs, the maximum allowed under the procurement, and one PLE. AmeriHealth Caritas North Carolina, Blue Cross and Blue Shield of North Carolina, UnitedHealthcare of North Carolina, and WellCare of North Carolina serve beneficiaries across six Medicaid managed care regions. A regional contract with provider-led Carolina Complete Health, a partnership between the North Carolina Medical Society and Centene, covers Regions 3, 4, and 5. The total value of the contracts is approximately $6.4 billion. The plans serve more than 2 million members as of year-end 2023. 

The state plans to implement BH IDD Tailored Plans July 1. Tailored plans will be provided through the awarded local management entity-managed care organizations (LME-MCOs): Alliance Health, Partners Health Management, Trillium Health Resources, and Vaya Health. Implementation has been delayed multiple times since 2022. As a result, the state issued a directive last year to dissolve the Sandhills Center and consolidate Eastpointe and Trillium Health Resources to hasten the delayed rollout. The tailored plans are expected to cover approximately 160,000 beneficiaries. 

Details about the CFSP 

The following populations will be enrolled automatically in CFSP: 

  • Beneficiaries who are in foster care 
  • Beneficiaries who are receiving adoption assistance 
  • Beneficiaries enrolled in the former foster youth eligibility group 
  • The minor children of enrolled parents 

The following populations will be eligible for enrollment in CFSP during contract year two: 

  • Parents, caretaker relatives, guardians and custodians with children in foster care 
  • Minor siblings of beneficiaries in foster care 
  • Adults identified on an open Child Protective Services (CPS) In-Home Family Services Agreement case and any minor children living in the same household 
  • Adults identified in an open Eastern Band of Cherokee Indians Department of Public Health and Human Services Family Safety program case and any children living in the same household 
  • Any other beneficiary that has been involved with the child welfare system who could benefit from enrollment  

RFP 

The state will award the contract to a single statewide managed care plan. Applicant MCOs will need to develop strategies for engaging with historically marginalized populations, addressing health disparities, and incorporating health equity. Technical proposals will be evaluated based on the following criteria: 

  • Medicaid Managed Care Qualifications and Experience 
  • Medicaid Managed Care Program Administration
    • Administration and management 
    • Program operations 
    • Claims and encounter management 
    • Financial requirements 
    • Compliance 
    • Technical specifications 
    • Historically underutilized businesses 
    • Diversity, equity, and inclusion 
  • Integrated and Coordinated Delivery of Services
    • Members and recipients 
    • Benefits and services 
    • Providers 
    • Stakeholder engagement 
  • Comprehensive Care Management
    • Care management 
    • Quality and value 

Timeline 

The CFSP data book and capitation rate methodology will be released March 1, with an overview for presentation at a pre-proposal conference on March 7. Proposals are due May 1 and awards are expected to be announced August 15. Contracts are scheduled to run December 1, 2024, through June 30, 2028, with one additional option year. The RFP indicates that the Department will work with awardee to establish an appropriate launch date. 

Link to RFP 

Blog

Driving change in healthcare delivery: HMA Spring Workshop builds towards policy and strategy frameworks necessary to implement value-based care

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Federal policy frameworks establishing alternative payment models in Medicare and Medicaid have been the kick-starter of value-based care (VBC) innovation in healthcare delivery. However, employers provide health insurance to most Americans, and very few employers – with the exception of jumbo, self-insured employers  – have leaned heavily into VBC. Small- and medium-sized firms rely on brokers to find an affordable health insurance plan, and often lack the resources required to negotiate more. Though the tide has been changing, our fragmented payment system has yielded only a subset voluntarily taking substantial risk for patient outcomes.

It has been said that to truly transform our American healthcare system to pay for value – improved outcomes for lower cost – it would require better alignment across public and commercial payers to support care providers in shifting their business models to take risk.

Quality and cost information are critical to implement VBC payment and delivery systems. Federal initiatives in Medicare and Medicaid have opened the door for providers, payers, and innovators  to use health information to improve outcomes, with patients more engaged and more in control; the “Universal Foundation” announced by the Centers for Medicare and Medicaid Services (CMS) in 2023 seeks to align quality measures across the more than 20 CMS quality initiatives; and policies included in the 21st Century Cures Act and CMS Interoperability and Patient Access rule are creating more transparency on price and quality.

