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HMA Fall Conference: Highlights and Takeaways

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HMA Fall Conference October 2023

As we look back at our 2023 Fall Conference on publicly sponsored healthcare held in October, we wanted to highlight a few key takeaways from the event:

  • Behavioral Health Pre-Conference workshop: An impactful pre-conference session convened influential leaders in behavioral health to deliberate on the urgent need for a purposeful disruption of mental health accessibility across multiple sectors. Participants were actively challenged to reimagine strategies that could effectively disrupt the prevailing status quo in behavioral health, focusing on three key components essential for constructing a comprehensive system of care: population health and prevention, quality, and network.

The discourse highlighted pervasive issues such as silos that contribute to a lack of accountability within the system. There was a unanimous recognition of the imperative to eliminate barriers to access, accompanied by a resounding call for a pivotal transformation in payer models. Throughout the session, a prevailing theme underscored the critical need for fostering collaborative efforts across different sectors, emphasizing the creation of opportunities for cross-sector groups to work together.

Participants echoed a shared sentiment regarding the urgency of dismantling the current lacking system and replacing it with a more inclusive, patient-centered approach. The session served as a platform for thought-provoking discussions, inspiring innovative solutions to address the challenges in behavioral health, paving the way for a more effective and accessible system.

The three main conference themes – Equitable Access, Digital Innovation, and Value-based Care – were touched upon in many of the panels and plenary sessions.

  • Equitable Access: Several panels and speakers talked about health equity as a moral imperative as well as an organizational priority. Payers and providers understand that the Centers for Medicare and Medicaid Services (CMS) is developing metrics and measures to incorporate equity into accreditation and reimbursement and are anxious to get down to the details of the specific items that will be included. There was also robust discussion about how to incorporate community-based organizations and social services into Medicaid managed care plans to ensure that health-related social needs are being addressed in a more holistic way. There are opportunities to ensure contracting parameters and quality metrics work as intended to enable payers and providers to improve outcomes and reduce inequities of all types.
  • Digital Innovation: In addition to a “shark tank” style presentation of innovative technology vendors, the HMA conference featured a panel of experts in data liquidity and interoperability. They discussed the opportunity to embrace application programming interfaces (APIs) and digital health as a strategic imperative instead of a compliance issue. The new electronic prior authorization requirements are already starting to produce big results by expediting approvals, which is good for patients, but also reducing workload to allow staff to be redeployed to other areas of need. The panel also discussed the real need to improve digital access for rural health clinics (RHCs) and federally qualified health centers (FQHCs) that serve rural communities, where fee-for-service payment creates barriers to greater data coordination. And finally, the panel discussed the need to improve Medicaid procurement, so it does not impose barriers to digital innovation for vulnerable populations.
  • Lessons of Value-Based Care: This session featured a lively conversation about how value-based care is more important than ever, and frankly, that it is the right thing to do for mission-driven organizations to improve the health of patients. The organizations represented discussed how it has not been easy to learn new approaches to care coordination and managing financial risk, but they can do what is best for the patient by investing in the right things up front. Value-based care approaches are proliferating, including FQHCs where the providers’ motivation to serve vulnerable families is now supported by the right financial incentives.

HMA is committed to bringing together experts from across the healthcare spectrum, and advancing the conversation about ways to improve access, equity, and innovation in healthcare. In early March 2024, we will be offering an HMA Spring Workshop on value-based care in Chicago. Registration will open soon; to receive the invitation, please be sure you are subscribed to the HMA News and Events list.


Proposed changes to opioid treatment: what they will mean for providers, payers, and regulators

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After more than two decades, SAMHSA and its Center for Substance Abuse Treatment (CSAT) is revisiting regulations governing opioid treatment programs (OTPs), as required by the 2023 Consolidated Appropriations Act passed by Congress. These new federal rules around treatment will change how medications are delivered to persons with opioid use disorder (OUD), offering opioid treatment centers a unique opportunity to advance person-centered care, and can build on the lessons learned from the flexibilities offered during the public health emergency.

This is a real opportunity to change how care is delivered. It will increase access to lifesaving medications, including:

  • A change in take-home schedules, which will allow for additional take-home medications sooner in the treatment process to reduce the burden of coming to the program daily, alleviating transportation challenges and the disruption of work and family routines.
  • Emphasizing and codifying the importance of harm reduction.
  • Clarifying diagnoses required for admission to be active moderate-to-severe OUD, OUD in remission, or at high risk for recurrence or overdose.
  • Removing access barriers for persons under 18; expanding use of telehealth; and finally, expanding interim maintenance dosing up to 180 days in a 12-month period. 

These new changes will help alleviate admission barriers caused by workforce shortages and allow patients better access to medication and treatment. The increase in use of telehealth combined with medications for opioid use disorder (MOUD) will remove time and travel barriers for treatment, allowing persons treated with methadone and buprenorphine, including new persons, to be treated remotely.

What does this mean for the field?

OTPs have historically been reimbursed based on volume, with daily attendance as a steady source of revenue and a “captive” audience for counseling services. For persons with OUD to feel the full benefits of the new rule, changes will need to be made at all levels:

  • OTPs will need to rethink their clinical models to develop a service mix driven by a person’s need as opposed to regulations. Engagement will drive attendance, outcomes and thus revenue. Additionally, there will be a need to:
    • Retrain staff.
    • Work with medical team to develop new clinical protocols.
    • Structure revenue cycle management processes and business models of service delivery.
  • Regulators will need to adapt state licensing rules and re-train licensing staff.
  • Payers have an opportunity to move Value-Based Payment (VBP) more steadily into the OUD treatment space and will need to realign payment structures to incentivize providers to provide care according to a person’s need.

If you want to learn more about the changes ahead, HMA hosted a 3-part webinar series on the effect of proposed regulations on delivery of opioid treatment services. The series New Rules in Treatment of Opioid Addiction was aimed at helping stakeholders prepare for and adapt to these changes to ensure a successful transition for the people they serve. Our series focuses on three areas where changes can help those managing OUD:

  1. How do OTPs deliver services to better support persons with OUD?
  2. How do payers create the right financial incentives to help providers deliver better behavioral health solutions for OUD?
  3. How do state regulators make changes to rules and laws to promote a treatment system that prioritizes a person’s health and recovery?

Watch here:

Part 1 Opioid Treatment Providers

Part 2 Opioid State Payers – Aligning Incentives for Treatment

Part 3 Opportunities for State Regulators to Shape Policy and Regulation of Treatment

If you are ready to explore these changes in your organization, HMA can help. We have experience in:

  • Developing clinical workflows
  • Aligning revenue cycle and clinical operations
  • Developing and implementing state OUD code
  • Supporting health plans and providers in moving into VBP
  • Supporting health plans in adapting to new clinical models


Advancing the Life Sciences with expertise from all aspects of healthcare

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Your organization’s success relies on understanding evolving market dynamics and navigating a complex statutory and regulatory environment. Drug, device, and diagnostic firms, from established to start-up, come to HMA when they want experienced partners who can help with regulatory strategy, coding, coverage, and payment solutions, investment strategy, navigating the complexities of federal and state law, or even creating new policy HMA, working with our partner companies, provides consulting with depth and breadth throughout the life sciences sector and the broader healthcare industry.

