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SAMHSA’s next chapter: priorities, programs, and possibilities

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The prospect of new leadership due to a presidential election brings with it the potential for significant shifts in priorities, policies, and programs within federal agencies. The Substance Abuse and Mental Health Services Administration (SAMHSA) plays an increasingly critical role in shaping the nation’s mental health and substance use disorder services in the United States. Mental health and the opioid crisis are a salient political issue that will receive some attention on the campaign trail, but candidates are unlikely to detail the specifics on how the rhetoric becomes reality.

SAMHSA’s budget could see adjustments, channeling resources toward initiatives that align with the new administration’s vision. This could mean increased funding for specific programs deemed critical under the new leadership and decreases for other programs. Any major shifts in funding will require the support of Congress. Also possible with new leadership are changes to programmatic approaches that revolve around the introduction of novel interventions, expansion of access to treatments, and addressing emerging challenges such as the opioid crisis with renewed vigor.

The intersection of technology and mental health is likely to receive heightened attention. Telehealth expansions, digital tools for prevention and intervention, and data-driven innovations may become focal points of SAMHSA’s strategy.

As SAMHSA adapts to new leadership, the opportunity arises to forge innovative pathways toward improved mental health outcomes and enhanced support for individuals and communities affected by substance use disorders. By embracing whatever change may come, SAMHSA can continue its vital mission of promoting behavioral health and resilience across the nation. The results of the 2024 election will have a significant impact on federal mental health policy in the coming years; DC Direct subscribers get a steady stream of insight to stay on top of what’s coming next.


Takeaways from the ensuring access to Medicaid services final rule

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This week’s second In Focus section delves into the Ensuring Access to Medicaid Services final rule. The Centers for Medicare & Medicaid Services (CMS) published the access rule May 10, 2024, alongside the similarly significant Medicaid managed care final rule. The two rules include new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and the Children’s Health Insurance Program (CHIP) across the fee-for-service (FFS) and managed care delivery systems and provide targeted regulatory flexibility in support of this goal.   

Five Takeaways from the CMS Medicaid Managed Care Final Rule, which Health Management Associates, Inc. (HMA), published April 24, 2024, outlined key issues and implications that CMS advanced in the Medicaid managed care program. The Ensuring Access to Medicaid Services final rule, meanwhile, focuses on the following:   

  • Payment adequacy for direct care workers (80/20 rule) 
  • The role of self-direction and the 80/20 rule 
  • Establishment of a pathway to national benchmarking of Medicaid rates   
  • Potential impacts of the rule on programs that serve individuals with dual eligibility 


The Ensuring Access to Medicaid Services finalized policies are designed to create an updated federal framework for Medicaid’s home and community-based services (HCBS) programs. These changes come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs). Table 1 provides an overview of several significant final policies. 

Table 1. Ensuring Access to Medicaid Services: Overview of Final Rule Policies 

Below HMA reviews several key questions we are fielding regarding the impact of the rule.  

Ensuring Payment Adequacy: How will states demonstrate that 80 percent of Medicaid payments go to direct care workers?  

The final rule requires at least 80 percent of Medicaid payments be spent on compensation for DCWs workers, including homemaker, home health aide, and personal care services. In response to public comment, CMS adjusted the final rule to include some employer costs in the 80 percent calculation.  

Recognizing it will take substantial time for providers to establish the necessary systems, data collection tools, and processes to collect the required information to report to states, CMS is providing states six years to implement the HCBS Payment Adequacy policy, and four years for reporting requirements. States and providers must ensure that that they are prepared to meet the payment adequacy requirements in the final rule. Being successful will require collaboration between states and providers, investments in systems, and analysis of – and potentially changes to – reimbursement levels.  

How does the 80/20 rule apply to self-directed care?  

CMS finalized its proposal to require that at least 80 percent of all payments for homemaker, home health aide, and personal care services in HCBS programs, including managed care programs, be spent on compensation for DCWs. In a change from its proposed policy, CMS limits the 80/20 compensation mandate to certain types of self-directed models. Specifically, the 80/20 rule will apply to models in which the beneficiary directing services does not set the payment rate for the worker, such as Agency with Choice and other self-directed models that use a fiscal intermediary or fiscal employer agent, in both managed care and FFS delivery systems. The compensation rule does not apply to self-directed models in which the beneficiary sets the rates paid to workers.  

CMS will hold states accountable for compliance with the 80/20 rule, regardless of whether their HCBS are delivered through an FFS delivery system, managed care delivery system, or both. States will need to determine an approach to track compliance with the minimum performance requirement at the provider level, not the managed care plan level. States and managed care plans should collaborate to determine their respective roles in activities such as the data collection and mandatory reporting, and they should continue to seek and monitor clarifying guidance from CMS. 

How will the Ensuring Access final rule affect national benchmarks in Medicaid rates? State Medicaid programs have many nuances that make it difficult to obtain applicable comparison data and best practices. Beginning July 1, 2026, the final rule requires that states publish their payment rates, specifically the average hourly Medicaid FFS fee schedule payment rates, separately identified for payments made to individual providers and provider agencies, if the rates vary. States also must conduct a comparative analysis of their base Medicaid FFS fee schedule payment rates with the Medicare non-facility payment rate. CMS does not, however, require that states change their payment rates based on the comparative analysis.  

Payment rate transparency publications, comparative payment rate analyses, and payment rate disclosures present opportunities for states, MCOs, and providers to assess the adequacy of payment rates and their impact on access to services. The forthcoming data also will help federal and state level policymakers in their efforts to improve quality, access, and affordability. States will need to do baseline assessments comparing Medicaid and Medicare rates. States, managed care plans, and providers should monitor for CMS sub-regulatory guidance, including hypothetical examples of the service codes that would be subject to the comparative payment rate analysis.  