By enabling an infrastructure to measure, digitize, and share cost and quality information, federal and state governments have set the stage for greater collaboration among all purchasers – including employers – and the healthcare delivery system to redesign care that addresses health related social needs and behavioral health, ensuring that healthcare is provided equitably and sustainably. As the care delivery system is better able to deliver high value care, more employers will demand this for their workforce to provide a better benefit to their workers.

These issues, and more, will be a part of the expert-led conversation on VBC at HMA’s 2024 Spring Workshop March 5-6, in Chicago. This workshop offers a unique opportunity for payers, government officials, community organizations, vendors, and providers to have an unvarnished conversation about the challenges, lessons, and opportunities in implementing VBC. The meeting is designed to share insights, change-oriented strategies and actions that advance VBC from top industry experts, health plan executives, state and federal leaders, and policy experts. 

CLICK HERE TO register

Our working sessions will feature solutions-focused conversations among peers:

  • Care delivery measures that drive outcomes, equity, population health
  • Payment & risk management models for payment, pricing, attribution
  • Data that is interoperable, consumer focused, deploying technology that is aligned to deliver on strategic objectives
  • Policy & Strategy Frameworks at federal, state, and local levels that incentivize VBC

The closing panel will look at ways to take action through policy and collaboration to move our industry toward more sustainable approaches to healthcare payment and delivery.

To learn more and register for this unique event, please visit HMA’s 2024 Spring Workshop page. Act fast – online registration ends Wednesday, February 28!

Blog

Interoperability and patient access final rule: the next phase in the data exchange journey

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This week, our In Focus section reviews the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule, published on January 17, 2024. This is CMS’s latest effort to flesh out regulations mandating payer interoperability and fully electronic prior authorization (PA) policies. The 2024 final rule also represents a new phase in the agency’s work to advance interoperability as it moves beyond policymaking focused on building interoperable systems to policies centered on the applications and usage of shared data.

The new requirements affect a large segment of the nation’s public health insurance programs, including Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children’s Health Insurance Program (CHIP) FFS programs, Medicaid managed care plans, CHIP managed care organizations, and qualified health plan (QHP) issuers on the federally facilitated exchanges (FFEs). These payers must implement and adhere to Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs). These APIs were developed by the DaVinci project and the CARIN Alliance which are both HL7 FHIR accelerator programs. Leavitt Partners, an HMA company, leads the work of the CARIN Alliance.

The final rule demonstrates a commitment to information sharing across the industry landscape and confidence in the FHIR standard to support health data exchange across all required APIs. Ultimately, FHIR APIs are creating a more patient-centered data ecosystem that can provide a tangible return on investment.

Following are details about the requirements, opportunities, and next steps for stakeholders.

Prior Authorization API and Process

Payers must build and maintain PA APIs by January 1, 2027, allowing providers to ask payers whether PA is required for a patient’s procedure, what documents must be submitted to attain authorization, and to receive the final decision and reason for denied requests electronically within a specified timeframe (seven days for standard procedures and three days for expedited decisions).

The rule finalizes requirements for the PA process, regardless of whether the payer receives the PA request through the Prior Authorization API. Specifically, CMS is requiring that:

  • Affected payers send notices to providers when they make a prior authorization decision, including a specific reason for denial when they deny a PA request
  • Payers, other than QHP issuers on the FFEs, respond to prior authorization requests within specific timeframes
  • Affected payers publicly report certain metrics about their PA processes

These prior authorization process requirements become effective January 1, 2026. The last 12 months of PA information also must be shared with patient, providers, and other payers when the member switches a plan through the respective APIs.

To promote adoption of electronic prior authorization processes, CMS is adding an Electronic Prior Authorization measure for Medicare clinicians who participate in the Merit-based Incentive Payment System (MIPS) and hospitals and critical access hospitals in the Medicare Promoting Interoperability Program as an attestation measure.

Payer to Payer FHIR API

To support continuity of care and value-based programs, payers must be able to send, receive, and incorporate enrolled member data from previous and concurrent payers if members are dually enrolled.

To comply with the new electronic data sharing, the final rule requires payers to build and use FHIR API by January 1, 2027. Payer-to-payer (P2P) data sharing will include the last five years of claims/encounters, clinical data, and the active and pending PA requests. The data collected through the P2P APIs will need to be available to the other APIs (i.e., provider, patient, and prior authorization). The rule requires payers to request data from previous payers within a week after the patient opts in to sharing data. For dually enrolled members, data sharing will incur at least quarterly.

