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This week, our In Focus reviews the Oklahoma Medicaid managed care SoonerSelect Program request for proposals (RFP) and the SoonerSelect Children’s Specialty Program RFP released by the Oklahoma Health Care Authority (OHCA) on November 10, 2022.
Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state’s 1.3 million Medicaid members are in SoonerCare Choice, a Primary Care Case Management (PCCM) program in which each member has a medical home. Other programs include SoonerCare Traditional (Medicaid fee-for-service), SoonerPlan (a limited benefit family planning program), and Insure Oklahoma (a premium assistance program for low-income people whose employers offer health insurance).
Prior efforts to transition to Medicaid managed care have encountered roadblocks, starting in 2017 with a failed attempt to move aged, blind, and disabled members to managed care.
More recently, in June 2021, the Oklahoma Supreme Court struck down a planned transition of the state’s traditional Medicaid program to managed care, ruling that the Oklahoma Health Care Authority does not have the authority to implement the program without legislative approval.
Contracts had been awarded to Blue Cross Blue Shield of Oklahoma, Humana, Centene/Oklahoma Complete Health, and UnitedHealthcare. Centene/Oklahoma Complete Health also won an award for the SoonerSelect Children’s Specialty Program.
In May 2022, Governor Kevin Stitt signed a new Oklahoma law to implement Medicaid managed care by October 1, 2023.
Oklahoma will award contracts to at least three entities to provide medical, behavioral, and pharmacy coverage to nearly one million eligible children, pregnant women, newborns, parents and caretake relatives, and the expansion population. However, enrollment in these populations is expected to drop following the end of the public health emergency (PHE).
At least one of the contracts may be awarded to a provider-led entity (PLE). PLEs would need to provide proof that a majority of their ownership is held by Oklahoma Medicaid providers or the majority of the governing body is composed of individuals who have experience serving Medicaid members and are licensed providers. PLEs would also be able to bid on urban regions if the PLE agrees to develop statewide readiness within a timeframe set by the OHCA. If no PLEs meet OHCA standards, Oklahoma can choose not to award a PLE.
Goals of the program will include:
Improve health outcomes for Medicaid members and the state as a whole
Ensure budget predictability through shared risk and accountability
Ensure access to care, quality measures, and member satisfaction
Ensure efficient and cost-effective administrative systems and structures
Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.
Proposals will be due on February 8, 2023, and contract implementation is scheduled for October 1, 2023. The contract is expected to run through June 30, 2024, with five, one-year options.
Bidder’s technical proposals will be scored out of a total 1550 points. OHCA will award PLEs an additional 50 points for qualifying, bringing the total up to 1600 points. OHCA may also choose to conduct oral presentations for an extra total of 50 points.
SoonerSelect Children’s Specialty Program RFP
Oklahoma will select one of the awarded SoonerSelect plans for a separate statewide contract to provide comprehensive integrated health coverage to foster children, former foster children up to 25 years of age, juvenile justice-involved children, and children receiving adoption assistance. Contract terms will be the same as the main SoonSelect procurement, running from October 1, 2023, through June 30, 2024, with five one-year renewal options.
While the current federal COVID-19 Public Health Emergency (PHE) declaration could be in place through the winter months, HMA’s team of experts see many reasons to put the PHE’s Medicaid unwinding planning at the top of your list now.
Without an extension, the PHE declaration will expire on January 11, 2023. U.S. Department of Health and Human Services (HHS) officials pledged to provide 60-days’ notice before ending the PHE. As a result, since HHS did not announce an extension by November 12, we can assume that HHS Secretary Xavier Becerra will extend the PHE beyond January.
However, congressional leaders are again considering proposals that would impact the PHE’s Medicaid policies. Such a change could advance during the lame duck session of Congress. For a variety of reasons, lawmakers could seek a statutory change that would de-link Medicaid’s continuous enrollment requirement, the 6.2 percentage point increase in the federal Medicaid match, and other Medicaid maintenance of effort policies from the PHE declaration. Congress could set a specific date for ending these Medicaid policies. Doing so would provide more certainty for planning for the end of the continuous Medicaid enrollment policy and its downstream implications for health insurance programs.
What can Medicaid agencies, health plans, providers and other stakeholders do now?
The transition from Medicaid’s continuous enrollment requirement to normal eligibility operations involves a myriad of policy decisions and operational changes that will impact enrollees. In turn, the end of Medicaid’s continuous coverage policy will also have great bearing on the business and operational strategies of managed care plans, providers and other stakeholders participating in the Medicaid and Marketplace programs.
HMA’s experts are working with state agencies, health plans, hospitals and health systems, and other stakeholders to identify options and workable solutions to prepare for these major changes. This work touches policy, organizational workstreams, systems, and payment. There are issues specific to Medicaid as well as the intersection with Marketplace, the Supplemental Nutrition Program (SNAP), and other public programs.
Combining our collective on-the-ground experience in states with our federal policy insights, experts from across the HMA family of companies list below themes and immediate actions stakeholders can consider. These action steps are focused on ensuring states, managed care plans, providers and other stakeholders are prepared to immediately respond to the end of the Medicaid continuous enrollment policy and work with individuals to provide information and other support they may need to stay enrolled in a coverage program.
1. Monitor and prepare for federal activities, particularly during the lame duck session of Congress and into 2023. Healthcare policies are likely to feature prominently in Congress’ lame duck session in November and December. Decoupling the Medicaid continuous enrollment and enhanced Federal Medical Assistance Percentage (FMAP) policies from the PHE is one issue under consideration. Any statutory changes to these policies may also include new requirements for the unwinding process. Stakeholders will want to closely monitor these discussions.
If Congress sets a statutory end date for the PHE’s Medicaid eligibility policies, this will provide the certainty needed for states to finalize PHE unwinding action plans with target dates for resuming normal eligibility operations. Notably, this may also drive conversations during states’ 2023 legislative sessions.
Consider the impact to your state and your organization – and any decisions you’ll be faced with – if the enhanced FMAP is decoupled from the PHE. For example, if your state had the option to maintain continuous eligibility without the enhanced FMAP, would it do so? States and stakeholders will want to revisit their Medicaid unwinding plans, consider options for meeting any new requirements, and update existing plans accordingly. Also, stakeholders can offer to serve as a resource to your state Medicaid agency and/or Congressional delegation regarding lame duck legislative proposals pertaining to Medicaid and the PHE.
2. Stay informed about state-specific landscapes. With statewide elections largely decided and expectations for a PHE end date sometime in the first part of 2023, now is the time for stakeholders to revisit when and how to engage with state Medicaid and other state agencies to support Medicaid eligibility unwinding plans. Stakeholders will want to solidify strategies and timing for engaging with states as unwinding plans are further solidified and eventually implemented.
Stakeholders can also monitor changes to states’ eligibility and enrollment rules – including initiatives designed to simplify eligibility rules, enhance eligibility and enrollment systems, and adjust managed care rate setting policies, among others. Many states are utilizing the temporary federal Medicaid flexibilities to alleviate the significant eligibility unwinding workload. Federal agencies also continue to regularly publish new information for states and stakeholders to consider. Some states are implementing policies designed to improve the transition from Medicaid to Marketplace. Understanding the implications of such policies will help stakeholders anticipate how ending Medicaid’s continuous coverage requirement will directly affect them.
3. Refresh strategies and messaging for outreach and assistance. While the PHE end date remains in flux, state plans for ending the Medicaid continuous coverage policy are still evolving. States are refining their beneficiary communication plans and may be developing updated guidance for stakeholders. Health plans, providers, and other stakeholders should align their messaging and outreach work accordingly and continue to build partnerships in communities across the state.
However, outreach alone will not be enough to reach all Medicaid enrollees. Many will need assistance in understanding and complying with changes that come with the end of the continuous enrollment policy. For example, stakeholder-provided redetermination assistance will be key to minimizing the number of enrollees who lose coverage for failure to complete the redetermination process and state requirements for stakeholder assistance will vary state by state.