Does the final rule affect integrated models of care for people who are dually eligible for Medicaid and Medicare? CMS finalizes policies that will have a variable impact on states and individuals dually eligible for Medicare and Medicaid because of differences in state approaches to integrated care for this population. For example, the new grievance system policies apply differently depending on the level of integration the state requires of Medicare Advantage (MA) dual-eligible special needs plans (D-SNPs) programs. Like grievance systems, states, providers, and MCOs should monitor how states address the final rules for critical incidents for individuals with dual eligibility when a Medicaid managed care plan is unable to access Medicare data.  

CMS intends to provide additional sub-regulatory guidance and technical assistance to support implementation of policies that affect dually eligible individuals. States should verify their access to and readiness to use Medicare data related to the new requirements, and seek technical assistance to maximize use of these data for individuals enrolled in non-integrated D-SNPs. Commentors have also asked how the changes to the HCBS quality measure set may work in programs for dually eligible members.  

Connect with Us  

HMA is ready to support your efforts to understand and take action to account for the Ensuring Access to Medicaid Services final rule’s effects on your state’s or organization’s strategy and operations. Our experts are developing policies and procedures at the intersection of the access and managed care final rules. Please contact Susan McGeehan, Dari Pogach, and Patrick Tigue to connect with our expert team members on this vital set of issues.


HMA opens registration for fall conference: Unlocking Solutions in Medicaid, Medicare, and Marketplace

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Unlock Solutions in Medicaid, Medicare, and the Marketplace at HMA’s Fall Conference, October 7−9 

This week, we preview what to expect at the 7th annual Health Management Associates, Inc. (HMA) Fall Conference “Unlocking Solutions in Medicaid, Medicare, and Marketplace,” October 7−9, 2024, at the Marriott Marquis Chicago, IL. Learn more about our Keynote Speaker and take advantage of our Early Bird Registration

Keynote Speaker Announced 

We are pleased to announce our Keynote Speaker will be Darshak Sanghavi, MD, program manager at the Advanced Research Projects Agency for Health (ARPA-H)—a newly created multibillion dollar federal agency tasked with developing health programs that are “so bold no one else, not even the private sector, is willing to give them a chance.” His talk, “Unlocking Health Solutions through Innovation,” will highlight the innovative collaborations and projects ARPA-H is advancing. A trained clinician who has served in high level public and private sector advisory roles, Dr. Sanghavi will discuss how this new wave of research and innovations is changing how we think about healthcare’s challenges and will address why the agency is so important at this time. He will highlight ARPA-H investments and commitments and the timeline for impact, including how healthcare systems and states should be thinking about ARPA-H funded innovations and preparing for scaling breakthroughs that improve outcomes.  

Before joining ARPA-H, Dr. Sanghavi was global chief medical and clinical operating officer for Babylon, the global end-to-end digital healthcare provider serving more than a dozen countries and 24 million-plus people, with the mission of bringing “affordable and accessible healthcare to everyone on earth.” He also has served in senior roles at UnitedHealthcare’s Medicare & Retirement, OptumLabs, the R&D hub of UnitedHealth Group, and in the Obama Administration as the Director of Preventive and Population Health at the Center for Medicare and Medicaid Innovation, where he directed the development of large pilot programs designed to improve the nation’s healthcare costs and quality. He is an award-winning medical educator, who has worked in medical settings around the world. He will draw on these diverse experiences to inspire and challenge attendees to unlock solutions to some of our healthcare system’s most complex issues. 

Network with Leaders in Healthcare 

This is an important moment for ever-changing publicly sponsored healthcare programs like Medicaid, Medicare, and the Marketplace, with greater focus on value and federal initiatives that encourage improved health equity, affordability, quality, and outcomes. Don’t miss out on this opportunity to form new partnerships as you dig into today’s urgent issues and immerse yourself in insightful discussions, networking opportunities, and engaging workshops on the new Medicaid managed care rule, applications for AI in healthcare, approaches to meet rural workforce needs, value-based care contracting, and insights from state Medicaid services.  

Preconference tactical workshops will focus on exclusive tools, insights, and strategies to guide program design, navigate new regulatory frameworks, and advance value-based care. HMA’s premier national conference plenary and breakout sessions will focus on the landscape for innovation in healthcare, emerging service delivery models, and growth strategies in pursuit of improved value, quality, and better outcomes. 

Who should attend? 

Executives and leaders from federal, state, and local government agencies, health plans, payers, managed care, hospitals and health systems, provider and provider enablement organizations, community-based organizations, IT companies, life sciences organizations, investment firms, foundations, and associations. 


The 2024 Presidential Election and its long-term impact on Medicaid

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The prospect of new leadership due to a presidential election brings with it the potential for significant shifts in priorities, policies, and programs within federal agencies. Medicaid now provides healthcare coverage for more than 84 million Americans. Since 2010, Medicaid has been subject to significant federal policy changes, starting with expansion as part of the Affordable Care Act, pandemic-related continuous eligibility provisions, expanded coverage for postpartum women, and just recently updated rules for managed care plans. The 2024 election will have a significant impact on Medicaid in the coming years, although you won’t hear much about it on the campaign trail (but our DC Direct subscribers get a steady stream of insight to stay on top of what’s coming next).

Medicaid’s political salience has been quiet but steadily increasing since 2010, with now 41 states (including DC) having expanded access, changing the political narrative about the program. Medicaid coverage churn due to the unwinding of the pandemic related continuing-coverage provisions has been politically fraught for governors and legislatures, even bringing some states like Mississippi to finally consider the expansion opportunity to improve stability of coverage.