We work with drug, device, and diagnostic companies and their trade associations, pharmacies, physician specialty societies, hospitals, health systems, and community health centers, as well as investment firms and their portfolio companies.

Before joining HMA, our team spent years as senior officials in Medicare and Medicaid; cabinet-level health secretaries; and policy advisors to governors and other elected officials. They also served as directors of large nonprofit and social services organizations, top-level advisors, and C-level executives. Our team is expert in federal and state policy, reimbursement, actuarial consulting, medical coding support, public affairs, and corporate development.

Our Life Sciences team, comprised of experts across our firm, can help with:

We help you navigate the complexities of FDA regulation to help with product development and marketing authorization strategies and regulation throughout the product lifecycle. 

Regulatory policy counseling

Product development and target product profile

FDA authorization strategy

Post-approval compliance  

Contact our FDA Experts:

Clay Alspach, Principal, Leavitt Partners
Ralph Hall, Principal, Leavitt Partners
Eric Marshall, Principal, Leavitt Partners
Amy Rick, Principal, Leavitt Partners
Vince Ventimiglia, CEO, Leavitt Partners Collaborative Advocates

We help your organization understand the commercial market for life sciences products and develop strategies to support patient access, product launches and growth, and value.

Market intelligence, including market, customer, and stakeholder analysis

Strategic planning, considering risk-based contracting, value-based care, and population health

Business development and strategy

Formulary and market access insights

Go-to-market and launch strategies

Contact our Commercial Experts:

Jeremy Bahr, VP, Client Relations, HMA
Thomas Gubbay, Senior Consultant, Leavitt Partners
David Kulick, Managing Director, The Focus Group
Spencer Morrison, Associate Principal, Leavitt Partners
Rebecca Nielsen, Managing Director, Leavitt Partners
Alex Rich, Managing Director, The Focus Group

Experts in Medicare, Medicaid, and the commercial market, we help you understand and navigate the complexities of coding, coverage, and payment for approved products and develop and execute strategies to support product access and value.

Code assessment and recommendation

Coverage mapping and guidance

Payment strategy across settings

CMS engagement

Emerging technology strategies

Alternative payment model (APM) development

Payment change impact modeling

Contact our Reimbursement Experts:

Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, The Moran Company
Charlene Frizzera, Advisor, Leavitt Partners
Zach Gaumer, Principal, HMA
Kevin Kirby, Managing Director, The Moran Company
Rachel Kramer, Principal, The Moran Company
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, The Moran Company

We help you understand how evolving Federal policy impacts your business and develop strategies for creating and advancing Federal policy that advances value and your business.

Congressional and Administration intelligence and strategy

Policy development and strategy

Multi-sector alliances to create and advance new policy

Policy modeling and CBO scoring projections

Contact our Federal Experts:

Clay Alspach, Principal, Leavitt Partners
Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, The Moran Company
Zach Gaumer, Principal, HMA
Ralph Hall, Principal, Leavitt Partners
Kevin Kirby, Managing Director, The Moran Company
Rachel Kramer, Principal, The Moran Company
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, The Moran Company
Eric Marshall, Principal, Leavitt Partners
Sara Singleton, Principal, Leavitt Partners
Josh Trent, Managing Principal, Leavitt Partners
Vince Ventimiglia, CEO, Leavitt Partners Collaborative Advocates
Liz Wroe, Principal, Leavitt Partners

We help you understand how evolving State policy impacts your business and develop strategies to support product access and value in Medicaid programs.

State-related access issues

State policy impact modeling

State research support

Contact our State Experts:

Clay Alspach, Principal, Leavitt Partners
Anne Marie Lauterbach, Principal, Leavitt Partners
Stephen Palmer, Managing Principal, HMA
Matt Powers, Managing Director, HMA
Josh Trent, Managing Principal, Leavitt Partners

We work with investment firms and their portfolio companies to provide insight that helps you invest wisely in the rapidly evolving healthcare marketplace.

Comprehensive due diligence studies

In-depth research projects

Billing and compliance reviews

Identification, analysis, and outlook on federal, state, and local reimbursement/regulatory issues

Contact our Investment Strategy Experts:

David Kulick, Managing Director, The Focus Group
Greg Nersessian, Managing Director, HMA
Alex Rich, Managing Director, The Focus Group

Project Spotlight

Pipeline research and policy recommendations to address new innovative therapies

A large national pharmaceutical manufacturer hired HMA, The Moran Company, and Leavitt Partners, both HMA subsidiaries, to assess the current pipeline of innovative therapies, examine current reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process.


CMS proposes significant changes to Medicare Advantage and Medicare prescription drug benefit programs for 2025

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This week, our In Focus section reviews a wide-ranging proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) on November 6, 2023. The rule would update various policies governing Medicare Advantage (MA, or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly. These proposed policy reforms would implement changes related to Star Ratings, marketing and communications, agent/broker compensation, health equity, dual eligible special needs plans (D-SNPs), utilization management, network adequacy, and other programmatic areas. The proposals reflect the agency’s continuing focus on increasing program transparency, improving health equity, reducing the cost of care for Medicare beneficiaries, and expanding access to behavioral health services.

MA and Part D stakeholders are encouraged to provide CMS with feedback and analysis regarding the potential impact of these changes. Comments on the proposed rule are due by January 5, 2024. The final rule would take effect in contract year 2025.

Improving Access to Behavioral Health Care Providers

CMS proposes regulatory changes intended to improve access to behavioral healthcare by adding certain provider specialties to the MA network adequacy standards as follows.

  • CMS proposes to add a new facility-specialty type to the existing list of facility-specialty types evaluated as part of its plan network adequacy reviews. The new facility-specialty type, outpatient behavioral health, would be included in network adequacy evaluations, including marriage and family therapists (MFTs), mental health counselors (MHCs), opioid treatment programs, community mental health centers, and/or other behavioral health and addiction medicine specialists and facilities.
  • MFTs and MHCs will be eligible to enroll in Medicare and start billing for services beginning January 1, 2024, because of the new statutory benefit category established in the Consolidated Appropriations Act (CAA) of 2023. CMS proposes to make corresponding changes to its network adequacy requirements for MA organizations.
  • For purposes of the network adequacy requirements, the new facility-specialty type would be evaluated using time and distance and minimum number standards in the proposed regulation.