4. Update projected impact of enrollee transitions between Medicaid and Marketplace programs. For states and stakeholders, especially health plans, it is time to update projections about 2023 Medicaid and Marketplace enrollment. This may also require new analysis and strategies to address the changing population acuity and resulting impact on capitation revenue. For healthcare providers, health systems, and other healthcare facilities, the end of the Medicaid continuous enrollment policy is expected to drive significant changes in payer mix, and it could reduce revenue as well as impact qualifications for special payment programs, the 340B program, among others. Understanding these dynamics can help with budgeting and implementation of specific patient outreach and support strategies.
5. Develop strategies to translate experiences from Medicaid to Marketplace. Medicaid agencies, managed care plans, and providers have gained valuable insights about the needs of individuals who have remained continuously enrolled in Medicaid during the COVID-19 PHE. This is particularly true for Medicaid enrollees diagnosed with a mental illness, substance use disorder, or both. Medicaid providers and health plans have gained valuable insight on effective clinical care models, whole person care, partnerships with community-based organizations and reimbursement strategies that can better meet the needs of complex populations. Providers and plans can utilize these experiences to better support the millions of individuals who are expected to become eligible for Marketplace coverage after Medicaid’s continuous enrollment policy ends.
The HMA team continues to monitor the dynamic state and federal policy landscapes, including state planning documents and new federal guidance and informational tools. We have the ability to support stakeholders to prepare for the end of PHE and to support state and communities by modeling projected enrollment and payer mix changes across health coverage categories. Stakeholders should be using this time to address gaps in their plans for PHE unwinding and continue to identify and evaluate new options that may emerge to support beneficiaries in retaining health coverage.
This week, our In Focus section reviews highlights and shares key takeaways from the 22nd annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA). Survey results were released on October 25, 2022, in two new reports: How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023 and Medicaid Enrollment & Spending Growth: FY 2022 & 2023. The report was prepared by Elizabeth Hinton, Madeline Guth, Jada Raphael, Sweta Haldar, and Robin Rudowitz from the Kaiser Family Foundation and by Kathleen Gifford, Aimee Lashbrook, and Matt Wimmer from HMA; and Mike Nardone. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD).
This survey reports on policies in place or planned for FY 2022 and FY 2023, including state experiences with policies adopted in response to the COVID-19 pandemic. The conclusions are based on information provided by the nation’s state Medicaid Directors.
Key Report Highlights
In the following sections, we highlight a few of the major findings from the reports. This is a fraction of what is covered in the 50-state survey reports, which include significant detail and findings on policy changes and initiatives related to delivery systems, health equity, benefits, telehealth, provider rates and taxes, and pharmacy. The reports also look at the opportunities, challenges, and priorities facing Medicaid programs.
Medicaid Enrollment and Spending Growth
The COVID-19 pandemic created significant implications for Medicaid. During this time, Medicaid enrollment has reached record highs due to the Families First Coronavirus Response Act (FFCRA), enacted in March 2020, which authorized a 6.2 percentage point increase in the federal match rate, or Federal Medical Assistance Percentage (FMAP), retroactive to January 1, 2020, and until the Public Health Emergency (PHE) ends. The increase was available to states that meet certain “maintenance of eligibility” (MOE) requirements. Since the survey, the PHE was extended to mid-January 2023, somewhat delaying the anticipated effects described in survey.
Medicaid enrollment growth slowed to 8.4 percent in FY 2022, after a sharp increase in FY 2021 (11.2 percent). Almost all responding states reported that the MOE continuous enrollment requirement was the most significant factor driving FY 2022 enrollment growth. Responding states expect Medicaid enrollment growth to decline (-0.4 percent) in FY 2023, based largely on the assumption that the PHE and the related MOE requirements would end by mid-FY 2023. States anticipate larger declines as Medicaid redeterminations and renewals resume.
In FY 2022, total Medicaid spending is expected to reach a peak growth of 12.5 percent, with enrollment growth as the primary driver. For FY 2023, total spending growth is expected to slow to 4.2 percent, assuming slower enrollment growth after the unwinding of the PHE. State Medicaid spending grew by 9.9 percent in FY 2022 and is projected to increase by 16.3 percent in FY 2023 once enhanced federal fiscal relief expires. If the PHE is extended, state spending increases and enrollment decreases that states anticipated for FY 2023 could occur later.
Figure 1 – Percent Change in Medicaid Spending and Enrollment, FY 1998-23
SOURCE: FY 2022-2023 spending data and FY 2023 enrollment data are derived from the KFF survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2022. 49 states submitted survey responses by Oct. 2022; state response rates varied across questions. Historic data reflects growth across all 50 states and DC and comes from various sources.
Capitated managed care remains the predominant delivery system for Medicaid in most states. Forty-six states operated some form of Medicaid managed care (managed care organizations (MCOs) and/or primary care case management (PCCM)). Forty-one states contracted with risk-based MCOs. Of these, only Colorado and Nevada did not offer MCOs statewide. Only five states – Alaska, Connecticut, Maine, Vermont, and Wyoming – lacked a comprehensive Medicaid managed care model.
Thirty-four states, including Distrct of Columbia, operate MCOs only, five states operate PCCM programs only, and seven states operate both MCOs and a PCCM program.
Twenty-seven states contracted with one or more PHPs to provide Medicaid benefits, including behavioral health care, dental care, vision care, non-emergency medical transportation (NEMT), and long-term services and supports (LTSS).
Of the forty-one states that contracted with MCOs, 35 reported that 75 percent or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2022.
Figure 2 – MCO Managed Care Penetration Rates for Select Groups of Medicaid Beneficiaries as of July 1, 2022
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2022.
Medicaid Managed Care and Delivery System Changes
California, Missouri, Nevada, New Jersey, and New York reported expanding mandatory MCO enrollment for targeted populations.
Missouri and Ohio reported introducing specialized managed care programs for children with complex needs.
California, Nevada, and Tennessee indicated that they were carving in certain long-term services and supports (LTSS) into their managed care programs.
California and Ohio reported carving out pharmacy services in FY 2022 or FY 2023, respectively. The District of Columbia carved out emergency medical transportation from its MCO contracts in FY 2022.
Maine, North Carolina, Oregon, and Washington reported changes to their PCCM programs.
Virginia plans to implement Cardinal Care in FY 2023, merging the state’s two existing managed care programs: Medallion 4.0 (serving children, pregnant individuals, and adults) and Commonwealth Coordinated Care Plus (CCC Plus) (serving seniors, children and adults with disabilities, and individuals who require LTSS).
Forty-one states reported at least one specified delivery system and payment reform initiative (e.g. Patient-Centered Medical Home (PCMH), ACA Health Homes, Accountable Care Organization (ACO), Episode of Care Initiatives, All-Payer Claims Database (APCD)).
Twenty-five states reported using at least one specified strategy to improve race, ethnicity, and language (REL) data completeness. Of the 45 responding states, 16 states reported requiring MCOs and other applicable contractors to collect REL data, 12 states reported that eligibility, renewal materials, and/or applications explain how REL data will be used and/or why reporting these data are important, nine states reported linking Medicaid enrollment data with public health department vital records data, and eight states reported partnering with one or more health information exchanges (HIEs) to obtain additional REL data for Medicaid enrollees.
Twelve of 44 responding states reported at least one financial incentive tied to health equity in place in FY 2022. The vast majority of these incentives were in place in managed care arrangements (11 of 13). Within managed care arrangements, states most commonly reported linking or planning to link capitation withholds, pay for performance incentives, and/or state-directed provider payments to health equity-related quality measures. Only two states (Connecticut and Minnesota), reported a FFS financial incentive in FY 2022. Five additional states report plans to implement financial incentives linked to health equity in FY 2023.