States each have their own approach to designing Medicaid coverage, but federal rules set the parameters within which they choose how to maintain access and quality of healthcare for low-income individuals and families.  New CMS rules are requiring require more from managed care plans who contract to administer Medicaid in many states, increasing network adequacy, quality measurement standards, consumer protections and tailored approaches for long-term services and supports. These changes will shape the future of procurements for managed care services.

The election is very likely to touch on broad issues of affordability and equity, which are relevant to all healthcare programs but especially to Medicaid. Current policy priorities that center on equity have resulted in program design features that can impact the social determinants of health, including initiatives to address housing insecurity, food access, and mental health services. Increasingly these concerns have been bipartisan, although the proposed approaches will differ based on who is in charge.

Changes in national leadership – whether at CMS, HHS, or in the White House – will inevitably result in changes to the Medicaid program that impacts states and the agencies that serve the millions of Americans who rely on the program for essential healthcare services. Our Leavitt Partners colleagues provide regular intelligence on all the federal activity in D.C. that impacts Medicaid and other state health programs. Learn more about DC Direct and how this steady stream of insight can help inform your strategic decisions.


Succeeding in the world of value-based payments: assess your organization’s VBP readiness

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In the ever-evolving landscape of healthcare, the shift towards value-based care (VBC) has emerged as a transformative force, promising improved outcomes, reduced costs, and enhanced patient experiences. While the benefits of VBC are clear, the path to implementation can be complex and challenging, particularly for behavioral health (BH) providers. In this blog post, we delve into the significance of assessing readiness for VBC and value-based payment (VBP) systems, with a specific focus on BH providers, and why it serves as a crucial step towards success.

Behavioral health plays a pivotal role in holistic patient care, addressing mental health and substance use disorders that significantly impact overall well-being. However, traditional fee-for-service models often inadequately incentivize preventive and coordinated care, leading to fragmented services and suboptimal outcomes. Recognizing this gap, the transition to VBC offers a promising avenue to realign incentives, improve care coordination, and enhance patient outcomes in the realm of behavioral health.

Insights from the HMA Spring Workshop

In March 2024, HMA hosted a workshop on value-based care, (you can read more of the key takeaways here). A consensus emerged on the indispensable role of data and technology in driving informed decision-making. Dr. Katie Kaney’s keynote address on innovative approaches to holistic care metrics resonated with attendees, highlighting the need to move beyond conventional measurements towards a comprehensive understanding of patient well-being.

A pivotal aspect of VBC lies in the collaborative effort between payers and providers to align measures and incentives while ensuring these measures hold significance for all stakeholders, including payers, providers, and patients. The conversations with attendees on Empowering Care Delivery through Tangible Measures underscored the imperative of clinician involvement in outcome measurement establishment. We discussed the importance of meaningful measurement for state-level initiatives and local strategies, all aimed at achieving better outcomes for our communities.

The Importance of Readiness Assessment

Embarking on the journey towards VBC demands a comprehensive understanding of organizational strengths, challenges, and readiness to embrace change. As we navigate the transition to value-based care, understanding where your organization stands is key. This is where readiness assessment tools play a pivotal role. By systematically evaluating various aspects of organizational preparedness, such as infrastructure, data capabilities, care delivery models, and cultural readiness, organizations can identify areas for improvement and tailor strategies to navigate the transition effectively.

Tailoring Strategies for Success

Assessing readiness enables organizations to tailor strategies that align with their unique circumstances and challenges. For instance, organizations lacking robust data infrastructure may prioritize investments in health information technology and analytics capabilities to support population health management and outcome measurement. Similarly, addressing workforce training and cultural transformation can foster a patient-centric approach and promote collaboration across care teams.

Mitigating Risks and Maximizing Opportunities

VBC presents both opportunities and risks for organizations. While it offers incentives for preventive care, care coordination, and improved outcomes, it also requires operational and cultural shifts that may pose challenges. Readiness assessment enables organizations to identify potential risks, such as inadequate data systems, reimbursement uncertainties, or staff resistance, and develop mitigation strategies to address them proactively. Moreover, it empowers organizations to capitalize on opportunities, such as alternative payment models, partnerships with primary care providers, and value-based contracting, to enhance sustainability and growth.

Driving Quality and Equity in Behavioral Health

At its core, VBC embodies a commitment to delivering high-quality, equitable care that addresses the diverse needs of patients. By assessing readiness and embracing VBC principles, BH providers can enhance care delivery, improve outcomes, and reduce disparities in access and quality of care. Furthermore, by integrating behavioral health into broader care delivery models and payment structures, organizations can foster a more holistic approach to health and well-being, promoting resilience and recovery for individuals and communities alike.

Moving Forward with Confidence

As organizations navigate the complexities of VBC, assessing readiness serves as a guiding compass, illuminating the path forward and empowering organizations to embrace change with confidence. By leveraging readiness assessment tools, organizations can identify strengths, address weaknesses, and chart a course towards sustainable, value-driven care delivery. In doing so, they not only enhance their own viability and success but also contribute to a more resilient, equitable healthcare system that prioritizes the well-being of all individuals.

How HMA Can Help

There are many tools online that offer to help organizations determine their readiness for implementing VBC. By using HMA’s new VBP Readiness Assessment tool, you also can gain access to the experts on HMA’s behavioral health and VBC teams. Meticulously crafted to gauge your organization’s preparedness, HMA’s value-based payment readiness assessment surveys six domains of core functions necessary for successful payment reform models.

Taking the survey and receiving one analyzed response is free, but you may find value in contracting with HMA for a more in-depth analysis of your organization.

Assessing readiness for VBC is not merely a preparatory step but a fundamental aspect of organizational transformation. For behavioral health providers, it represents a critical opportunity to reshape care delivery, drive quality and equity, and ultimately, improve the lives of those served. As the healthcare landscape continues to evolve, readiness assessment will remain an indispensable tool for navigating change, fostering innovation, and realizing the full potential of value-based care in behavioral health.