Increased Transparency for Special Supplemental Benefits for the Chronically Ill

In 2018, Congress enacted new authorities pertaining to supplemental benefits for MA members with chronic health conditions. CMS refers to this category of benefits as Special Supplemental Benefits for the Chronically Ill (SSBCI). These services are available only to enrollees with ongoing conditions and who meet certain criteria established in the statute. In contrast to the general policy that MA benefits should be offered uniformly to all plan members, MA plans may offer SSBCI tailored to a qualifying individual’s specific medical diagnosis and needs.

Supplemental benefits, including SSBCI, are generally funded with MA plan rebate dollars. CMS notes that the number of MA plans that offer SSBCI—and the number and scope of SSBCI that individual plans provide—has increased since their introduction in 2019.

Under the proposed rule:

  • MA organizations would be required to demonstrate, through relevant and acceptable evidence, that an item or service offered as SSBCI has a reasonable likelihood of improving or maintaining the health or overall function of chronically ill beneficiaries. MA plans also must, by the date on which they submit a bid to CMS, include a bibliography of evidence supporting this position. According to CMS, this expectation would shift the burden of proof from the agency to MA organizations, requiring plans to demonstrate compliance with this standard and that SSBCI items and services are evidence-based.
  • MA plans must follow their written policies based on objective criteria for determining enrollee eligibility for SSBCI when making determinations.
  • Require that MA plans document denials of SSBCI eligibility rather than its approvals.
  • CMS would codify its authority to review and deny approval of an MA organization’s bid if the plan cannot demonstrate, through relevant and acceptable evidence, that its proposed SSBCI has a reasonable expectation of improving or maintaining the health or overall function of a chronically ill enrollee.
  • CMS also would codify its authority to review SSBCI offerings annually for compliance and in light of the available evidence.

According to CMS, these proposals, if implemented, would better ensure that the benefits offered as SSBCI are reasonably expected to positively affect the health and well-being of chronically ill beneficiaries and guard against the use of MA rebate dollars for SSBCI that unsubstantiated.

In addition, CMS is proposing new policies to improve transparency regarding SSBCI so that beneficiaries are aware that SSBCI are only available to enrollees who meet the eligibility criteria. More specifically, CMS proposes to:

  • Modify the current requirements for the SSBCI disclaimer that MA organizations must use whenever SSBCI are mentioned. The SSBCI disclaimer would have to list the relevant chronic condition(s) that qualify for the benefits that MA organizations offer.
  • Establish specific font and reading pace parameters for the SSBCI disclaimer in print, television, online, social media, radio, other voice-based ads, and outdoor advertising, including billboards. Finally, it would clarify that MA organizations must include the disclaimer in all marketing and communications materials that mention SSBCI.

Requiring Mid-Year Enrollee Notification of Available Supplemental Benefits

As noted previously, over the past several years, the number of MA plans offering supplemental benefits has increased. The benefits offered are broader in scope and variety, and an increasing amount of MA rebate dollars are being directed toward these benefits. At the same time, plans have reported that the number of enrollees who use many of these benefits is low.

  • CMS proposes requiring MA plans to notify enrollees mid-year of the unused supplemental benefits available to them. The notice would list any supplemental benefits that a beneficiary does not use during the first six months of the year (January 1−June 30).
  • At present, MA plans are not required to send any communication specific to an enrollee’s usage of supplemental benefits. This policy is intended to educate enrollees on their access to supplemental benefits and encourage greater use of these benefits.

Enhancing “Guardrails” for Agent and Broker Compensation

For many years, CMS has set upper limits on the compensation that agents and brokers can receive for enrolling Medicare beneficiaries in MA and Part D plans. CMS believes that many MA and prescription drug payment plans, as well as third-party entities with which they contract, make structured payments to agents and brokers that circumvent these compensation caps.

  • In this regulation, CMS proposes to generally prohibit contract terms between MA organizations and agents, brokers, or other third party marketing organizations (TPMOs) that may interfere with the agent’s or broker’s ability to objectively assess and recommend the plan that best-suited to a beneficiary’s healthcare needs; to set a single reimbursement rate for all plans; to revise the scope of items and services included within agent and broker compensation; and to eliminate the regulatory framework that currently allows for separate payment to agents and brokers for administrative services.
  • The agency would make conforming changes to the Part D agent broker compensation rules.

Requiring an Annual Health Equity Analysis of Utilization Management Policies and Procedures

CMS proposes several regulatory changes to the composition and responsibilities of an MA organization’s utilization management (UM) committee.

  • The new rules would require that a member of the UM committee have expertise in health equity and that the UM committee conduct an annual health equity analysis of the use of prior authorization.
  • The proposed analysis would examine the impact of prior authorization on enrollees with one or both of the following social risk factors (SRFs): receipt of the low-income subsidy, dual eligibility for Medicare and Medicaid (LIS/DE), or a disability.
  • The proposed analysis must compare metrics related to the use of prior authorization for enrollees with the specified SRFs with enrollees without the specified SRFs. The results of the analysis must be made publicly available on the MA organization’s website in an easily accessed manner.

Enhancing Enrollees’ Right to Appeal an MA Plan’s Decision to Terminate Coverage for Non-Hospital Provider Services

Beneficiaries enrolled in traditional Medicare and MA plans have the right to a fast-track appeal by an independent review entity (IRE) when their covered skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. At present, quality improvement organizations (QIOs) function as IREs and conduct these reviews.

Furthermore, MA enrollees do not have the same access to QIO review of a fast-track appeal as traditional Medicare beneficiaries.

CMS proposes to:

  • Require that QIOs, instead of MA plans, review untimely fast-track appeals of an MA plan’s decision to terminate HHA, CORF, or SNF services
  • Fully eliminate the provision requiring the forfeiture of an enrollee’s right to appeal a termination of services decision when they leave the facility

According to CMS, these proposals would align MA regulations with the parallel reviews available to beneficiaries in traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.

Increasing the Percentage of Dually Eligible Managed Care Enrollees Who Receive Medicare and Medicaid Services from the Same Organization

In the proposed rule, CMS expresses concern that a significant number of dually eligible enrollees receive Medicare services through one managed care entity and Medicaid services through another (misaligned enrollment), rather than from one organization (aligned enrollment. The proposed rule states that in the long run, “for dually eligible individuals who are in Medicare and Medicaid managed care, we believe that we should continue to drive toward increasing aligned enrollment until it is the normative, if not only, managed care enrollment scenario…. For dually eligible individuals that elect MA plans, we are focused on increasing enrollment in integrated D-SNPs: fully integrated dual eligible special needs plans (FIDE SNPs), highly integrated dual eligible special needs plans (HIDE SNPs), and applicable integrated plans (AIPs) [pages 286-287].”