Sixteen of 37 responding MCO states reported at least one specified health equity MCO requirement in place in FY 2022. The number of MCO states with at least one specified health equity MCO requirement in place is expected to grow significantly in FY 2023, from 16 to 25 states. Examples of MCO requirements to address health equity include having a health equity plan, designating a Health Equity Officer, and staff training on health equity and/or implicit bias.
Figure 3 – MCO Requirements to Address Health Equity, FYs 2022-23
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; n=37 states.
Thirty-three states reported new or enhanced benefits in FY 2022 and 34 states are adding or enhancing benefits in FY 2023. Two states reported benefit cuts or limitations in FY 2022 and no states reported cuts or limitations in FY 2023.
Figure 4 – Select Categories of Benefit Enhancements or Additions, FYs 2022-23
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; Arkansas and Georgia did not respond.
Behavioral Health Services. States reported service expansions across the behavioral health care continuum, including institutional, intensive, outpatient, home and community-based, and crisis services. States reported addressing SUD outcomes, including coverage of opioid treatment programs, peer supports, and enhanced care management. At least ten states are expanding coverage of crisis services, which aim to connect Medicaid enrollees experiencing behavioral health crises to appropriate community-based care, including mobile crisis response services and crisis stabilization centers.
Pregnancy and Postpartum Services. In April 2022, a temporary option under ARPA to extend Medicaid postpartum coverage from 60 days to 12 months took effect. In addition to the states that took advantage of this eligibility change, some states are enhancing coverage of pregnancy and post-partum services. Nine states (California, District of Columbia, Illinois, Maryland, Michigan, New Mexico, Nevada, Rhode Island, and Virginia) are adding coverage of services provided by doulas and seven states (Alabama, Delaware, Illinois, Maryland, Ohio, Oregon, and Vermont) are investing in the implementation or expansion of home visiting programs.
Preventive Services. Sixteen states reported expansions of preventive care in FY 2022 or FY 2023. For example, seven states are expanding services to prevent and/or manage diabetes, such as continuous glucose monitoring. Other reported preventive benefit enhancements relate to asthma services, vaccinations, and genetic testing and/or counseling.
Services Targeting Social Determinants of Health. Many states reported new and expanded benefits targeting social determinants of health. Twelve states reported new or expanded housing-related supports, as well as other services and programs tailored for individuals experiencing homelessness or at risk of being homeless.
Dental Services. Nine states are adding comprehensive adult dental coverage, while additional states report expanding specific dental services for adults.
Most states have or plan to adopt permanent Medicaid FFS telehealth expansions that will remain in place even after the pandemic, though some are considering guardrails on such policies. Nearly all responding states that contract MCOs reported that changes to FFS telehealth policies would also apply to MCOs.
Figure 5 – Changes to FFS Medicaid Telehealth Policy, FY 2022 or FY 2023
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; n=48 states.
Nearly all responding states added or expanded audio-only telehealth coverage in Medicaid in response to the COVID-19 pandemic. Twenty-eight states reported that they newly added audio-only coverage while 19 states expanded existing coverage. Nearly all states reported audio-only coverage of mental health and substance use disorder (SUD) services. States least frequently reported audio-only coverage of home and community-based services (HCBS) and dental services. Two states (Mississippi and Wyoming) reported no coverage of audio-only telehealth for the services in question.
Telehealth utilization by Medicaid enrollees has been high during the pandemic but has decreased and/or leveled off more recently. States noted that telehealth utilization trends over time correspond to COVID-19 outbreaks, with higher utilization during COVID-19 surges and lower utilization when case counts are lower. In general, states reported that telehealth utilization was projected to continue at higher levels than before the pandemic, at least for some service categories.
Thirty-seven states (out of 47 responding) reported that behavioral health services were among those with the highest utilization. Additionally, a majority of states reported high utilization of evaluation and management (E/M) services and/or other physician/qualified health care professional office/outpatient services, including primary care.
States reported ACA expansion adults as one of the groups most likely to use telehealth (about one-third of responding states), followed by children and individuals with disabilities (each identified by about one-sixth of responding states).
Concerns regarding services delivered via telehealth included the quality of diagnoses, whether audio-only telehealth may be less effective, and inadequate access.
Key issues that may influence future Medicaid telehealth policy decisions include analysis of data, state legislation and federal guidance, and cost concerns.
Provider Rates and Taxes
In FY 2022, all 49 responding states reported implementing rate increases for at least one category of provider and 19 states reported implementing rate restrictions. In FY 2023, 48 states reported at least one planned rate increase and the number of states planning to restrict rates increased to 25 states.
States reported rate increases for nursing facilities and home and community-based services (HCBS) providers more often than other provider categories. The survey also found an increased focus on dental rates with about half of reporting states (20 in FY 2022 and 25 in FY 2023) reporting implementing or plans to implement a dental rate increase
Figure 6 – FFS Provider Rate Changes Implemented in FY 2022 and Adopted for FY 2023
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2022.
States continue to rely on provider taxes and fees to fund a portion of the non-federal share of Medicaid costs. All states but Alaska have at least one provider tax or fee in place. Thirty-eight states had three or more provider taxes in place in FY 2022 and eight other states had two provider taxes in place.
The most common Medicaid provider taxes in place in FY 2022 were taxes on nursing facilities (46 states), followed by taxes on hospitals (44 states), intermediate care facilities for individuals with intellectual disabilities (33 states), and MCOs (18 states).
Three states (Alabama, Mississippi, and Wyoming) reported plans to add new ambulance taxes in FY 2023.
Most states that contract with MCOs report that the pharmacy benefit is carved into managed care (34 out of 41 states that contract with MCOs). Six states (California, Missouri, North Dakota, Tennessee, Wisconsin, and West Virginia) report that pharmacy benefits are carved out of MCO contracts as of July 1, 2022. California was the latest to carve out pharmacy benefits as of January 1, 2022. Two states (New York and Ohio) report plans to carve out pharmacy from MCO contracts in state FY 2023 or later.
In FY 2022, Kentucky began contracting with a single PBM for the managed care population. Louisiana and Mississippi report that they will require MCOs to contract with a single PBM designated by the state in FY 2023 and FY 2024, respectively.
Seven states (Alabama, Arizona, Colorado, Massachusetts, Michigan, Oklahoma, and Washington) have value-based arrangements (VBAs) in place with one or more drug manufacturers.
More than half of responding states reported newly implementing or expanding at least one initiative to contain prescription drug costs in FY 2022 or FY 2023.
Six states (Florida, Kentucky, Massachusetts, Maryland, Nebraska, Nevada) reported recently implemented or planned policies to prohibit spread pricing or require pass through pricing in MCO contracts with PBMs.
Key Opportunities, Challenges, and Priorities in FY 2023 and Beyond
When asked to identify the top challenges for FY 2023 and beyond, Medicaid directors listed the following:
The unwinding of PHE emergency measures and the resumption of redeterminations.
Expiration of emergency authorities.
Lasting focus on COVID-19, including vaccinations, long-COVID, decreased utilization of preventive care services, and future emergency preparedness.
Medicaid directors stated that future priorities shaped by COVID-19 include:
Specific populations and service categories, including behavioral health, long-term services and supports, and maternal and child health.
Health care workforce challenges.
Payment and delivery system initiatives and operations.
IT system modernization.
Social determinants of health.
Medicaid directors note that COVID-19 has presented both new opportunities and challenges and has also shifted and shaped ongoing Medicaid priorities.
Health Management Associates (HMA) has a rich history of serving the healthcare infrastructure needs of Native American and Alaska Native communities – through healthcare IT support, clinical governance for change management, culturally competent stakeholder engagement, and revenue cycle management that implements an approach that is tailored to the provider and payer entities that deliver care in Native American and Alaska Native communities.
American Indian and Alaska Native (AI/AN) people experience disproportionately poorer health status compared to Americans as a whole. AI/ANs born today have a life expectancy that is 5.5 years less than the national average for all races. HMA has expertise with healthcare issues that uniquely impact American Indian and Alaska Native populations and is experienced in addressing these issues through American Indian and Alaska Native leadership engagement that is culturally sensitive and respectful.