Medicaid Unwinding Check-in: Data Informed Observations to Guide Future Action

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In this week’s In Focus section, HMA Managing Director Matt Powers and Associate Principal Lora Saunders discuss observations and perspectives as we approach completion of the Medicaid unwinding.   


In response to the COVID-19 pandemic, CMS offered states an enhanced federal match in exchange for states pausing Medicaid disenrollments. As a result, Medicaid enrollment increased from around 71 million at the start of the pandemic to more than 92 million in December 2022, when Congress passed a bill to end the “continuous eligibility” provision. States began to resume normal (pre-pandemic) redetermination activities in early 2023—a massive undertaking of attempting to reach and verify eligibility for the then 94 million Medicaid enrollees known as “unwinding.”  

More than 70 percent of the efforts that will precipitate the largest one-year drop in enrollments since the program’s inception in 1965 have been completed. The enrollment reductions to date have been virtually identical to HMA’s aggregate projections, and overall enrollment remains well above pre-pandemic levels. Perhaps most importantly, the Medicaid unwinding has put policymakers in a position to better evaluate how to improve enrollment and redetermination processes going forward.   

Figure 1 summarizes pre-pandemic enrollments, unwinding enrollments, and the projected end of 2024 enrollment. If the current trend holds, national Medicaid enrollment will be approximately 80 million enrollees—down from the 94 million pre-unwinding enrollment peak and nearly 10 million greater than the 71 million pre-pandemic enrollment. 

Our team’s assessment of the status of and data related to the Medicaid unwinding has led us to the following observations: 

  • Arkansas, Iowa, Nebraska, Utah, and West Virginia have completed the redetermination process. More than half of the states are within two months of finishing the process. 
  • The states that saw Medicaid enrollment grow the most under the continuous coverage policy are generally the same ones that are experiencing the greatest enrollment declines during the Medicaid unwinding. 
  • Some larger states—including California, New York, and Texas—have sizeable outstanding redeterminations.   
  • Nationally, more than 70 percent of all Medicaid enrollees have completed the redetermination process.  Figure 2 points out how far along states are with the redetermination process as of late April 2024. 

Medicaid Unwinding: The Road Ahead 

As the Medicaid unwinding process enters its final phase in most states, we are looking back at the experiences and lessons that can be applied to make impactful changes to Medicaid eligibility policies, systems, and procedures. 

Despite the challenges that the pandemic presented, the safety net was tested and responded well. In early 2020, the number of employed Americans decreased from 158 million to 133 million, and unemployment levels quickly reached 15 percent. Many new healthcare policies targeted direct access issues (e.g., financial supports to providers and telehealth regulatory relaxations), whereas the Medicaid continuous coverage requirement was intended to mitigate the effects of the abrupt spike in unemployment and potential effects on healthcare insurance. Table 1 shows how HMA projects national coverage patterns to change by type of coverage from before the pandemic through the end of the Medicaid unwinding. While the number of people with employer-sponsored insurance (ESI) or uninsured remains essentially flat, Medicaid enrollment grows significantly, and marketplace enrollment nearly doubles. Myriad federal and state policy changes contributed to a remarkably stable uninsurance rate during one of the most volatile economic periods in the past century. 

A next question for policymakers is whether, or to what extent, the rate of uninsured people can be sustained or reduced. The broad state adoption of policies to expand postpartum coverage to 12 months from two months and the nationwide January 2024 requirement for states to offer 12 months of continuous Medicaid coverage for children provide a coverage and continuity boost, especially given that nearly 40 million children will benefit from the new law. Other policy levers have the potential to be widely accepted and provide a further incentive to move people who are uninsured toward coverage, more stable insurance products, and more predictable outcomes and costs relative to the inefficiencies and ineffectiveness of non-coverage. 

Pivoting to best practices and making policy changes permanent. Just as the relaxation of relatively rigid telehealth policies has become more accepted, post-Medicaid unwinding will provide a natural opportunity to assess best practices and consider permanent policy changes.    

  • Making Ex Parte Durable Policy.  Evidence suggests that ex parte policies effectively reduce churn. Further refinement of longstanding ex parte policies is within reach. Ensuring ex parte appropriately manages both the complexities of household versus individual eligibility issues and addresses the weaknesses of unreliable member contact information can improve the likelihood that ex parte can effectively serve as durable policy.  
  • Pivoting from Paper to Electronic Communications.  The Medicaid unwinding has seen more partnerships and innovation with state and federal workers, providers, managed care organizations, and consumer advocates, and allowed the increased use of mobile devices for outreach and engagement. Making more deliberate strides to simplify eligibility and move the eligibility platform, patient engagement, and member outreach to more reliable communication methods (e.g., email, text, and member portals rather than paper communication) while adhering to privacy and security requirements is a logical next step.   
  • Continuing to Measure Better. Call abandonment rates, call center wait times, and application processing times—metrics that focused on some of the key challenges to a successful redetermination and timely access to care—received greater attention during the unwinding but were frequently overshadowed by other primary metrics like “disenrollments” and “procedural terminations.” Though disenrollment data and procedural terminations could be used to identify potential areas of concern, their emergence as primary metrics often diverted energy from innovative engagement and redetermination efforts. A focus on contextualized metrics that provide actionable information will support effective oversight and monitoring.

Marketplace growth may be the real story. Throughout the pandemic, marketplace enrollment has steadily increased, jumping nearly 90 percent from 2020 to 2024 and 30 percent from 2023 to 2024, to reach more than 21 million enrollees. Driving the growth in marketplace enrollment are temporarily increased marketplace subsidies and Medicaid unwinding public awareness campaigns.  