Patients must opt in and agree to the P2P data sharing. To this end, health plans must adjust their enrollment administrative process to allow members to easily share previous and concurrent payer information and consent to data sharing. CMS allows Medicaid or CHIP agencies to contract with entities, such as Health Information Exchanges (HIEs), for the digital access and transfer of a patient’s medical records, which supports the Payer-to-Payer API.

Provider Access FHIR API

Payers also must build and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship, enabling continuity and coordination of care, by January 1, 2027. Affected payers must maintain an attribution process to associate patients with the appropriate in-network providers responsible for the patient care. The data from the payer via the Provider Access API must be added to a provider’s electronic health record, practice management solution, or any other technology solution that a provider uses for treatment purposes.

The Provider Access API includes the same data covered in the Payer to Payer Access API (claims/encounters, clinical data, and prior authorizations). The payer has one business day to deliver the required information. Payers must offer a mechanism for members to opt out from making their data available to the attributed providers.

Patient Access FHIR API

The final rule further enhances patient access to data to improve their treatment and shopping experience. In addition to claims and clinical data, as of January 1, 2027, payers must make PA data available through the Patient Access API to inform patients on their plan’s PA process and the status of requests.

In addition, affected payers must report annual metrics about Patient Access API usage and data requests to CMS beginning January 1, 2026.

Key Considerations and Early Results

The rule presents a significant opportunity to improve patient experiences and outcomes and to address some of the administrative burden on clinicians. Though CMS made some adjustments to timeframes in the proposed rule, immediate attention is needed to evaluate technological solutions available to payers, assess gaps between current and future required state, and develop policies to comply with new requirements and measures reporting.

Commercial payers may also leverage the improved electronic data sharing but are not required to do so. CMS-funded payers must respond to any inquiries from commercial payers and must require commercial payers to provide the same information as affected payers. Commercial payers, state governments, and other stakeholders have an opportunity to collaborate around the electronic data exchange.

This rule may have positive downstream application to other areas beyond PA, including quality measurements, risk adjustment, and population health. Early adopters who have implemented the prior authorization APIs have, on average, recorded a 150% – 300% return on investment (ROI). The implementation of API-based prior authorization represents a demonstrable increase in efficiency and significantly reduced provider burden. Given the measurable ROI, state-based regional collaboratives being led by Leavitt Partners are forming between payers and providers to implement the core tenants of the CMS rule well in advance of the 2027 deadline.

Similar initiatives are taking place in the technology space, like the Digital Quality Implementers Community, which was recently convened by Leavitt Partners and National Committee for Quality Assurance (NCQA) to build industry readiness for transitioning to FHIR-based digital measurement that hinges on improved electronic data sharing

What to Watch

The HMA team will continue to analyze the CMS’s Interoperability and Patient Access rule in the context of other federal and state policy changes affecting MA organizations, Medicaid FFS programs, state CHIP FFS programs, Medicaid and CHIP managed care programs, and QHPs.

The work and opportunities afforded with the Interoperability and Patient Access final rule will be featured prominently at The HMA Spring Workshop: Getting Real About Transforming Healthcare Quality and Value, March 5-6. In addition to rich discussions, HMA and HMA companies, including Leavitt Partners and Wakely Consulting LLC, are available to support planning and implementation and related system redesign initiatives. If you have questions about these topics, contact Ryan Howells ([email protected]) and Daniela Simpson ([email protected]).

Blog

Pennsylvania releases community HealthChoices (CHC) Medicaid managed care RFA

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This In Focus section reviews the request for applications (RFA) that the Commonwealth of Pennsylvania Department of Human Services (DHS) released January 30, for the Community HealthChoices (CHC) Program. CHC is the mandatory managed long-term services and supports (MLTSS) program, which serves five CHC zones that cover all 67 counties in the commonwealth.  

Notably, this procurement, as compared to the original CHC procurement in 2018, has increased emphasis on innovative approaches to address health equity and the Social Determinates of Health (SDOH). The health equity focus goes beyond traditional health-related social needs such as access to housing, transportation, food, and employment, and addresses some SDOHs that have a particular impact on the CHC population, such as environmental conditions and addressing hazardous or unsafe living conditions.  

Behavioral health remains carved-out to separate behavioral health managed care organizations (BH-MCOs). Instead, CHC applicants will need to articulate how they will coordinate with the BH-MCOs to ensure access to appropriate BH services, which continues to be an area of significant interest for state Medicaid officials.  

Background 

The CHC Program serves individuals who are dually eligible for Medicare and Medicaid and people with physical disabilities who receive home and community-based waiver services or nursing facility care.  