To move in this direction, CMS offers several interconnected proposals as follows:

  • Replace the current quarterly special enrollment period (SEP) with a monthly SEP for dually eligible individuals and others enrolled in the Part D low-income subsidy program to elect a standalone PDP
  • Create a new integrated care SEP to allow dually eligible individuals to elect an integrated D-SNP on a monthly basis
  • Limit enrollment in certain D-SNPs to individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO)
  • Limit the number of D-SNP plan benefit packages an MA organization, its parent organization, or an entity that shares a parent company with the MA organization, can offer in the same service area as an affiliated Medicaid MCO

According to CMS, these initiatives would increase the percentage of dually eligible MA enrollees who are in plans that are also contracted to cover Medicaid benefits, thereby expanding access to integrated materials, unified appeal processes across Medicare and Medicaid, and continued Medicare services during an appeal.

Impose New Contracting Standards for Dual Eligible Special Needs Plan (D-SNP) Look-Alikes

Under existing regulations, CMS does not contract with and will not renew the contract of a D-SNP look-alike; that is, an MA plan that is not a SNP but in which dually eligible enrollees account for 80 percent or more of total enrollment. CMS proposes to lower the D-SNP look-alike threshold from 80 percent to 70 percent in 2025 and to 60 percent in 2026. CMS states that this proposal is intended to help address the continued proliferation of MA plans that serve high percentages of dually eligible individuals without meeting D-SNP requirements.

Other Topics in the Proposed Rule

In addition, the proposed rule calls for:  

  • Providing greater flexibility for Part D plan sponsors to substitute biosimilar products during the plan year
  • Limiting out-of-network cost sharing for D-SNP PPOs
  • Standardizing the MA risk adjustment data validation appeals process
  • Expanding permissible data use and data disclosure for MA encounter data including for support for Medicaid and state Medicaid agencies to better coordinate care for dually eligible individuals

The Health Management Associates Medicare team will continue to analyze these proposed changes. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support the drafting of comment letters to this rule. For more information or questions about the policies described, contact Amy Bassano ([email protected]), Julie Faulhaber ([email protected]), Andrea Maresca ([email protected]), or John Richardson ([email protected]).


November is National Adoption Month

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When Love is Not Enough to Preserve a Forever Family for a Child

National Adoption Month image

Families formed by adoption face unique challenges in their lifelong journey as adoptees, parents, and siblings. Adoption-competent mental health is a necessary resource for adoptive families. This November, we are honoring adoption as a vital permanency strategy and the importance of forever families in the lives of children and youth who need this sense of permanency, security, and wellbeing.

The Children’s Bureau, part of the U.S. Department of Health and Human Services Office of the Administration for Children and Families (ACF) created National Adoption month to increase national awareness of adoption issues, encourage the development of permanent relationships, and bring attention to the need for adoptive families to provide placement for teens in the U.S. foster care system. The theme for 2023, “Empowering Youth: Finding Points of Connection,” focuses on ways to provide opportunities and services that connect youth to their identity—including culture, background, interests, and ambitions – to support meaningful permanent relationships with adults.

Adoption Statistics

The following are key data from the fiscal year 2021 report for the Adoption and Foster Care Analysis and Reporting System.

In the U.S., as of September 30, 2021, there were 114,000 children and youth waiting to be adopted who were at risk of aging out of foster care without permanent family connections.

  • More than one in five children waiting for adoption were 13–17 years old.  
  • The average age of all children waiting to be adopted was 7.5 years old.  
  • The average time in care for all children waiting to be adopted was 33.7 months.  
  • The average time in care for children waiting to be adopted after termination of parental rights was 19 months.  

The National Council for Adoption reports an 18 percent decrease in adoptions from FY19-FY21, with over 19,000 children who aged out of foster care without a permanent family. There has been a 24 percent decrease in domestic adoptions from 2019-2020 and 93 percent decline in intercountry adoptions since peaking in 2004.[1] .  These data points reflect the urgency of revitalizing adoption as an important tool for the wellbeing of children who need permanent loving families.

Recognizing that adoption is just the beginning of the family’s journey and the fact that adoptive families need special attention, especially when the children who have been adopted have suffered the trauma of entering the child welfare system, mental health treatment and resources are critical to the wellbeing of these families and the children in them.

Importance of Identity

Research has shown that strong cultural identity can contribute to mental health resilience, higher levels of social well-being, and improved coping skills, greater self-esteem, higher education levels, better psychological adjustment, and improved coping abilities.[2]  But many youth in foster care often have lower cultural identity strength than those who did not experience foster care. This can lead to higher levels of loneliness and depression, lower self-esteem, and difficult psychological adjustments that in turn affect coping skills and learning.[3]

In her book You Should be Grateful, Angela Tucker offers many practical insights and tools aimed at nurturing identity and helping transracial families and adoptees to center around the cultural norms and experiences of the adoptees themselves.[4] 

A Changing Landscape

Many states now have safe-haven laws where parents can drop off their babies without penalty at hospitals, fire stations or police department if they are not able to care for them knowing their babies will be cared for and placed in families through the child welfare system. At the same time there are many children and youth who languish in foster care waiting for a ‘forever family’ to adopt them. Thousands of teens in foster care are looking for the love, support, and encouragement that families provide throughout their lives—not just until they turn 18. Youth who were adopted from the foster care system when they are 16 or older may be able to access Education and Training Vouchers (ETV) of up to $5,000 per year. Those who were adopted from foster care when they are 13 or older are more likely to qualify for federal financial student aid because they do not have to count family income when applying.[5]

When it comes to medical and mental health benefits, qualifying families may receive federally funded monthly maintenance payments, and other support, often until a child turns 18 or 21, depending on the state where they live, and medical assistance until age 26 if they were in foster care at a certain age depending on the state. Recognizing the need for adoption competent mental health, the Federal Administration for Children and Families has awarded the Center for Adoption Support and Education the grant to build a national Center to Support Mental Health Services in the Child Welfare System.[6]

The recent Biden-Harris regulations strengthen services and supports for children and families in the child welfare system. These regulations require additional support for kinship families, and protections for LGBTQI+ youth and expansion of access to legal services for children and families entering the child welfare system. Congress could use the momentum from these regulations to make the Adoption Tax Credit fully refundable and extend it to legal guardians to assist with the financial resources of raising children.

The recent Supreme Court Dobbs decision will likely impact adoption trends, but that trend is still evolving and will need to be monitored before conclusions can be drawn.

How HMA Can Help

HMA assists organizations working in child welfare and adoption, and grounds our work in human-centered design, lived expertise, and change management and leadership principles in state and county program development. We can help support organizations working with children and youth in foster care or with adoption agencies by:

  • Providing technical assistance to state and local government, and community-based organizations
  • Developing system redesign and strategic planning
  • Facilitating stakeholder engagement
  • Implementing workforce and leadership development strategies

Visit the ACF website to learn more about National Adoption Month and find tools and resources to educate yourself and your community about how we can achieve better outcomes for youth in foster care. 

If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact:

Uma Ahluwalia, MSW, MHA, Managing Principal,

Jon Rubin, Principal, or

Caitlin Thomas-Henkel, Principal.

[1] Adoption by the Numbers – National Council for Adoption (

[2] Anderson, M., & L.O. Linares. “The Role of Cultural Dissimilarity Factors on Child Adjustment Following Foster Placement.” Children and Youth Services Review 34(4), 2012, 597-601.