  • The marketplaces are proving to be a reliable source of coverage for consumers without health insurance access through ESI or other public programs, particularly in times of significant change such as the Medicaid unwind. With more marketplace enrollees and, therefore, broader risk pools, more health insurers are considering offering marketplace plans and are assessing competitive advantages like lower costs, broader provider networks, and more robust drug formularies. 
  • Figure 3 shows that marketplace growth in non-expansion states is far outpacing marketplace growth in Medicaid expansion states, suggesting that the key elements of the Affordable Care Act have developed deep roots.  

HMA’s experts continue to monitor Medicaid unwinding developments. We are taking a comprehensive approach to assessing lessons learned and opportunities to improve Medicaid as state and stakeholder experiences and data continue to become available over the next two quarters. 

For more information or questions about Medicaid unwinding developments, contact Matt Powers and Lora Saunders. 


Analysis of five key proposals in CMS’s FY2025 Medicare hospital IPPS rule

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Our second In Focus section reviews the policy changes proposed by the Centers for Medicare & Medicaid Services (CMS) on April 10, 2024, for the Fiscal Year (FY) 2025 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Proposed Rule (CMS-1808-P). This year’s IPPS Proposed Rule includes several policy changes that will alter hospital margins and change administrative procedures, beginning as soon as October 1, 2024. 

We highlight five proposed policies that are likely to have the greatest impact on Medicare beneficiaries, hospitals and health systems, payors, and manufacturers:  

  • Annual inpatient market basket update  
  • New technology add-on payments (NTAP) policy changes  
  • Transforming Episode Accountability Model (TEAM) 
  • Hospital wage index and labor market adjustments 
  • Revision to housing-related diagnosis coding  

Stakeholders have until June 10, 2024, to submit comments to CMS on the contents of this regulation and request for information. 

Market Basket Update  

Proposed rule: Overall CMS’s Medicare 2025 Hospital Inpatient Proposed Rule will increase payments to acute care hospitals by an estimated $3.2 billion in 2024−2025; however, recent trends in economy-wide inflation may alter this estimate by the time the agency releases the final regulation in August 2024.  

HMA/Moran analysis: CMS’s 2.6 percent increase is based largely on an estimate of the rate of increase in the cost of a standard basket of hospital goods—the hospital market basket. For beneficiaries, this payment rate increase will lead to a higher standard Medicare inpatient deductible and increase out-of-pocket costs. For hospitals and health systems, payors, and manufacturers the proposed payment increase (2.6%) falls below economywide inflation over the past year (3.5%) and below what Medicare Advantage plans will receive for 2025 (3.7%).1,2 Importantly, based on our expertise with the calculation of the hospital market basket, we anticipate the proposed 2.6 percent increase will increase slightly by the time rates are finalized later this year.  

New Technology Add-on Payments (NTAPs)  

Proposed Rule: CMS proposes three changes to the NTAP program and discusses NTAP applications for FY 2025: 

  • CMS proposes to shift the date used to determine whether an otherwise qualifying product is within its newness period. As proposed, if the product’s three-year anniversary occurs after the beginning of the fiscal year on October 1, the product will receive NTAP payments that year. 
  • CMS proposes to allow products with a hold on their FDA marketing authorization application to be considered eligible for NTAP. 
  • Beginning with applications approved in the current FY 2025 cycle, the NTAP add-on percentage for gene therapies treating sickle cell disease would increase to 75 percent.  

HMA/Moran Analysis: The first two proposed changes are in response to concerns about more restrictive application requirements finalized last year. When CMS shifted the FDA approval deadline to May 1 last year, commenters noted that fewer products would be eligible to receive NTAPs in their third year of the newness period. Allowing all products with a third anniversary that falls within a fiscal year (rather than only those with expirations in the second half of the fiscal year) to receive NTAPs narrowly addresses this concern. More products will qualify for NTAPs during their third year of newness, but that does not necessarily mean that more products will receive three years of NTAPs.   

The second proposal tweaks last year’s change requiring a “complete and active” FDA application at the time an NTAP application is submitted to ensure that NTAP applications were far enough along in the FDA review process that information about the product would be available to the public and for CMS staff review. CMS proposal acknowledges that the original bright line rule may have inappropriately excluded potential applicants.   

Finally, CMS’s proposal to increase the NTAP percentage for gene therapies treating sickle cell disease aligns with the Cell and Gene Therapy Access Model’s focus on sickle cell therapies. Of note, CMS seeks comment on whether the increased NTAP percentage should be applied only to applicants that have entered value-based purchasing agreements or are “otherwise engaging in behaviors that promote access to these therapies at lower cost.” CMS seems willing to increase NTAP payments in limited situations to boost selected policy goals, but the proposals in this regulation do not represent widespread NTAP payment increases. 

Transforming Episode Accountability Model (TEAM) 

Proposed Rule: CMS proposes to establish a new mandatory episode-based CMS Innovation Center model, Transforming Episode Accountability Model (TEAM). In the TEAM model, selected acute care hospitals would coordinate care for people with traditional Medicare who undergo one of the five specified surgical procedures: 

  • Lower extremity joint replacement 
  • Surgical hip femur fracture treatment 
  • Spinal fusion 
  • Coronary artery bypass graft 
  • Major bowel procedure 

Hospitals in the model will assume responsibility for the cost and quality of care from surgery through the first 30 days after the Medicare beneficiary leaves the hospital. Hospitals also must refer patients to primary care services to support optimal long-term health outcomes.  

In a first of its kind program, CMS has created a voluntary decarbonization and resilience initiative through which participating hospitals can report metrics related to greenhouse gas emissions to CMS. CMS will provide individualized feedback reports and public recognition of participation and potential performance in the initiative. 