Examples of HMA’s work with tribal health providers include:
HMA provided training and technical assistance to Skokomish Indian Tribal Health Center in Skokomish, Washington. This support includes the provision of clinical oversight services by one of HMA’s clinicians as Interim Medical Director.
HMA: (1) assessed the Tribal Health Center’s billing practices and assisted in the development of a procurement and contract with a new third-party billing vendor; (2) developed a screening and intervention program for medications for addiction treatment (MAT) of opioid and alcohol use disorders, including training for providers and administrative and medical staff; (3) established policies and procedures to support the clinic to move to a primary care medical home model of care, including development of a back office manual and trainings to clinic staff and providers; and (4) provided technical assistance to the Tribal Health Center as it developed telehealth programs for both video visits and remote patient monitoring (RPM), including development of policies and procedures for maintaining operations during emergencies, procedures and workflow approaches for working with IT vendors and potential purchase and implementation of a new electronic health record.
HMA conducted a feasibility assessment to determine how best Fort Belknap Tribal Health Department could take over administration of behavioral health services through a 638 contract with the Indian Health Service (IHS) agency. To do this, HMA conducted a review of select documentation, contracts, and data sets, including clinical and financial data. Through site visits, HMA conducted focus groups and interviews with tribal, IHS, and community stakeholders. HMA also provided research of other tribal behavioral health programs and interviews with tribes successfully delivering comprehensive behavioral health services.
HMA provided consultation regarding integration of behavioral health into primary care sites, sharing expertise and advice on privacy and confidentiality regulations and integrated care, how to manage during the transition from traditional behavioral health to integrated care, ideas for including medical family therapy more broadly in patient care, and the implementation of patient assessments.
The Montana Healthcare Foundation (MHCF) convened tribal health care leaders to develop shared priorities to jointly pursue with the Montana Department of Public Health and Human Services (DPHHS) and the Legislature. HMA was engaged by MHCF to help the group assess implementation options related to the Centers for Medicare and Medicaid Services’ (CMS) revised interpretation of the 100 percent federal match for state Medicaid programs for American Indian Medicaid enrollees for services. HMA proposed options for how DPHHS can use the new match funding to support IHS and tribal health facilities as they implement these new processes and support shared priorities. Priorities identified by the tribal health leaders included operational and policy issues such as improving health information technology capacity; identifying opportunities to compact aspects of health care delivery from IHS; and improving clinic operations through business management training.
HMA served as the independent evaluator for Montana Office of Public Instruction (OPI) Substance Use and Mental Health Services Administration (SAMHSA) Tribal Systems of Care Evaluation. The five-year evaluation assesses the impact of High-Fidelity Wraparound services being provided to American Indian students in schools on six tribal reservations throughout the state. Evaluation activities include tracking quantitative data to measure progress toward grant goals and tracking qualitative data to assess impact of wraparound activities through key informant interviews, small group listening sessions, and site visits. Evaluation findings are regularly reported to SAMHSA and presented locally to key stakeholders.
Montana Tribally Operated Substance Use Disorder (SUD) Continuum of Care Concept Brief
HMA worked in coordination with the American Indian Health Leaders (AIHL) workgroup, a group made up of leadership from Montana’s seven tribes representing tribal health departments and urban Indian health centers, to develop a SUD Continuum of Care Concept brief, describing potential approaches for design and financing of a jointly tribally operated SUD treatment facilities. This work was conducted through a contract with Montana Healthcare Foundation.
Montana Tribally Operated Substance Use Disorder Continuum of Care
HMA provides technical assistance and facilitation and consulting expertise to support the development of a statewide joint tribally operated SUD Continuum of Care. HMA facilitated discussions with AIHL and Chemical Dependency Center (CD) directors. HMA provided subject matter expertise on the various design options available based on American Society of Addiction Medicine (ASAM) service needs criteria as well as analysis support. HMA is also providing consulting support on financial and operational planning for the development of new facilities. This work could include methods for short-term and long-term forecasting and scenario modeling, identification, and negotiation of capital and operational financing for construction and start-up phase, and technical assistance on revenue cycle best practices to ensure satisfactory patient experience and sustainable revenue. This work is being conducted through a contract with the MHCF.
Health Policy and Advocacy
HMA consultants have worked with the following organizations associated with American Indian health policy and advocacy issues:
A tribally driven non-profit organization with a mission of improving health outcomes for American Indians and Alaska Natives through a health policy focus at the Washington state level. AIHC works on behalf of the 29 federally recognized Indian tribes and two urban Indian health organizations.
An Alaska Native-owned, nonprofit health care delivery and advocacy organization serving nearly 65,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Borough and 55 rural villages. Southcentral Foundation and the Alaska Native Tribal Health Consortium own and manage the Alaska Native Medical Center that serves the entire Alaska Native and American Indian population in the state.
Engaged in many areas of Indian health, including legislation, policy analysis, health promotion and disease prevention, as well as data surveillance and research. The Northwest Portland Area Indian Health Board (NPAIHB) is a non-profit tribal advisory organization serving the forty-three federally recognized tribes of Oregon, Washington, and Idaho.
A non-profit organization located on the Apsáalooke (Crow) Reservation in Montana whose mission is to improve the health of individuals on the Crow Indian Reservation and outlying areas through community-based projects that empower communities to assess and address their own unique health-related challenges.
For more information about HMA’s Native American and Alaska Native support services, contact firstname.lastname@example.org.
This week, our In Focus section reviews the remaining Medicare payment and policy rules, finalized over the last several days by the Centers for Medicare & Medicaid Services (CMS), that will shape the landscape for the Medicare program in 2023 and beyond. These include the Physician Fee Schedule (PFS), the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System, the Home Health Prospective Payment System and Home Infusion Therapy Services updates, and the End Stage Renal Disease (ESRD) payment rules.
The final Medicare rules are directionally aligned with the agency’s policy priorities, including improving health equity and addressing the health and health-related needs of rural and underserved communities, promoting value-based, whole-person care, and removing barriers to behavioral health services, among other issues.
Across these rules, CMS took some steps where they have authority to mitigate reductions in payment rates for some provider types. Final payment and policy changes, however, will inform stakeholders’ federal advocacy efforts with Congress. Specifically, as part of an end of year legislative package lawmakers are considering legislative proposals to address the 2023 payment levels and their relationship to general inflation and the scheduled payment cuts for physicians. These issues and Medicare program solvency are expected to remain hot topics throughout 2023.
For today’s blog our HMA experts highlight a few of the finalized policy changes contained in the aforementioned regulations that will take effect on or after January 1, 2023. The HMA Medicare team will continue to analyze these policies for their immediate implications. Additionally, final policies and CMS’ response to commenters offer important insights that providers, vendors, and other stakeholders will want to incorporate in their future policy, financial, and operational strategies.
Medicare Physician Fee Schedule Final Rule
On November 1, 2022, CMS released final updates and policy changes for Medicare payments under the PFS, and other Medicare Part B issues. This rule largely finalizes many of the policies described in HMA’s earlier summary of the PFS proposed rule. Notably, CMS finalized updates to the Medicare Shared Savings Program (MSSP) largely as proposed. The agency expects these changes will renew and broaden provider interest in participating in the Medicare Shared Savings Program (MSSP). The new MSSP opportunities will support CMS’ work towards its goal that by 2030 100 percent of Medicare beneficiaries will be in a care relationship with accountability for quality and total cost of care. As expected, CMS also finalized proposals intended to enhance access to behavioral health services and strengthen the behavioral health model within the Medicare program. The changes represent a major shift in traditional Medicare’s coverage of services to identify and treat mental health conditions and substance used disorders. CMS plans to address payment for new codes that describe caregiver behavioral management training in CY 2024 rulemaking.