Participants may receive LTSS in the community or in a nursing facility.

CHC is the sole program option for fully dual eligible beneficiaries and most nursing facility clinically eligible (NFCE) individuals who reside in the five zones. The regional CHC zones are as follows:  

  • Southwest zone: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Green, Indiana, Lawrence, Somerset, Washington, and Westmoreland counties.  
  • Southeast zone: Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.  
  • Remaining zones and respective counties, including
    • Lehigh/Capital zone: Adams, Berks, Cumberland, Dauphin, Fulton, Franklin, Huntingdon, Lancaster, Lebanon, Lehigh, Northampton, Perry, York
    • Northeast zone: Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming.
    • Northwest zone: Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Potter, Venango, Warren 

RFA

Medicaid managed care organizations (MCOs) may submit applications for one or more zones. Applications are due March 15, 2024. The department anticipates awarding agreements to three to five CHC-MCOs in each of the five CHC zones. Selected applicants must provide CHC services in all counties in the zone(s) for which they are selected to participate and improve the accessibility, continuity, and quality of services for participants in the CHC program. The contract will run for five years and will have three one-year renewal options.  

DHS indicates that the awarded CHC-MCOs must have an aligned dual-eligible special needs plan (D-SNP) and a current Medicare Improvement for Patients and Providers Act (MIPPA) agreement with the department. The aligned D-SNP must be operational and the MIPPA agreement must be in place by the anticipated implementation date (January 1, 2025).

DHS indicates selected MCOs must be as flexible and adaptable as possible and demonstrate the ability to coordinate services for multiple populations and across multiple programs, including programs with a focus that is broader than the delivery of healthcare services and LTSS. 

Other RFA highlights include the following:  

  • Does not require a cost submittal. 
  • Includes small diverse business (SDB) or veteran business enterprise (VBE) goals of 11 percent and 3 percent respectively. Applicants must include separate SDB and VBE submittals for each zone in its application.  
  • Includes a contractor partnership program (CPP) which requires entities that are awarded a contract or agreement with DHS to establish a hiring target to support Temporary Assistance for Needy Families (TANF) beneficiaries in obtaining employment with the contractor, grantee, or their subcontractors. 

Notably, DHS has provided itself flexibility within the RFA to implement a pay-for-performance incentive to MCOs. Under this policy, DHS could make incentives available to MCOs that help participants successfully complete the financial eligibility redetermination process with their local County Assistance Offices (CAOs). The department may implement additional pay-for-performance incentives in later years. 

Timeline

Evaluation 

For an applicant to be considered responsible for this RFA and eligible for selection of best and final offers (BAFOs) and negotiations:  

  • The total score for the technical submittal of the application must be greater than or equal to 75 percent of the available raw technical points  
  • The applicant’s financial information must demonstrate that the organization possesses the financial capacity to fulfill the good faith performance of the agreement 

The evaluation committee will evaluate technical submittals for each zone separately. For each zone, DHS must select for negotiations the applicants with the highest overall score. The weight for the technical criterion is 100 percent of the total available points. Technical evaluation will be based on soundness of approach, applicant qualifications, personnel qualifications, and understanding the project. 

The final technical scores will be determined by giving the maximum number of technical points available to the application with the highest raw technical score. The remaining applications will be rated by applying the formula located at RFP Scoring Formula

Financial information will not be scored as part of the technical submittal. It will be reviewed only to determine an applicant’s financial responsibility. 

SDB and VBE participation submittals will not be scored, however, if an applicant fails to satisfy the SDB or VBE requirements described, and DHS will reject the application. 

DHS will not score the CPP submittal. Once an applicant has been selected for negotiations, DHS will review the CPP submittal.

Current Market

The CHC incumbents are AmeriHealth Caritas, Centene, and University of Pittsburgh Medical Center (UPMC), serving 411,034 CHC members as of October 2023.

DHS has published a historical data summary for the CHC program along with other DHS reports at: Community HealthChoices Historical Data

Link to solicitation: All files on PA eMarketplace 

Link  to RFP 

Want to know more about how the next phase of Community Health Choices will impact your organization?

HMA’s Pennsylvania-based teams can assist organizations seeking to understand the implications of this important procurement, key program changes and what the outcome may mean for providers, community base organizations, and other stakeholders. Please contact Dianne Bisacky with questions or if you are seeking more detailed analysis of this procurement or the Community Health Choices program generally. 