HMA/Moran Analysis: The critical aspect of the TEAM model that stakeholders need to understand is that it will be mandatory. TEAM will begin in 2026 and continue for five years. The TEAM model builds on and combines previous models such as the Bundled Payment for Care Improvement (BPCI) model and the Comprehensive Care for Joint Replacement (CJR) model. Hospitals will be required to report various quality measures, and payment will be based on spending targets and include retroactive reconciliation. TEAM also seeks to integrate specialty and primary care. The model complements existing accountable care organization (ACO) models such as ACO REACH or the Medicare Shared Savings Program as beneficiaries would be able to be assigned to both TEAM and ACO programs.  

Hospital Wage Index Adjustments and Labor Market Changes:  

Proposed Rule: CMS proposes two wage index policies for FY 2025. First, CMS proposes to extend the temporary policy finalized in the FY 2020 IPPS/LTCH PPS final rule for three additional years to address wage index disparities affecting low-wage index hospitals, which includes many rural hospitals. Second, as required by law, CMS proposes to revise the labor market areas used for the wage index based on the most recent core-based statistical area delineations issued by the Office of Management and Budget (OMB) based on 2020 Census data. 

HMA/Moran analysis: The two wage index policies that CMS proposes for FY 2025 will have important positive and potentially negative consequences for hospital payment. The policy to extend the low-wage index policy for three additional years will allow many hospitals with low wage indexes to increase their wage index and their payment rates across all MS-DRGs. This policy will bring millions of additional dollars to rural hospitals in FY 2025.  

The second policy is a statutorily required update to the labor markets used to establish CMS’s hospital wage indexes. CMS will redefine 53 counties from urban to rural and 54 counties from rural to urban, which will disrupt various hospital payment policies for hospitals in the affected counties. The overall impact of both proposed geographic policy changes for FY 2025 will be to increase inpatient payment rates for rural hospitals.  

Revision to Housing-Related Diagnosis Coding  

Proposed Rule: CMS proposes to change the severity designation of the seven ICD-10-CM diagnosis codes that describe inadequate housing and housing instability from non-complication or comorbidity (non-CC) to complication or comorbidity (CC).  

HMA/Moran Analysis: In proposing this change, CMS is building on its previous policy of including diagnosis codes for describing when a beneficiary is homeless (e.g., unspecified, sheltered, unsheltered). Importantly, this new policy proposal will enable hospitals to be paid higher inpatient payment rates when patients with inadequate or unstable housing are served. Specifically, this proposal would result in cases involving patients to whom these codes apply to be coded in a higher-level MS-DRG within a given family of MS-DRG codes. If finalized, this change in coding policy will result in higher payment rates for hospital patients who are experiencing housing insecurity.  

Connect with Us 

HMA’s Medicare Practice Group, including consultants from The Moran Company, works to monitor legislative and regulatory developments in the inpatient hospital space and to assess the impact of inpatient payment, quality, and policy changes on the hospital sector. Our Medicare experts interpret and model inpatient policy proposals and use these analyses to assist clients in developing their strategic plans and commenting on proposed regulations. We replicate the methodologies CMS uses in setting hospital payments and model alternative payment policies using the most current Medicare (100%) claims data. We assist clients with modeling for DRG reassignment requests and to support NTAP applications.  We also support clients in analyzing CMS Innovation Center alternative payment models.  

For more information or questions about the policies described above, contact Zach Gaumer, Amy Bassano, Kevin Kirby or Clare Mamerow.


Five takeaways from the CMS Medicaid managed care final rule

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This week, our In Focus section reviews significant Medicaid policy announcements from the Centers for Medicare & Medicaid Services (CMS). For example, both the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F) (CMS fact sheet available here) and the separate Ensuring Access to Medicaid Services Final Rule (CMS-2442-F) (CMS fact sheet available here) were released April 22, 2024. 

Taken together, these two final rules create new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and the Children’s Health Insurance Program (CHIP) across the fee-for-service and managed care delivery systems and provide targeted regulatory flexibility in support of this goal.  

HMA’s April 11, 2024, “What to Watch For” article outlined several proposed changes that CMS was poised to advance in the Medicaid managed care program. We focus today on the approved changes, including:  

  • In lieu of services and settings (ILOSs)  
  • The Medicaid and CHIP quality rating system (MAC QRS)  
  • Medical loss ratios (MLRs)  
  • Network adequacy 
  • State directed payments (SDPs) 

Following are HMA’s insights on the key takeaways in each of these major areas for states, managed care organizations (MCOs), providers, and other stakeholders. In addition, HMA experts will discuss the final rule during a LinkedIn Live on event at 2:00 pm (EDT) April 25, 2024. Go to the HMA LinkedIn feed to watch. 

In future weeks, HMA will review the Ensuring Access to Care final rule. 


The final rule makes clear that CMS remains committed to the conviction that ILOSs can play an important role in supporting state and MCO efforts to address many of the unmet physical, behavioral, developmental, long-term care, and other enrollee needs. At the same time, CMS continues to put forward requirements in this area to ensure adequate assessment of these substitute services and settings in advance of approval, ongoing monitoring for sufficient beneficiary protections, and financial accountability for related expenditures. 

The final rule presents an opportunity to leverage ILOSs to improve population health, reduce health inequities, and lower total healthcare costs in Medicaid and CHIP, including by addressing unmet health-related social needs as well as through other avenues. To take full advantage of this opportunity, states and MCOs must ensure that that they are prepared to meet the accountability measures outlined in the final rule and partner with existing providers and community-based organizations that already provide such services and settings. 

Medicaid and CHIP Quality Rating System  

CMS finalized most proposed provisions related to mandatory quality measures, the process used to update these measures, the ability of states to include additional measures, and the ability of states to apply an alternative QRS if desired. On this last point, CMS is making several modifications to its MAC QRS proposal to clarify the scope of and to reduce the implementation resources needed for an alternative MAC QRS if a state elects to implement one. 