Notable policies that will be of interest to Medicare stakeholders include:
Payment Rates and Inflation: The conversion factor used to determine payments to physicians through the PFS will be $33.06 in 2023, a decrease of $1.55 from the 2022 conversion factor. The final payment update reflects the following dynamics:
Expiration of a statutory one-year 3 percent increase in payments,
A statutory 0 percent payment update for CY 2023, and
A budget neutrality adjustment across all billing codes resulting from modifications to PFS weights which increased the relative value of primary care billing codes.
This cut to the conversion factor is driven by statutory requirements. The physician community is actively advocating to Congress that they need an update to their payments given the high levels of inflation and the lack of automatic updates built in to the PFS.
CMS also updated the information under the PFS to account for current trends in the delivery of health care, especially concerning independent versus facility-based practices. CMS indicated the updates and improved public use files respond to requests the agency has received to provide more granular information that separates the specialty-specific impacts by site of service. According to CMS, stakeholders are seeking to better understand how Medicare payment policies are directly responsible for the consolidation of privately-owned physician practices and freestanding supplier facilities into larger health systems.
Medicare Shared Savings Program: CMS finalized significant updates to MSSP that are aligned with the agency’s overall value-based care strategy of growth, alignment, and equity. These policies include paying advance shared savings to certain new ACOs that can be used to support their participation in the Shared Savings Program, a health equity adjustment to an ACO’s quality score, a revised benchmarking methodology, and allowing longer periods of time for ACOs to transition to downside risk. This package of changes are intended to increase participation in MSSP and in particular participation in rural and underserved areas.
Behavioral health: The final rule expands the types of behavioral health providers eligible for reimbursement under Medicare Part B. Marriage and family therapists, licensed professional counselors, addiction counselors, certified peer recovery specialists, and others will be able to provide behavioral health services while being under general supervision rather than “direct” supervision. Psychologists and social workers that are part of a primary care team will also be eligible for payment to help manage behavioral health needs. Additionally, CMS confirmed that Opioid Treatment Programs may bill Medicare for services performed by mobile units without obtaining a separate registration and increasing payment rates to Opioid Treatment Programs.
Telehealth: CMS finalized several policies related to Medicare telehealth services, reflecting statutory requirements of the Consolidated Appropriations Act (CAA) of 2022 and the agency’s ongoing evaluation of temporarily available services. The changes related to the CAA of 2022 include extending for 151 days beyond the end of the Public Health Emergency (PHE) the following coverage provisions: allowing telehealth services to be furnished in any geographic area and in any originating site setting (including the beneficiary’s home); allowing certain services to be furnished via audio-only telecommunications systems; allowing physical therapists, occupational therapists, speech-language pathologists, and audiologists to furnish telehealth services; delaying the onset of the in-person visit requirements for mental health services furnished during the PHE; and making policy changes consistent with those named above under the payment systems for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHC).
Ground Ambulance: CMS affirmed that its expanded list of covered destinations for ground ambulance transports was for the duration of the COVID-19 PHE only. The regulation also finalized changes to the long awaited Medicare Ground Ambulance Data Collection Instrument, including clarifying to process for requesting exemption from reporting cost data through this collection device.
Outpatient Prospective Payment System and Ambulatory Surgical Care Payment System Final Rule
Payment rates and Inflation: CMS increased hospital outpatient and ambulatory surgical center payments by 3.8 percent in 2023 above 2022 rates. This reflects a 4.1 percent hospital market basket increase plus a 0.3 percentage point reduction for productivity and is consistent with Medicare’s 2023 hospital inpatient payment increase. The hospital industry has expressed deep concern to Congress and CMS that although the 4.1 percent market basket increase is as high as it has been in many previous years, it lags behind the measure of general inflation (October 2022 consumer price Index = 8.2 percent)
Remote Behavioral health: CMS finalized its proposal to cover as an outpatient service remote behavioral health services provided by clinical staff of hospital outpatient departments, including critical access hospitals (CAHs), to beneficiaries in their homes. This policy was initially permitted under CMS’ COVID-19 PHE emergency rulemaking but this is now covered on a more permanent basis.
In 2023 beneficiaries would need to receive an in-person service within the 6 months prior to the first time hospital clinical staff provide the remote behavioral health services. CMS also is requiring an in-person service without the use of communications technology within 12 months of each behavioral health service furnished remotely.
The agency also finalized coverage of audio-only telehealth services in instances where the beneficiary is unable to use, does not wish to use, or does not have access to two-way, audio/video technology.
Algorithm driven services: CMS finalized policy to pay separately (rather than bundle payment) for Algorithm-driven services that assist practitioners in making clinical assessments. This includes clinical decision support software, clinical risk modeling, and computer aided detection (CAD).
Rural Emergency Hospitals (REH) : CMS finalized conditions of participation, payment rates, and Medicare enrollment procedures for the new REH provider type largely as proposed. The new REH program will be effective January 1, 2023. Federal policymakers believe the REH provider type could provide a more sustainable option for rural hospitals facing closure and to support access to care in rural and underserved communities. A previous HMA blog explains the payment and service parameters for the REH option.
Hospitals and health systems and the rural communities they serve will want to analyze the final requirements for health and safety standards, staffing, and physical environment and emergency preparedness and other expectations and balance these with community perspectives to determine the feasibility of this pathway.
Site neutral payment policy: CMS finalized its proposal to exempt Rural Sole Community Hospitals (SCHs) from the Medicare policy which pays clinic visit services 40 percent of the OPPS payment rate when provided at hospital outpatient departments. Instead, CMS will pay these providers full OPPS rates for clinic visits.
340B Drug Program: CMS finalized a payment rate of Average Sales Price plus 6 percent under the 340B program.
Home Health Prospective Payment System Rate Update and Home Infusion Therapy Services Requirements
On October 31, 2022, CMS finalized the calendar year 2023 Home Health Prospective Payment System (HH PPS) payment rates. CMS projects that aggregate spending for home health agencies in 2023 will increase by 0.7 percent, compared to 2022. This is a significant update as compared to the 4.2 percent decrease the agency proposed earlier this year. The originally proposed payment cut was in part due to CMS’s requirement to implement at statutory budget neutrality requirement for the Patient-Driven Groupings Model. While there was fervent industry pushback and advocacy to eliminate the proposed payment adjustments, CMS instead used its discretionary authority to implement a phased approach to payment reductions. The first half will be effective in 2023, and the remaining permanent adjustment and any other potential adjustments needed to account for behavior change will be proposed in future rulemaking. CMS’ payment approach is expected to factor heavily in the overall stability and market dynamics within the home health agency industry in the months ahead.
Other notable final rule Home Health policies include:
CMS finalized a permanent cap on wage index decreases to promote predictability in payments and smooth year-to-year changes. This was also implemented within the Inpatient Prospective Payment System.
CMS finalized the Expanded Home Health Value-Based Purchasing (HHVBP) Model home health agency baseline year to CY 2022 and the Model baseline year to CY 2023.
CMS will begin collecting data on the use of telecommunications technology on home health claims voluntarily starting on January 1, 2023, and on a mandatory basis beginning on July 1, 2023. Further details are expected to be issued in January 2023.
ESRD Prospective Payment System Final Rule
Also on October 31, 2022, CMS released the calendar year 2023 ESRD Prospective Payment System Final Rule. In addition to updating the payment rates, the rule updates requirements for the ESRD Quality Incentive Program (QIP). Looking ahead CMS plans to consider comments in response to several requests for information as it updates the ESRD QIP, works to align resource use with payment, ensure equitable access to technologies that improve health and quality of life.
Additional impactful policies for providers and stakeholders include:
CMS did not approve any of the three new technologies which applied for pass-through payment. While CMS has created a payment mechanism to promote innovation, it has proved challenging to actually access this payment mechanism. That may slow investment in the space if CMS continues to set such a high bar.