[3] Children on AdoptUSKids – AdoptUSKids

[4] “You Should Be Grateful” Stories of Race, Identity and Transracial Adoption — Angela Tucker

[5] Teens need families – AdoptUSKids

[6] Adoption Support Center & Services | C.A.S.E


Preventing Type 2 Diabetes in correctional settings

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Today is World Diabetes Day, a day created to keep the importance of diabetes prevention and management in the public and political spotlight. One in every four U.S. healthcare dollars is spent on individuals diagnosed with diabetes, and more than half of that expenditure is directly attributable to diabetes. An estimated 37 million people in the U.S. have type 2 diabetes, and another 96 million (more than one out of every three people) have prediabetes, meaning they are at risk of developing type 2 diabetes.[i]

The urgency of preventing and managing type 2 diabetes is as applicable in correctional facilities as it is in populations in the community. Especially as there is an overrepresentation of populations that have a higher burden of prediabetes and type 2 diabetes in correctional facilities including individuals who:

  • are older,
  • have serious mental illness,
  • have poorer physical and mental health than counterparts in the community,
  • are above recommended body weight,
  • have reduced access to health insurance, and
  • are from racial and ethnic minority groups. 

Administrators of correctional facilities are responsible for the healthcare costs for individuals in their custody who have type 2 diabetes, and the cost of managing this condition in these settings is particularly high.

Fortunately, type 2 diabetes is preventable. One evidence-based and effective strategy for preventing type 2 diabetes is the National Diabetes Prevention Program (National DPP) lifestyle change program. This program is a year-long evidence-based program delivered over 22 sessions using a CDC-approved curriculum. Program participants are expected to lose 5−7 percent of their weight and engage in physical activity for 150 minutes each week.[ii] The National DPP lifestyle change program can be offered in person, online, through distance learning, or a combined approach and is led by a trained lifestyle coach.[iii] The program has been proven to reduce the risk of individuals with prediabetes developing type 2 diabetes by 58 percent (71 percent for people older than age 60).[iv] Projections in other settings that compare the cost of the National DPP lifestyle change program to the costs of treating type 2 diabetes show that the program is cost-effective.[v]

HMA recently published a white paper, “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings,describing how the National DPP lifestyle change program can be used to achieve cost savings and better health for people at risk of developing type 2 diabetes in correctional settings. There have been two successful implementations of the National DPP lifestyle change program to date. The first is described in the study “Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting,” where 47 people from a federal correctional facility participated in a modified version of the National DPP lifestyle change program. Participants who completed the program demonstrated significant reductions in their body mass index and A1C levels. Weight loss in the study was similar to what participants of the National DPP lifestyle change program in the community typically achieve.[vi]

The second successful implementation is with the Wisconsin Department of Corrections (DOC), which has successfully offered the National DPP lifestyle change program in three correctional facilities. To date, 19 Wisconsin DOC staff have trained as lifestyle coaches and 131 individuals across the three facilities have participated in the program. The Wisconsin National DPP state quality specialist shared the following cohort data in 2018−2019:

  • 16 percent of the participants were Black and 84 percent were White
  • 100 percent of participants were male, with an average age of 45.6 years
  • 58 percent of participants were eligible for the program based on a blood test
  • 100 percent of participants attended 14 or more sessions in months one through six (typically, 16 sessions take place in the first six months)
  • 71 percent of participants attended six or more sessions in months 7−12 (typically, six sessions take place in the second six months)

Overall average weight loss was 8.3 percent during the year-long cohort, well above the National DPP lifestyle change program goal of 5−7 percent weight loss. The response from program participants was positive. Wisconsin DOC plans to scale the National DPP lifestyle change program to all appropriate facilities in the future.

For additional information, consult the white paper “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings.

If you would like to learn more about how HMA can help your organization implement a DPP program, contact:

Angela Bowen, Consultant

Chris Wilks, PhD, Senior Consultant

[i] Centers for Disease Control and Prevention. The Facts, Stats, and Impacts of Diabetes. Available at: Accessed April 18, 2023.

[ii] Centers for Disease Control and Prevention. Research Behind the National DPP. Available at: Accessed on June 15, 2023. 

[iii] National DPP Coverage Toolkit. National DPP Coverage Toolkit: Delivery Options. Available at:  Accessed January 18, 2023.

[iv]Centers for Disease Control and Prevention. National Diabetes Prevention Program. Available at:  Accessed December 19, 2022.

[v]National DPP Coverage Toolkit. Cost & Value. Available at: Accessed June 15, 2023.

[vi]Fine A, Gallaway SM, Dukate A. Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting. Diabetes Spectrum. 2019;32(4):331-337.


CMS issues final 2024 provider payment rules

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This week, our In Focus section reviews several calendar year (CY) 2024 Medicare payment final rules that the Centers for Medicare & Medicaid Services (CMS) issued in recent weeks, including those pertaining to:

CMS also announced the OPPS Rule for 340B-Acquired Drug Payment Policy in response to court-invalidated payment rates and on November 6, 2023, released the 2025 Contract Year Policy and Technical Changes to Medicare Advantage. The latter regulation addresses guardrails for brokers, behavioral health expansions, and several dual eligible-related policies. We will analyze these provisions in next week’s In Focus.

These final rules set the payment rates and other Medicare payment policies for services that applicable providers provide under the fee-for-service Medicare program and take effect January 1, 2024. Additionally, the final rules, particularly the Physician Fee Schedule, are expected to further inform Congress’ discussions and, ultimately, any action on healthcare policies in a possible year-end legislative package.

For example, the Senate Finance Committee has released draft language that would mitigate the projected physician payment reduction, among other policy changes. Provider organizations and interested stakeholders will want to analyze the impact of the final policies across the rules, including new codes, payment rates, and opportunities to participate in accountable care organizations (ACOs).

Overall, Health Management Associates (HMA) notes several trends across these three Medicare payment regulations:

  • Health equity remains a significant focus of CMS under the Biden Administration.
  • The agency continues to expand its coverage of behavioral health services under Medicare and enhance payment for and access to these services.
  • Medicare is moving toward incrementally supporting care delivered in accordance with beneficiaries’ preferences, such as moving away from reimbursing largely for in-person services and toward supporting telehealth services.
  • CMS is creating pathways for reimbursement for a broader range of clinicians and caregivers who are addressing Medicare beneficiaries’ needs.
  • CMS continues its efforts to improve hospital price transparency with policies aimed at encouraging providers to publicly report data.

2024 Medicare Physician Fee Schedule and Other Part B Payment Policies Final Rule

On November 2, 2023, CMS released the final rule for the Medicare Physician Fee Schedule (MPFS) for CY 2024. CMS finalized an overall 1.25 percent decrease in MPFS payment rates from 2023 to 2024. The final 2024 PFS conversion factor remains largely unchanged ($32.74) from the proposed rule ($32.75) but will result in a 3 percent decrease from the CY 2023 conversion factor ($33.89). Among the most important policy changes in the final rule is the establishment of a new add-on code (G2211) for complex care provided in the primary care setting.