States will be required to collect from MCOs the data necessary to calculate ratings for each measure and ensure that all data collected are validated. This will require MCOs to assess their capability to produce the mandated data upon request by states and, to the extent possible, to assess baseline performance on measures and proactively operationalize strategies to improve performance where necessary. 

Medical Loss Ratios 

The final rule aligns Medicaid and CHIP MLR QIA reporting requirements with the private market to ensure that only those expenses that are directly related to healthcare QIAs are included in the MLR numerator. CMS notes that this provision will allow for better MLR data comparisons between the private market and Medicaid and CHIP markets as well as reduce administrative burden for MCOs participating across these markets.  

MCOs will need to model the impact of QIA expenditures that are no longer available for inclusion in the MLR numerator to ensure that a resulting failure to meet any minimum MLR requirements can be avoided, and, if it is projected to occur, a strategy can be developed and executed to avert the problem. CMS made this requirement effective as of the effective date of the final rule with no delay because it believes it is critical to the fiscal integrity of Medicaid and CHIP, adding urgency to MCO compliance action here. 

Network Adequacy 

The final rule makes clear that CMS has been persuaded that it needs to increase oversight of network adequacy and overall access to care through a new quantitative network adequacy standard. To measure network adequacy, the agency intends to implement wait time standards, complemented by secret shopper surveys to support enforcement. 

Wait time standards and secret shopper surveys present opportunities for states, MCOs, and providers to collaborate to enhance access where needed and ensure compliance with the final rule. Undertaking secret shopper surveys ahead of implementation of the wait time standards (effective the first rating period beginning on or after three years after the effective date of the final rule) to determine the current performance relative to maximum wait times is a proactive step that is worth consideration by states and MCOs and can also be employed to foster dialogue with providers to address any areas of concern identified. 

State Directed Payments 

CMS is adopting its proposal in the final rule to use the average commercial rate as a limit for SDPs for inpatient and outpatient hospital services, nursing facility services, and professional services at academic medical centers. CMS believes that this approach represents a reasonable limit that is supportive of appropriate fiscal guardrails, while still affording states the flexibility to achieve SDP policy goals. States and providers will need to account for this requirement, along with others, as SDPs are developed going forward.  

Connect with Us 

HMA is ready to support your efforts to understand and take action to account for the managed care final rule’s effects on your state or organization’s strategy and operations. Please reach out to [email protected] to connect with our expert team members on this vital set of issues. 


Policy and operational implications of the Change Healthcare cyberattack

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This week, our second In Focus explores a new Issue Brief published by Leavitt Partners, a Health Management Associates, Inc. (HMA) Company, which addresses the February 21, 2024, cyberattack on Change Healthcare. The cyberattack is one of the most significant on the healthcare industry and has had short-term effects on the entire healthcare sector, with potential for longer-term impacts across the industry.  

Because of the ransomware attack, more than 100 applications were taken offline, preventing medical professionals from conducting out many patient-facing activities, including filling prescriptions, managing care plans, and performing prior authorization checks. Six weeks after the crippling cyberattack on Change Healthcare, some systems are still only partially operational and many claims remain unpaid. This situation has disrupted patient access to care and placed significant financial strain on providers. 

Change Healthcare is maintaining a daily status report on operations here:  In addition, the Department of Health and Human Services (HHS) provided the following resources for providers to work with payers directly:   

With billions of dollars in loans and advance payments already disbursed and ongoing investigations into Health Insurance Portability and Accountability Act (HIPAA) violations, the healthcare industry is bracing for long-term impact, while the Administration and Congress are just beginning to act. Leavitt Partners experts, an HMA Company, is monitoring and analyzing the impacts on payers and providers, as well as current and future policy implications.  

For more information and to obtain in-depth issue briefs, including “Cyberattacks: Health Care Industry Impacts and the Federal Response,” contact Mark Marciante and Ryan Howells.


Medicaid managed care enrollment update—Q4 2023

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This week, our In Focus section reviews recent Medicaid enrollment trends in capitated, risk-based managed care in 30 states.1 Many state Medicaid agencies post monthly enrollment figures by health plan for their Medicaid managed care population on their websites. These data allow for timely analysis of enrollment trends across states and managed care organizations. All 30 states highlighted in this review have released monthly Medicaid managed care enrollment data into quarter four (Q4) of 2023. The analysis that follows reflects the most recent data posted. HMA continues tracking enrollment as states work towards concluding their Public Health Emergency (PHE) unwinding-related redeterminations and resuming normal eligibility operations. 

Health Management Associates, Inc., (HMA) has reviewed the Q4 enrollment data (see Table 1) and offers the following observations:  

  • Across the 30 states tracked in this report, Medicaid managed care enrollment declined by 7.3 percent year-over-year as of December 2023. 
  • Of the 30 states, 26 experienced decreased enrollment in December 2023, compared with the previous year, as the result of Medicaid redeterminations. 
  • A total of 23 of the states—Arizona, California, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, Washington, and West Virginia—saw net Medicaid managed care enrollment decrease by 469,000 (0.9%) to 51.5 million members at the end of Q4 2023. (Note: North Carolina expanded Medicaid in December 2023 and was added to the expansion group, in part inflating the change). 
  • The seven states that had yet to expand Medicaid as of December 2022—Florida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and Wisconsin—have seen Medicaid managed care enrollment decrease 25.2 percent to 13.9 million members at the end of Q4 2023.  

Table 1. Monthly MCO Enrollment by State, October 2023−December 2023 

Note: In Table 1, “+/- m/m” refers to the enrollment change from the previous month. “% y/y” refers to the percentage change in enrollment from the same month in the previous year.