As laid out in the final rule, CMS remains on track to fold all oral drugs including phosphate binders into the bundle when the statutory ban expires in 2025.
CMS received many comments for its RFI regarding TDAPA, the new drug pass-through payment program in ESRD. It is likely that CMS will dedicate significant attention to this topic in the next rulemaking cycle. In particular, the RFI focused on how CMS might add new money to the ESRD bundle when new drugs exit pass-through, including the potential for accounting for other drugs which are replaced by the new products.
While providers and stakeholders must analyze the immediate impact of the final rules, it is also essential to consider the broader context of CMS’ reimbursement and policy decisions.
Notably, there is more urgency for the provider community, Medicare Advantage plans, and the broader Medicare stakeholder community to prepare for the imminent end of the federal COVID-19 Public Health Emergency (PHE) declaration. Congress and the Administration have already begun to identify and make permanent certain flexibilities afforded during the COVID-19 PHE. Other flexibilities will be phased out or ended. Looking ahead to this transition, thoughtful preparation and consideration of the Medicare policy context and opportunities will be critical.
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). The rural health crisis is a health equity concern that affects all rural residents, including dually eligible individuals. There are 47 to 60 million people residing in rural areas. Twenty-one percent of dually eligible individuals live in rural areas—that’s about 2.6 million people. Based on these numbers, the authors calculate that the dual eligible population residing in rural communities accounts for about 5 percent of the total rural population. Dually eligible individuals living in rural areas are at risk of falling through the cracks.
Dually eligible individuals lack access to adequate medical, behavioral health, home-and community-based services (HCBS) and other social services; those living in rural areas face even steeper challenges. Since dually eligible individuals are among the poorest of all individuals covered under Medicare, they are at significant risk of paying a steep rural mortality penalty.
With these challenges there are opportunities for innovation for the dually eligible population living in rural communities. The US can reverse the mortality-disparity rate trajectory. Public and private entities are interested in revitalizing rural America, confronting the rural health crisis, and harnessing the power of rural communities. Investment in the rural health care sector is essential given it is a major economic driver of rural communities.
HMA is creating a toolkit with actionable solutions to improve access to services and integrated care and health equity for individuals dually eligible for Medicare and Medicaid who live in rural areas across the country. This project is a follow-on project to a previous HMA project supported by Arnold Ventures. In 2021, HMA prepared a brief, Medicare-Medicaid Integration: Essential Elements for Integrated Care Programs for Dually Eligible Individuals, to increase and promote enrollment in integrated care programs (ICPs) meeting dually eligible individuals’ needs and preferences. Interviewees including dually eligible individuals helped HMA to identify “access to needed services in rural areas” as an essential element of ICPs. In response, HMA started a new project to create a toolkit with actionable strategies to improve access to needed services and improve integrated care opportunities, specific to dually eligible rural residents’ needs.
HMA designed the toolkit around four values: 1) rural health equity is an imperative for dually eligible individuals, 2) actionable solutions and innovations must come from the community, 3) there is no single pathway to integration, and 4) Medicare and Medicaid flexibilities are critical to inspiring innovations to advance health equity, access, and integration. The toolkit will provide actionable solutions for states with and without integrated care programs for dually eligible individuals to increase access to needed supports and services, care coordination, and integrated care programs. We expect that states and rural communities will use the toolkit as a foundation for mapping a holistic plan to advance access to care coordination and integrated programs for dually eligible individuals residing in rural communities. Other states may employ contractual tools listed in the toolkit to expand access to providers and new services; strengthen partnerships among entities serving the community such as community-based organizations, providers, and health plans; and increase community-wide accountability for meeting dually eligible individuals’ whole person-centered needs. The toolkit is scheduled for an early 2023 release.
This article was the latest in the Health Affairs Forefront series, Medicare and Medicaid Integration which features analysis, proposals, and commentary that inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.
This week, our In Focus section reviews the Mountain Health Promise request for proposals (RFP) released by the West Virginia Department of Health and Human Resources on September 30, 2022, for specialized Medicaid managed care for children and youth in foster care.
Mountain Health Promise RFP
The selected managed care organization (MCO) will provide physical and behavioral health services to children and youth in the foster care system, individuals receiving adoption assistance, youth formerly in foster care up to age 26 who aged out of foster care while on Medicaid in the state of West Virginia, and children eligible under the children with serious emotional disorders (CSED) waiver. Potential expansions could include, but are not limited to, children at risk for foster care placement and the family of youth in crisis. Additionally, the MCO will act as an administrative services organization (ASO) and provide statewide administrative services for all individuals accessing socially necessary services (SNS).
Some of the goals of the program include:
Enhance coordination and access to services
Enhance quality of care and minimize barriers for youth and families/improve access to treatment
Reduce fragmentation and offer seamless continuity of care
Improve health and social outcomes for youth and impacts on families
Help reduce the number of children removed from the home and reduce lengths of stay per episode of care through increased family-centered care that provides necessary and coordinated services to all members of the family
Decrease children involved with the juvenile justice and corrections systems
Reduce out-of-home and out-of-state placements
Develop new or enhance existing services, such as children’s mobile crisis response (CMCR), inState Psychiatric Residential Treatment Facilities (PRTF) to reduce the need for out-of-state placements, and intensive home-based treatment
Physical and behavioral health services will be reimbursed through a Medicaid per member per month (PMPM) capitation payment. For SNS administration, the Bureau for Social Services (BSS) will provide a fixed monthly rate. The PMPM capitation rate will not include carved out SNS costs.
It is encouraged, but not required, that the MCO subcontract with regional child welfare organizations, residential mental health treatment facilities (RMHTFs), and organizations that provide home and community-based services for children with serious emotional disorders to assist in the care coordination of services for this population.
There are nearly 28,000 individuals currently enrolled in Mountain Health Promise, with about 13,000 eligible for SNS. Enrollment, however, is expected to decrease following the end of the Public Health Emergency (PHE). CVS Health/Aetna is the incumbent plan. Aetna had contracted with Kepro to serve as the ASO for SNS.
Proposals are due November 1, 2022. The contract is anticipated to run from July 1, 2024, through June 30, 2025, with three one-year options.
The winning MCO will be chosen based on the highest score of a possible total 1,000 points. The technical evaluation will be a total of 700 of 1,000 points. Cost represents 300 of 1,000 total points.
Today, the Substance Abuse and Mental Health Services Administration (SAMHSA) released the highly anticipated Cooperative Agreements for Certified Community Behavioral Health Clinic (CCBHC) Planning Grants Notice of Funding Opportunity (NOFO). The NOFO can be found here.
The CCBHC model provides integrated and coordinated community-based care for individuals across the lifespan with and at risk for behavioral health conditions, with a focus on adults with serious mental illness, those with any mental illness, children with serious emotional disturbance, and those with substance use disorders. The model is designed to increase access to behavioral health services; provide a comprehensive range of services, including crisis services, that respond to local needs; incorporate evidence-based practices; and establish care coordination as a linchpin for service delivery. To date, CCBHCs have demonstrated:
Significant reductions in client hospitalizations
Increased access to high quality community-based care, including services like Medication Assisted Treatment and care coordination
Reduced impact of the mental health and substance use care workforce shortage
Innovative and strengthened partnerships with cross-system partners, including law enforcement, schools, and hospitals
About the Planning Grants
These CCBHC Planning Grants are established to support states to develop and implement certification systems for CCBHCs, establish Prospective Payment Systems (PPS) for Medicaid reimbursable services, and prepare an application to participate in a four-year CCBHC Demonstration program. Through this opportunity, SAMHSA anticipates making 15 Planning Grant awards of up to $1 million per award. Awarded states will have 12 months to use their Planning Grant dollars to accomplish the following:
Solicit input for the development of a state CCBHC Demonstration program from consumers (including youth), family members, providers, tribes, and other key stakeholders.
Create and finalize application processes and review procedures for clinics to be certified as CCBHCs.