In addition, CMS will begin allowing additional behavioral health providers to participate in Medicare (described further below) and make numerous telehealth policy changes mandated in the Consolidated Appropriations Act of 2023. CMS also finalized changes to the Medicare Shared Savings Program (MSSP), which CMS estimates will increase ACO participation in MSSP by roughly 10−20 percent.

CMS finalized several policies to address health equity, including coding and payment changes focused on providing access to new services and addressing Medicare beneficiaries’ unmet health-related social needs (HRSNs). The final changes affect mental health and substance use disorder (SUD) treatment providers, address payment accuracy for primary care in the context of whole-person care, and expand access to dental care for cancer patients. The changes for 2024 include:

  • Caregiver training: Medicare will now pay practitioners who train caregivers to support patients with certain diseases (e.g., dementia) in carrying out a treatment plan. Services must be furnished by a physician or a non-physician practitioner or therapist.
  • Community health integration (CHI) services: The final rule includes separate coding and payment for CHI services, including person-centered planning, health system coordination, and facilitating access to community-based resources to address unmet social needs that interfere with a practitioner’s diagnosis and treatment plan.
  • Principal illness navigation (PIN) services: The final coding and payment rules for PIN services describe care navigation services for individuals with high-risk conditions. CMS included a subset of PIN services to support individuals with severe mental illness and SUD through use of auxiliary personnel (i.e., peer support specialists). The definition of a serious, high-risk condition is dependent on clinical judgment. CMS will monitor utilization across beneficiaries and specialties to ascertain how PIN services are best used going forward.
  • Social determinants of health risk assessments: This evaluation can be provided and billed as an add-on service to an annual wellness visit or with an evaluation and management or behavioral health visit.
  • Marriage and family therapists and mental health counselors, including eligible addiction, alcohol, or drug counselors who meet qualification requirements for mental health counselors: These types of providers may now enroll in Medicare and bill for their services starting January 1, 2024. The rule expands coverage and increases payment for crisis care (including mobile units), SUD treatment, and psychotherapy as well as psychotherapy performed in conjunction with an office visit and for health behavior assessment and intervention services.

2024 Hospital OPPS and ASC Final Rule

On November 2, 2023, CMS released a final rule for hospital OPPS and ASCs. The following policies are included in the final rule:

  • A 3.1 percent increase in payment rates for hospitals and ASCs that meet certain quality reporting requirements. This amount is based on the projected 3.3 percent increase in the hospital market basket and is consistent with the 2024 payment increase for inpatient services.
  • No services will be removed from the inpatient-only (IPO) list, but 10 procedures will be added to the IPO.
  • The list of ASC-covered surgical procedures will be updated to include 37 additional surgical procedures.
  • Drugs and biologicals acquired through the 340B program will have the same payment rate as those not acquired under the 340B program—the average sales price plus 6 percent.
  • CMS will pay for intensive outpatient program services. The final rule includes the scope of benefits, physician certification requirements, coding and billing, and payment rates.

340B Rule

Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs or biologicals from manufacturers at discounted prices. Until 2018, the Medicare payment rate for Part B-covered outpatient drugs provided in outpatient hospitals was generally the average sales price (ASP) plus 6 percent. From 2018 through September 2022, CMS paid for these drugs at ASP (22.5 percent). After extensive litigation and a Supreme Court ruling, CMS returned payment for 340B drugs to ASP plus 6 percent in late 2022, and payment has continued at that level since. Consequently, payment for other services was reduced slightly more than 3 percent in 2023 to meet statutory budget neutrality requirements.

In this rule, CMS finalizes a remedy for 2018−22 payments in light of the court rulings. The agency will provide lump sum payments to 340B hospitals to cover the difference between ASP + 6 percent and ASP – 22.5 percent. Lump sum payments to 340B hospitals will result in roughly $9 billion in payouts to these facilities, in addition to the $1.5 billion they already have received through resubmitted claims. CMS had proposed that beginning in 2025, non-drug OPPS payments would be reduced by 0.5 percent to recover the budget neutrality-based payment increases resulting from the rescinded 340B cuts. According to CMS, hospitals received approximately $7.8 billion in additional spending on non-drug items and services because of budget neutrality. Earlier this year, CMS proposed a 0.5 percent pay cut to all hospitals, which would be in place for 16 years to fully adjust for the payment changes. CMS is finalizing the budget neutrality adjustment but will defer implementing these cuts to 2026 based on public comments about hospital budgetary pressures.

CY 2024 Home Health Prospective Payment System Final Rule

On November 1, 2023, CMS issued the CY 2024 Home Health Prospective Payment System (HH PPS) Rate Update final rule, which informs Medicare payment policies and rates for home health agencies (HHAs). This rule includes routine revisions to the Medicare Home Health PPS payment rates for CY 2024 in accordance with existing statutory and regulatory requirements. According to CMS estimates, Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, or $140 million, from CY 2023.

However, CMS also finalized a permanent prospective payment adjustment to the CY 2024 home health 30-day period payment rate that reduces the update. This adjustment is intended to account for any increases or decreases in aggregate expenditures that result from the implementation of the Patient-Driven Groupings Model (PDGM) and 30-day unit of payment as required in the Bipartisan Budget Act of 2018. The finalized −2.890 percent adjustment is half the total projected adjustment of negative 5.779 percent. As a result, CMS estimates that Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, rather than the 2.2 percent decrease as initially proposed.

CMS’ decision to implement only half of the permanent prospective payment adjustment in CY 2024 was in response to concerns from public commenters about the magnitude of implementing the proposed large single-year payment reduction. However, CMS also maintains that it will have to account for the remaining permanent adjustment it chose not to apply in CY 2024 and make other potential adjustments to the base payment rate in future rulemaking.

Other Proposals

CMS also is finalizing proposals to:

  • Rebase and revise the home health market basket to adopt a 2021-based home health market basket, including proposed changes to the market basket cost weights and price proxies
  • Reduce the labor-related share of the market basket to 74.9 percent based on the 2021-based home health market basket compensation cost weight (down from 76.1 percent)
  • Recalibrate the PDGM case-mix weights using CY 2022 data
  • Update the low utilization payment adjustment thresholds, functional impairment levels, and comorbidity adjustment subgroups for CY 2024
  • Codify statutory requirements for disposable negative pressure wound therapy
  • Establish regulations to implement payment for items and services under two new benefits: lymphedema compression treatment items and home intravenous immune globulin
  • Establish several enrollment provisions for hospices and other provider types and create a new informal dispute resolution process for hospice programs and a special focus program to provide enhanced oversight of the poorest-performing hospices
  • Implement various changes to the Home Health Quality Reporting Program and Home Health Value-Based Purchasing Model

2024 End-Stage Renal Disease Prospective Payment System Final Rule

On October 27, 2023, CMS issued a final rule that updates payment rates and policies under ESRD PPS for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2024. This rule also updates the acute kidney injury (AKI) dialysis payment rate for renal dialysis services that ESRD facilities furnish in CY 2024.