Nine States to Participate in Children’s Behavioral Health Policy Lab

LANSING, MICH. – Health Management Associates (HMA), in partnership with the Annie E. Casey Foundation, Casey Family Programs, National Association of State Mental Health Program Directors (NASMHPD), the Child Welfare League of America (CWLA), the American Public Human Services Association (APHSA), National Association of Medicaid Directors (NAMD) and the Centene Foundation, will convene a Children’s Behavioral Health (CBH) State Policy Lab, Feb. 7-9 in Baltimore. HMA today announced that Georgia, Kansas, Kentucky, Maryland, Missouri, Pennsylvania, Texas, Utah, and Wisconsin will participate in the policy lab. MITRE, which previously hosted a related federal convening, will also take part in this state convening.

This pioneering effort, made possible by the partner organizations, aims to convene state interagency teams – including child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education – to collectively strategize, learn from innovators in the sector and promote cross-system alignment to drive outcomes for children, youth, and families.

COVID-19 has exacerbated long-standing system collaboration challenges across state child welfare, behavioral health, and Medicaid that lead to unsatisfactory outcomes for the most vulnerable children in our communities. Most worrisome is the worsening of behavioral and physical health challenges and trauma because of uncoordinated or fragmented care. This lack of coordinated strategy and policy leads to higher costs of treatment and also increasingly exposes states and local jurisdictions to threats or filings of class action lawsuits, and related settlements or those arising from Department of Justice investigations. Fortunately, federal and state efforts and investments to address the youth systems of care – including schools, community, delivery systems, and community-based child placing agencies – are in motion.

In November, a call for applications was released to U.S. states and territories for potential participation in the State Policy Lab. Applicants were required to identify demonstrated need, existing state agency governance structures focused on children and youth, technical assistance needs, and outcomes for attending the policy lab. The applications required demonstrated participation from Medicaid, child welfare and behavioral health agencies; a commitment to creating sustainable interagency solutions for children, youth, and their families and had to certify formal support from the Governor/Cabinet level.

An external independent panel reviewed applications for state agency participation using a standardized rubric that covered four domains:

  • Gaps and opportunities analysis
  • Intent of collaborative partnerships
  • Approach to engagement of youth and adults with lived experience
  • Imminent risks to public agency operations as a result of poor outcomes for children, youth, and their families

This convening is aimed at assisting child welfare, juvenile justice, behavioral health, Medicaid, and K-12 public education where possible to build upon existing efforts to improve outcomes for children, youth, and families, strategically layering on missing components and promoting alignment between them and with other agency priorities. Examples of what could be co-designed with state partners:

  • Build a shared strategic vision for a comprehensive continuum of care that ensures access to the “right service, at the right time based on individual and family need.” This vision can strengthen prevention initiatives and ensure the full array of evidence-based community-based interventions including use of crisis response and stabilization models.
  • Develop policies and strategies for improving the engagement of children, youth, and families with lived experiences to the “right part of the system for the right level of care,” agnostic of the door through which they enter any coordinated child serving system, while ensuring that all aspects of this system are anchored in equity.

Following the event, learnings and findings will be disseminated to help states and counties adopt innovative solutions to improve outcomes for children, youth, and their families.

For more information email: [email protected]

Blog

CMS approves next phase of New York’s Medicaid 1115 waiver journey

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

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

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

Funding

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

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

HRSN

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

HERO

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

Workforce

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

Medicaid Hospital Global Budget Initiative

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

IMD Waiver for SUD

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

Curious About What the Waiver Means for Your Organization?

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

Webinar

Webinar Replay – Navigating change: exploring the opportunities of New York’s 1115 Medicaid waiver amendment

Watch Now

This webinar was held on January 24, 2024.

During this webinar, HMA panel guides you through the key provisions of the newly approved New York 1115 Medicaid waiver amendment. This groundbreaking development opens doors to transformative changes in healthcare delivery, impacting both providers and beneficiaries alike, including enhanced Health Related Social Needs (HRSN) benefits, workforce and hospital investments, and further commitment to Value Based Payment (VBP).

Gain valuable insights into the innovative strategies and opportunities presented by the waiver amendment, paving the way for new social care networking activities, funding opportunities, and regulatory flexibilities that will improve access to vital services.

Learning Objectives

  • Learn more about the waiver-specific details and what they mean.
  • Hear what potential opportunities will become available.
  • Hear from national experts on similar models implemented nationally.
HMA News

Health Management Associates Successfully Completes SOC 2 Type 2 Examination

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Health Management Associates (HMA), a leading independent, national healthcare consulting firm today announced that it has successfully completed a Service Organization Control Type 2 (SOC 2 Type 2) audit.