Assist clinics with meeting certification standards by:
facilitating access to training and technical assistance;
providing workforce supports, including assisting CCBHCs to improve the cultural diversity and competence of their workforce; and
facilitating cultural, procedural, and organizational changes to CCBHCs that will result in the delivery of high quality, comprehensive, person-centered, and evidence-based services that are accessible to the population(s) of focus.
Certify an initial set of clinics as CCBHCs, including those that represent diverse geographic areas, including rural and underserved areas. As an option, states can also develop a process for bringing additional clinics into the State CCBHC Demonstration program to reach the desired geographic spread by the end of the four-year CCBHC Demonstration.
Establish a PPS for behavioral health services furnished by a CCBHC in accordance with the original PPS Methodology Guidelines developed by CMS. A statement indicating that the State agrees to pay for services at the rate established under the PPS during the CCBHC. Demonstration program must be attached with the application.
Develop or enhance statewide data collection and reporting capacity.
Submit a proposal to participate in the CCBHC Demonstration Program no later than March 20, 2024.
The Planning Grant project period is anticipated to begin on March 30, 2023. As a Cooperative Agreement, SAMHSA anticipates having substantial federal programmatic participation, including providing input to selected states in the planning, implementation, and evaluation of the program.
These planning grants are the first phase of a two-phase process of the expansion of the CCBHC Demonstration, authorized by the Bipartisan Safer Communities Act. Beginning July 1, 2024, and every two years thereafter, 10 states that have completed planning grants and submitted successful applications to participate in the CCBHC Demonstration will be eligible to join the program for a four-year period.
Eligibility to Apply
Eligibility for this Planning Grant opportunity is limited to the State Mental Health Authorities, Single State Agencies, or State Medicaid Agencies that are located in the 41 states, including the District of Columbia, that were not previously selected to participate in the CCBHC Demonstration Program. Regardless of which state entity ultimately serves as the applicant, each application must include a signed Memorandum of Agreement between the Director of the State Mental Health Authority, the Director of the Single State Agency, and the Director of the State Medicaid Agency demonstrating a partnership to fulfill the requirements of the award.
Updates to CCBHC Certification Criteria and PPS Guidance Expected but Not Before Application Deadline
Updates are expected to both the CCBHC Certification Criteria and PPS Guidance in the coming months, but the NOFO is clear that these updates will not be available during the application period for these Planning Grants. Specifically:
SAMHSA is in the process of updating the CCBHC Certification Criteria through a process which will include a significant opportunity for public comment. SAMHSA intends to keep the existing framework for the criteria, which is included in the authorizing statute. SAMHSA does not intend to make major changes to the scope and shape of the Certification Criteria.
CMS is also working to update the CCBHC PPS guidance. Any PPS changes will be made available prior to the planning grant execution period and included as part of technical assistance provided to states during the planning grant execution period.
Because neither of these updates will be released prior to the application submission deadline, applicants will use the existing CCBHC Criteria and PPS Guidance to inform their applications.
Next Steps for Interested State Stakeholders
Applications for this opportunity are due December 19, 2022 at 11:59 pm. Each application will be scored on their 30-page narrative submission, which includes significant emphasis on each applicant’s approach to CCBHC planning (including both certifying CCBHCs and establishing the PPS rates) and the state’s experience with the model to date (including the steps already taken to develop a CCBHC program in their state).
HMA and the National Council for Mental Wellbeing will host a joint webinar about this NOFO on Monday, November 7, 2022 at 1-2 pm ET.Register here.
In addition, in anticipation to the NOFO’s release, HMA and the National Council hosted a webinar on October 6, 2022, on “Developing a Strategy for the CCBHC State Demonstration RFP.” During this webinar, we engaged representatives from New York and Michigan to share information about their Demonstration program implementation to date. View the recording.
This week, our In Focus explores a new trend to watch in Medicaid Section 1115 waiver demonstration programs. As discussed in our previous In Focus, state Medicaid agencies are exploring pathways and concepts to address the historic inequities and health disparities laid bare and exacerbated by the COVID-19 pandemic. These efforts are closely aligned with the Centers for Medicare and Medicaid Services’ (CMS) policy objectives for the Medicaid program, specifically:
Addressing health inequities
Improving access and coverage
Promoting whole person care
Teams of experts from across the HMA family of companies are supporting state agencies, counties, health plans, providers, community and consumer organizations, and other stakeholders with translating federal goals and parameters into concrete proposals for new demonstration programs. HMA’s experts assist stakeholders with proposals as they move through the stages of concept paper, application, negotiation, approval, and implementation. Demonstrations will reflect each state’s unique political and policy landscapes, but the programs will be grounded in certain federal goals and expectations to enhance accountability and improve outcomes.
In the earlierIn Focus, our experts shared initial insights and considerations for stakeholders about one of the emerging trends: state Medicaid leaders are seeking to improve health equity in communities by providing health-related social services and engaging community organizations. Building on this and informed by our collective “on the ground” expertise we are writing this week about a second emerging trend we see across states’ Section 1115 activities:
Trend #2: States are seeking to use Medicaid demonstration programs to build essential capacity and infrastructure at the community and organizational levels.
The recently approved and submitted demonstration proposals signal CMS’ willingness to allow states to support some limited capacity building for community-based organizations. Several state 1115 demonstration proposals describe the state-specific types of community-based organizations and other entities that Medicaid programs want to engage to address the social and health-related drivers of health outcomes. This requires augmenting the existing workforce, providing training on Medicaid health plan contracting requirements, and building an infrastructure platform and systems that will support efficient communications and service delivery.
CMS has indicated a strong interest in advancing states’ community-based activities. This is evident in CMS’ decision to revise the federal framework used to determine whether a state’s Section 1115 demonstration program is budget neutral for the federal government. CMS has also decided to reopen the opportunity for states to propose Designated State Health Programs (DSHPs) under more limited size and scope parameters. CMS articulated these updated policies in the recent approval letters for Section 1115 demonstration programs in Massachusetts and Oregon. The federal reinterpretation provides states significantly more flexibility relative to the prior policy to use federal Medicaid funding to do the following:
Design and implement a broader set of health-related service need (HRSN) initiatives,
Make investments in the infrastructure to support HRSNs; and
Invest in building workforce capacity.
States will continue to act on these shifts in federal priorities and policies, crafting proposals aligned with their state-specific environments and goals. However, CMS’ willingness to support capacity building as part of state demonstration programs will need to adhere to certain scope and financing parameters. These guardrails are articulated in more detail in the approval letters for Massachusetts and Oregon. States and stakeholders will also want to be responsive to CMS’ expectations that its investments will be sustainable over time. They may need to plan and develop additional capacity to utilize non-Medicaid sources of federal and non-federal funding in tandem with the demonstration initiatives.
Importantly, the terms of the approved demonstration projects reinforce the need for states, managed care plans, and providers engage in new partnerships with community leaders and ensure the perspectives and experiences of consumers are continuously reflected in programs. Examples of proposed capacity building partnerships include:
Massachusetts’ recently secured CMS approval for a Section 1115 demonstration program which will fund a variety of health-related service needs (HRSN) initiatives. As part of the HRSN initiatives, CMS is allowing the state to receive federal Medicaid funding to support capacity-building, infrastructure, and operational costs for these activities. For example, under the demonstration federal funding will be available for participating “community partners” to pay for health information technology system investments, expand workforce capacity, manage startup costs, and enhance operational infrastructure such as system change resources. Additionally, the state will be able to receive federal Medicaid funding for provider workforce recruitment and retention activities, specifically primary care and behavioral health provider student loan repayment programs and a family nurse practitioner residency program.