It is important to note the limitations of the data presented. First, not all states report the data at the same time during the month. Some of these figures reflect beginning of the month totals, whereas others provide an end of the month snapshot. Second, in some cases the data are comprehensive in that they cover all state-sponsored health programs offering managed care; in other cases, the data reflect only a subset of the broader managed Medicaid population, making it the key limitation to comparing the data described below and figures that publicly traded Medicaid MCOs report. Consequently, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be developed based on publicly available monthly enrollment information. 

Expand Your Awareness about Medicaid and Medicare Advantage via HMAIS 

If you are interested in gaining access to detailed information on the Medicaid managed care landscape, an HMAIS subscription is the key to unlock important data. The HMA Information Services (HMAIS) collects Medicaid and Medicare Advantage Special Needs Plan (SNP) enrollment data, health plan financials, as well as developments on expansions, waivers, and demonstrations. Your HMAIS login also provides access to a library of public documents all in one place, including Medicaid RFPs, responses, model contracts, scoring sheets and other procurement related materials. HMAIS combines this publicly available information along with HMA expert insights on the structure of Medicaid in each state, as well as a proprietary HMA Medicaid Managed Care Opportunity Assessment. 

For information on how to subscribe to HMA Information Services, contact Andrea Maresca.


HMA offers a new way to approach grant funding for behavioral health providers

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Grants from both government and foundations can be an essential component of a community behavioral health provider’s growth strategy. Every year billions of dollars are distributed to support program growth, quality improvement, training, and other essential needs. Finding the right opportunities and applying for grants that are aligned with your organization’s strategic growth interests can be an essential catalyst for organizational development, service continuum growth, and quality improvements.

Behavioral health providers often struggle with identifying and applying for the right grant opportunities. It is time consuming and takes resources away from your mission to serve your communities. The deluge of notices of funding opportunities, requests for proposals, requests for applications, and requests for expressions of interest can overwhelm even the most sophisticated and well-resourced provider. Few organizations have the internal capacity to devote to wading through the hundreds of opportunities that are published each week.

That is why we created HMA Grant Prospector. HMA will do the work, so you don’t have to.

The HMA Grant Prospector is a tool that combines HMA’s deep subject matter expertise in community behavioral health care with understanding of the process of grant procurement. We have embedded this expertise in proprietary software that can sift through grant opportunities and pick out the gold nuggets from the mountain of information.

When your organization subscribes to Grant Prospector, we interview you to find out what services you have, the communities you serve, and what gaps in your care continuum you seek funding to fill. We collect information on grant opportunities as they are released, and the Grant Prospector matches your organization’s criteria with funding opportunities. We’ll send you only those opportunities for which your organization is eligible, that are aligned with your strategy and organizational objectives, and targeted to your population. You can rely on HMA to do the legwork so you can focus your efforts on improving lives in your community.


“HMA has helped us quickly and easily identify the best opportunities for grants for Horizon Health Services. With their help, we have been able to find the right opportunities, apply with precision, and expand our service continuum.”

– Erin DiGirolamo, CEO and Brandy Vandermark-Murray, President, Horizon Health Services, Buffalo, NY


Announcing HMA’s new value-based payment (VBP) readiness assessment tool for behavioral health providers

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Dollars and Sense: Is Your Organization Positioned to Thrive in the World of Value-Based Payments?

As the healthcare system in the U.S. moves away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality, every Behavioral Health organization finds itself with challenges ahead. Whether your organization stands at the forefront, poised for a full dive into value-based payment implementation, or is tentatively exploring initial steps, understanding your organization’s readiness on the VBP spectrum is paramount to success. Health Management Associates (HMA) is helping provider organizations in every phase of readiness move forward. We understand the detailed steps to help you focus on value, change payment structures, adapt clinical and operation workflows, and prepare and train your workforce to improve quality. Our tool is not just a promise but a practical solution to assess your current organizational readiness, providing valuable insights to focus your attention toward the next level of value.

VBP Readiness Assessment Tool

HMA’s VBP Readiness Assessment is a free, online survey tool that can help you gauge your organization’s preparedness across six pivotal domains of core functions necessary for successful participation in payment reform models. Completing the survey will provide a snapshot about a single provider or an entire organization and determine where you stand on the value-based payment spectrum.  The six domains encompass measuring outcomes, evaluating board and leadership readiness, assessing technological capabilities for capturing and sharing data, gauging partnerships, payer engagement strategies, and financial alignment.

Readiness Assessment Results

VBP graphic 1
VBP graphic 2

Example plot of a readiness assessment showing an organization’s scores on the VBP spectrum.
This organization has an overall Intermediate level of readiness with the highest levels demonstrated in
Board & Leadership Readiness and Partnership and lowest levels in Financial Readiness.

The journey toward successfully navigating the realm of value-based payments demands a strategic and informed approach. The crucial first step is a comprehensive assessment of organizational readiness, and the HMA VBP Readiness Assessment Tool stands as a valuable resource for this purpose. The ever-changing landscape of healthcare payments requires organizations to be adaptive and forward-thinking. With HMA’s team of experts offering guidance at every stage, providers, associations, health plans, and states can gain a profound understanding of the necessary organizational efforts required to engage in VBP successfully. The current landscape increasingly emphasizes value, therefore, the importance of transitioning from fee-for-service to value-based models cannot be overstated. As the demand for value continues to grow, organizations that proactively position themselves to meet these evolving expectations will not only thrive but contribute significantly to shaping the future of healthcare delivery. The HMA VBP Readiness Assessment Tool is not just a survey; it’s a compass guiding you through the dynamic terrain of value-based payments, serving as a way to identify meaningful progressive steps you can take to strengthen your organizational position within the VBP space.

Taking the survey and receiving one analyzed response is free, but you may find value in contracting with HMA for a more in-depth analysis of your organization. Click below for more details and to access the survey.

For more information, please contact Rachel Bembas, PhD, Principal.