For CY 2024, CMS will increase the ESRD PPS base rate to $271.02, upping total payments to ESRD facilities by approximately 2.1 percent. The CY 2024 ESRD PPS final rule also includes several changes related to ESRD PPS payment policies.  First, the rule includes a payment adjustment that will increase payment for certain new renal dialysis drugs and biological products after the transitional drug add-on payment adjustment period ends. According to CMS, the increase will ensure payment is not a barrier to accessing innovative treatments for Medicare ESRD beneficiaries.

For more details about the policies described herein, contact Amy Bassano ([email protected]), Zach Gaumer ([email protected]), Andrea Maresca ([email protected]), John Richardson ([email protected]), Kevin Kirby ([email protected]), or Rachel Kramer ([email protected]).


Collaborating to improve children’s behavioral health

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Investments in children’s behavioral health represent a critical window of opportunity for fostering healthy child development and nurturing the resilience necessary for lifelong well-being. With over 40 percent of U.S. children and youth relying on the Medicaid system for healthcare coverage, it presents a platform to significantly enhance early intervention and prevention services, particularly for vulnerable children. Federal and state policymakers are increasingly active in formulating policies that prioritize investments in initiatives promoting mental and physical health at this pivotal developmental stage.

Health Management Associates (HMA) has partnered with the National Association of State Mental Health Program Directors (NASMHPD) Technical Assistance Coalition to produce a series of briefs that characterize the opportunities to improve coordination of services for children. Beyond the statistics lie the stories of countless vulnerable children and families facing immediate and critical needs. Addressing these issues requires comprehensive cross-system reforms, including policies that promote integrated financing, enhance care coordination, facilitate provider collaboration, and bolster upstream prevention efforts.

The importance of socio-emotional wellbeing as core to childhood development is underscored by evidence-based models and approaches, which consistently demonstrate the substantial value and long-term impact of investing in children’s mental and behavioral health. These investments not only benefit children and adolescents but also extend their positive effects to primary caregivers, creating a comprehensive and sustainable framework for fostering well-rounded, mentally resilient, and physically healthy lives.

The insights and recommendations presented in these briefs* underscore the urgency of coordinated action to improve the well-being of our nation’s youth and the opportunity for collaborative approaches to improve outcomes:

  1. Bolstering The Youth Behavioral Health System: Innovative State Policies To Address Access & Parity (previously published in 2022)
  2. System Integration Across Child Welfare, Behavioral Health, And Medicaid (previously published in 2022)
  3. State Policy and Practice Recommendations to Advance Improvements in Children’s Behavioral Health*
  4. Improving Outcomes for Children in Crisis with Evidence-Based Tools*
  5. The Role of Specialized Managed Care in Addressing the Intersection of Child Welfare Reform and Behavioral Health Transformation*
  6. Early Childhood Mental Health: the Importance of Caregiver Support in Promoting Healthy Child Development and Clinical Interventions for Children*
  7. Connecting Schools to the Larger Youth Behavioral Health System: Early Innovations from California*

*Briefs 3-7 were funded by SAMHSA’s TT1 grant award for FY 2023.

This is part of a larger effort supported by HMA and a number of partner organizations, including NASMHPD, The Annie E. Casey Foundation, Casey Family Programs, MITRE, National Association of Medicaid Directors (NAMD), Child Welfare League of America (CWLA), and the Federal Government agencies ACF and SAMHSA, to help create a dialogue among state agencies and stakeholders working to improve child welfare. The briefs HMA released are a starting point for much of the upcoming dialogue. A federal policy discussion is being held at SAMHSA in mid-November.

Recognizing the complexity of the challenges that lie ahead, it is evident that no single agency can tackle them in isolation. This approach requires adequate funding and robust partnerships at all levels, from local to state and federal. HMA and our partners are producing a unique convening of state agencies promoting a collective approach to improving child-centered care, one that emphasizes child and family-centered practices and fosters local collaborations across each community’s system of care. This invitation-only event in early February 2024 will convene eight state government child welfare agencies and experts to develop methods for improving their services.

The work HMA is doing with our partners highlights the gravity of the problems while providing inspiring examples of successful collaborations from across the country. By examining what works in these models, the way forward becomes evident —a path toward the development of more seamless systems of care for children and youth grappling with behavioral health needs. As states and communities navigate these critical issues, we put forward this body of work as a valuable resource, offering insights and strategies to transform our approach to children and youth well-being and behavioral health support.

HMA will be sharing more about this effort in the coming months, including a webinar with our partners on December 12; registrants will receive a summary of the findings following the February 2024 event. If you want to learn more about this and other initiatives in child behavioral health, please contact HMA children’s behavioral health experts Caitlin Thomas-Henkel and Uma Ahluwalia.

Timeline of Key Events

  • November 3, 2023: Release of SAMHSA funded briefs
  • November 16, 2023: Federal Policy Convening (private)
  • December 12, 2023: HMA Webinar featuring Partner Agencies to discuss federal convening insights, plans for February State Policy Lab. Register here.
  • February 7-8, 2024: State Policy Lab (invitation only)
  • Dates TBD: Release of blueprint/insights from State Policy Lab

Michigan releases Medicaid Managed Care RFP

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This week, our In Focus section reviews the Michigan Medicaid Managed Care Comprehensive Health Care Program (CHCP) request for proposals (RFP), which the Michigan Department of Health and Human Services released on October 30, 2023. CHCP covers 2.2 million Medicaid members and is worth approximately $15 billion.


The rebid is part of MIHealthyLife, an initiative that the department launched in 2022 to strengthen Medicaid services through new Medicaid health plan contracts. At that time, Michigan Medicaid sought input from nearly 10,000 stakeholders in an effort to strengthen Medicaid managed care contracts and create a more equitable, coordinated, and person-centered system of care. Based on the feedback, the department designed the RFP with a focus on five strategic pillars:

• Serve the Whole Person, Coordinating Health and Health-Related Needs
• Give All Kids a Healthy Start
• Promote Health Equity and Reduce Racial and Ethnic Disparities
• Drive Innovation and Operational Excellence
• Engage Members, Families and Communities


Medicaid managed care organizations (MCOs) serve 10 regions, each consisting of multiple counties. MCOs will bid on one or more of the regions throughout the state. Each region requires at least two plans, with the exception of Region 1, a rural area that includes Michigan’s Upper Peninsula, where members are enrolled in a single plan.