The SOC 2 Type 2 audit was developed by the American Institute of Certified Public Accountants to evaluate an organization’s information security controls over a period of time​. It assessed both the suitability of HMA’s controls and its operating effectiveness, covering the HMA organization as a whole, service offerings, resources used to deliver client work, and technical (cybersecurity) and non-technical controls (administrative strengths such as excellent training and a culture that promotes anti-fraud and ethical behaviors).

“Increasingly, completing a SOC 2 Type 2 audit is an important distinction for many of our clients and partners,” said Doug Elwell, chief executive officer. “Achieving this with no material findings across the firm is yet another way to meet client needs and further demonstrates our commitment to our core values of accountability, client commitment and integrity.”

Founded in 1985, HMA is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 30 locations across the country and over 700 multidisciplinary consultants coast to coast, HMA’s expertise, services, and team are always within client reach. Learn more about HMA at healthmanagement.com, or on LinkedIn and X.

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Rhode Island releases Medicaid managed care program RFP

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

Background

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

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

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

RFP

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

EOHHS will award contracts to two or three MCOs.

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

Timeline

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

Current Market

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

Evaluation

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

Link to RFP

Blog

Medicaid Business Transformation DC: recommendations for technical assistance

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

The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the Integrated Care DC webpage. https://www.integratedcaredc.com/medicaid-business-transformation-dc/  The report and other information about the program were published at https://dhcf.dc.gov/innovation.

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

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

To learn more about this effort, contact Caitlin Thomas-Henkel.

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

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

Blog

CMS Transforming Maternal Health Model offers state Medicaid agencies an opportunity to accelerate improvements in quality and outcomes

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

Pregnancy-related deaths have more than doubled since 1987 to 17.6 deaths per 100,000 live births, with health disparities only worsening outcomes for different racial and ethnic groups. For example, the pregnancy-related mortality rates for Black and Native American and Alaska Native women are approximately two to three times higher than the rate for White women. In recent years, 38 states have extended post-partum coverage and 11 states now offer doula coverage for Medicaid enrollees. This initiative accelerates the focus on maternal outcomes and, with nearly 43 percent of births paid for by Medicaid, has the potential to impact health across generations.

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

Model Overview

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

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

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

The Model will have two phases for participating SMAs:

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

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

TMaH Opportunities and Considerations

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

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

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

What’s next?

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

The HMA team will continue to evaluate the TMaH model as more information becomes available. For more information, contact Amy Bassano ([email protected]), Melissa Mannon ([email protected]), and Andrea Maresca ([email protected]).

Brief & Report

Medicaid Business Transformation DC: Recommendations for Technical Assistance

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

The HMA team implemented a mixed-methods assessment approach that included a literature review of national value-based payment (VBP) best practices, focus groups, interviews, and a technical assistance (TA) survey of District organizations, agencies, and stakeholders. This strategy identified the TA needs of   District healthcare providers that informed the design of an intensive 3-month technical assistance program that included a variety of tools, webinars, and trainings. All resources and tools are available on the Integrated Care DC webpage. https://www.integratedcaredc.com/medicaid-business-transformation-dc/  The report and other information about the program were published this week at https://dhcf.dc.gov/innovation.

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

Report authors include Caitlin Thomas-Henkel, Suzanne Daub, Art Jones, Hunter Schouweiler, Amanda White Kanaley, and Vicki Loner. It was peer reviewed by Jean Glossa and Sam DiPaolo.

Brief & Report

A Look at Swedish Maternity Care with Medicaid in Mind

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Health Management Associates (HMA) collaborates with state and federal agencies, health service providers, and community-based organizations to enhance access to comprehensive reproductive healthcare and address disparities in birth outcomes, particularly in the context of Medicaid. This involves evaluating and supporting the implementation of perinatal care models, addressing health determinants affecting birth outcomes, and overcoming barriers to reproductive health services. In an effort to inform these initiatives, Diana Rodin, an associate principal at HMA interviewed Swedish experts to understand the country’s universal, publicly funded maternity and reproductive healthcare system. The Swedish model emphasizes universal healthcare, generous socioeconomic supports, and collaborative team-based perinatal care led by midwives. Lessons from Sweden, such as the utilization of “kulturdoulas” for culturally aligned support, a consensus-driven decision-making approach, and a centralized perinatal data system, provide valuable insights for improving birth outcomes for Medicaid recipients in the United States.