As part of the MIHealthyLife initiative, the RFP will include the following changes:

• Prioritizing health equity by requiring Medicaid health plans to achieve National Committee for Quality Assurance Health Equity Accreditation
• Addressing social determinants of health through investment in and engagement with community-based organizations
• Increasing childhood immunization rates, including greater provider participation in the Vaccines for Children program
• Adopting a more person-centered approach to mental health coverage
• Ensuring access to health care providers by strengthening network requirements
• Increasing Medicaid Health Plan accountability and clarifying expectations to advance state priorities


Proposals are due January 16, 2024, and implementation is anticipated to begin October 1, 2024. Contracts will run through September 30, 2029, with three one-year optional periods.

Current Market

Michigan currently has nine plans, which serve more than 2.2 million Medicaid and expansion members. The table below provides a breakdown of the plan market share by enrollment.

Link to RFP


CMS releases Medicaid LTSS expenditures report for FY 2020

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This week, our In Focus section summarizes the Medicaid Long-Term Services and Supports (LTSS) Annual Expenditures Report, which the Centers for Medicare & Medicaid Services (CMS) released on October 17, 2023. The report includes detailed information about Medicaid LTSS expenditures for federal fiscal year (FY) 2020, which runs from October 1, 2019, through September 30, 2020. During this time, LTSS spending grew 20 percent to $199.4 billion from the previous year.

Medicaid LTSS Expenditures

Medicaid LTSS expenditures cover home and community-based services (HCBS), which includes personal care and home health, as well as institutional care, which includes services provided in nursing facilities, intermediate care facilities (ICF) for individuals with intellectual or developmental disabilities (IDD), and mental health facilities. HCBS accounted for 62.5 percent ($124.6 billion) of LTSS expenditures. The remaining 37.5 percent, or $74.8 billion, was directed toward institutional care (see Figure 1).

Figure 1. Medicaid LTSS Expenditures by Type

In addition, Section 1915c waiver program spending accounted for 43.1 percent of HCBS expenditures, followed by personal care at 20.5 percent. See Figure 2 for additional breakouts.

Figure 2. Percentage of Medicaid HCBS Expenditures by Service Category

Nursing facilities accounted for the largest percentage (78.2 percent) of institutional care spending. See Figure 3 for additional breakouts.

Figure 3. Percentage of Medicaid Institutional Expenditures by Service Category

Medicaid LTSS spending accounted for 33.5 percent of total Medicaid spending in FY 2020. States with the highest LTSS as a percentage of total Medicaid spending were North Dakota at 54.9 percent, Wyoming at 54 percent, Kansas at 51.2 percent, Minnesota at 49.6 percent, and Nebraska at 45.2 percent. Texas and Virginia did not report spending for Medicaid LTSS programs, which comprise a substantial share of total LTSS expenditures in those two states (see Table 1).

Table 1. Medicaid LTSS Expenditures by State

LTSS spending per resident also varied from state to state. On average, states spent $679 Medicaid LTSS dollars per state resident in FY 2020. Utah had the lowest Medicaid LTSS expenditures per state resident at $284, whereas the District of Columbia had the highest at $1,554 per resident.

Medicaid MLTSS Expenditures

Medicaid managed long-term services and supports (MLTSS) spending totaled $57 billion in FY 2020. HCBS accounted for $35.7 billion and institutional care accounted for $21.3 billion. As more states adopted and extended their Medicaid managed care programs, MLTSS spending grew 750 percent from FY 2008.

In FY 2020, 25 states had operational MLTSS programs. Of these, nine were Financial Alignment Initiative (FAI) capitated model demonstrations for dual eligible members. New York, Pennsylvania, Florida, and California accounted for 58 percent of total MLTSS spending nationally, with New York representing 23 percent of total national MLTSS expenditures. Three states—Idaho, Texas, and Virginia—did not report MLTSS spending (see Figure 4).

Figure 4. States with MLTSS programs, FY 2020

Source: Mathematica

Iowa had the highest share of MLTSS expenditures as a percentage of total Medicaid LTSS expenses in FY 2020 at 95 percent. Arizona and Kansas followed at 94 percent and Hawaii at 74 percent. The national average was 29 percent. At the lowest end were South Carolina at 4 percent and Rhode Island at 12 percent, both of which are fee-for-service states. Michigan followed at 14 percent.

Contributing Factors to LTSS Expenditures

The COVID-19 public health emergency, which includes the first six months of the pandemic that started in March 2020, had a major effect on LTSS expenditures in FY 2020. Many residents in long term care facilities are covered by Medicaid and disproportionately experienced the most COVID-19 deaths. States began to implement various policies to address the impact of COVID-19 among Medicaid LTSS users. This includes modifying utilization limits for covered services and increasing payment rates for certain institutional services and HCBS.

As mentioned earlier, Texas and Virginia did not report Medicaid LTSS expenditures, which undercut the national total. Other factors that affect the reliability of Medicaid LTSS data include changes in state MLTSS expenditure reporting methods, and changes in state Medicaid LTSS policies and programs.

Link to Report

Note: CMS hired Mathematica to conduct the research, which used CMS-64 Medicaid expenditure report data, state-reported MLTSS data, Money Follows the Person (MFP) worksheets for proposed budgets, CMS 372 data on section 1915(c) waiver program population groups, and U.S. Census data to compile the report


Cut to the Point: A Summary of 2024 Star Rating Cut Point Changes

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This week, our In Focus section highlights a white paper that Wakely, a Health Management Associates company, released in October 2023, “Cut to the Point: A Summary of 2024 Star Rating Cut Point Changes”. The paper reviews 2024 Medicare Star Rating data, including the Star Rating Technical Notes, which the Centers for Medicare & Medicaid Services (CMS) released October 13, 2023.

The data summarizes how Medicare Advantage Organizations (MAOs) performed on various quality measures during the 2022 measurement year and serves as an indication of changing Medicare Advantage spending in 2025 as a result of changes in Medicare Advantage Prescription Drug (MA-PD) Overall Star Ratings. The publication of the 2024 Star Rating Technical Notes provided an opportunity for Wakely to analyze measure-level cut point changes. This paper looks at the latest cut point changes to determine how the Tukey Outlier Deletion methodology and changes in the overall quality performance have affected Star Rating cut points.

Link to White Paper

Wakely will also host a webinar, Stars and Strikes: 2024 Star Ratings and the Impact of Tukey, at 2:30 pm ET on November 14, 2023. The webinar will cover the recently released 2024 Star Ratings, including an analysis of the expected impact on 2025 Medicare payments. Attendees should expect to hear discussions about the latest program changes and resulting impact on the contract-level star ratings, including implementation of the Tukey outlier deletion methodology. In addition, Wakely colleagues will cover the upcoming changes to the Star Rating program and discuss their potential impact on Medicare Advantage Organizations. Please register here.

For questions, please contact Suzanna-Grace Tritt, [email protected], or Lisa Winters, [email protected].


Florida releases procurement for statewide Medicaid prepaid dental program

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


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

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


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

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

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

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


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


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

Link to RFP