In September 2022, Oregon received approval for a Section 1115 demonstration program to provide increased coverage of certain services that address HRSN. These services include critical nutritional services and nutrition education, as well as transitional housing supports for individuals with a clinical need or transitioning out of institutional care, congregate settings, out of homelessness or a homeless shelter, or the child welfare system. Additionally, the state will be able to receive federal Medicaid funding to make infrastructure investments to support those services, such as cultural competency training, trauma-informed training, traditional health worker certification, accounting and billing systems among others.
New York State envisions that Social Determinant of Health Networks (SDHNs) will work to organize and coordinate small neighborhood organizations familiar with their communities’ needs and the capacity to address multiple social risk factors as well as larger county or regionally focused entities. The state aims to allow SDHNs to receive Medicaid funding to invest in developing the infrastructure they need to assist Medicaid enrollees, such as the IT and business processes and other capabilities. Alongside this, the state is proposing a minimum fee schedule for certain services addressing social care needs. In addition, New York is requesting support for a statewide social services referral technology platform.
Washington state has a proposal pending with CMS that builds on its earlier demonstration program to further invest in multi-sector, community-based partnerships and approaches using Accountable Communities of Health (ACH). Specifically, the state is proposing to invest in the development and operation of Community Hubs and a Native Hub, which will serve as centers for community-based care coordination. These hubs will focus on health-related social needs (HRSNs) that provide screening for and referral to community-based services for Medicaid enrollees. These hubs will also distribute funding to build capacity among community-based organizations (CBOs) and community-based providers.
New Jersey has designed an 1115 demonstration proposal focused on the lack of stable housing as a driver of unnecessary hospitalization, institutionalization, or other avoidable instances of high-cost care, negative clinical outcomes, and worsening of chronic conditions. While it does not plan to make direct investments in community-based entities, the state aims to enhance contractual requirements with its Medicaid managed care organizations around housing specialists. This includes requiring health plans to have their housing specialists coordinate with community-based organizations that provide housing services or other related services to address social drivers of health. Its proposal also is designed to facilitate coordination across state and community resources that are essential to the provision of health and housing services.
The Massachusetts and Oregon demonstration programs provide important insight on CMS’ willingness to support state investments in HRSN and the state and local infrastructure to support delivery of culturally appropriate services.
Stakeholders will want to monitor these and other proposals as they move forward, particularly to understand the conditions and timing for funding to flow to community entities. Additionally, each state demonstration will have reporting and accountability structures that could impact payment and future investments made by Medicaid health plans, providers, CBOs and other stakeholders.
HMA’s interdisciplinary teams of Medicaid, human services, and actuarial experts are assisting states as well as stakeholders as they conceptualize, develop, and implement Section 1115 programs. To learn more about our work and connect with an HMA expert in your state please contact Andrea Maresca.
This week, our In Focus reviews the New Mexico Medicaid managed care request for proposals (RFP), released on September 30, 2022, by the New Mexico Human Services Department (HSD). The state will transition to a new program called Turquoise Care in 2024, which will build upon the current Centennial Care 2.0 program through a new Section 1115 waiver demonstration. Managed care organizations (MCOs) will provide physical health, behavioral health, and long-term care (LTC) services to approximately 800,000 Medicaid managed care members.
New Mexico plans to award Turquoise Care contracts to three MCOs. One of the selected MCOs will also be awarded a specialized foster care plan contract to provide services to Children in State Custody (CISC) on a statewide basis. CISC will be mandatorily enrolled and Native American CISC members will have the option to voluntarily enroll.
Turquoise Care will introduce new practices aimed at improving quality based on population health outcomes. The program will focus on three goals:
Goal 1: Build a New Mexico health care delivery system where every Medicaid member has a dedicated health care team that is accessible for both preventive and emergency care that supports the whole person – their physical, behavioral, and social drivers of health.
Goal 2: Strengthen the New Mexico health care delivery system through the expansion and implementation of innovative payment reforms and value-based initiatives.
Goal 3: Identify groups that have been historically and intentionally disenfranchised and address health disparities through strategic program changes to enable an equitable chance at living healthy lives. The target populations will be:
Prenatal, postpartum, and members parenting children, including children in state custody
Seniors and members with long-term services and supports (LTSS) needs
Members with behavioral health conditions
Native American members
Other changes for Turquoise Care include:
90 percent Medical Loss Ratio (MLR) aimed at improving quality of care
Expanded MCO reporting and monetary penalties for non-compliance
Minimum reimbursement rate for contract providers at or above the state plan approved fee schedule
More stringent provider network requirements
A single centralized vendor to process applications
Enhanced MCO staffing requirements, including qualifications, staffing levels, and training
Focus on social determinants of health
New Mexico will submit the Section 1115 demonstration waiver for Turquoise Health to the Centers for Medicare & Medicaid Services (CMS) for approval by December 2022. HSD will update the model contract to reflect the requirements related to the waiver renewal upon its approval.
During this procurement, the state will also be developing and implementing a new Medicaid Management Information System (MMIS).
Approximately 83 percent of the Medicaid population is in managed care.
Populations exempt from mandatory managed care enrollment are:
Native American members not in need of LTC
Individuals with Intellectual Disabilities (ICF-IID) in Intermediate Care Facilities
Individuals enrolled in Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLIMB), or Qualified Individuals program
Individuals covered only under the Medicaid Family Planning program
Individuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE)
Individuals covered pursuant to Emergency Medical Services for Non-Citizens (EMSNC)
Members in the Developmental Disabilities 1915(c) Waiver and in the Medically Fragile 1915(c) Waiver will continue to receive home and community-based services (HCBS) through that waiver but are required to enroll with an MCO for all non-HCBS.
Proposals are due December 2, 2022. Contracts will run from January 1, 2024, through December 31, 2026, with optional one-year renewals, not to exceed eight years total.
New Mexico had 811,732 Medicaid managed care as of August 2022, served by Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, and Centene/Western Sky. The state also had an additional 163,361 fee-for-service members.
The evaluation process will consist of three phases: review of mandatory requirements, review and scoring of the technical proposals, and review and scoring of the CISC technical proposals.
Communities across the country are seeing elevated numbers of adolescents in the Emergency Department due to suicide attempts, self-harm, anxiety, depression, substance use disorder (SUD), and overdose. While this youth mental health crisis predates COVID, it has been greatly exacerbated by the pandemic. According to the Centers for Disease Control and Prevention (CDC), in 2019, 13% of adolescents reported having a major depressive episode, a 60% increase from 2007, and suicide rates rose nearly 60% for youth ages 10 to 24 by 2018. Then it got worse. Last December, the U.S. surgeon general issued a public health advisory about the adolescent mental health crisis as emergency room visits due to suicide attempts rose 51% for adolescent girls in early 2021, compared to the same period in 2019. For boys, the increase was 4%.
The surgeon general recommends a “whole-of-society effort,” including a focus on mental health education and prevention, early identification, and access to high-quality mental healthcare. School-based intervention is ideal because only 20% of students in need of more intensive services typically receive needed care when referred to external providers.
The Bipartisan Safer Communities Act has committed $1.7 billion for mental health support in schools and communities via an array of methods including grant programs. The following programs are currently available for a wide array of eligible entities, including states, cities/counties, Local Education Agencies (LEAs), Indian tribes or tribal organizations, health facilities, and nonprofit entities:
Project AWARE (Advancing Wellness and Resiliency in Education). This grant program provides up to $1.8 million per year for up to 4 years to develop a sustainable infrastructure for school-based mental health programs and services. Grant recipients are expected to build collaborative partnerships with the State Education Agency (SEA), LEA), Tribal Education Agency (TEA), the State Mental Health Agency (SMHA), community-based providers of behavioral health care services, school personnel, community organizations, families, and school-aged youth. Grant recipients will leverage their partnerships to implement mental health-related promotion, awareness, prevention, intervention, and resilience activities to ensure that students have access to and are connected to appropriate and effective behavioral health services. Applications are due October 13th.
Resiliency in Communities After Stress and Trauma (ReCAST). This program provides up to $1,000,000 a year for up to 4 years to promote resilience, trauma-informed approaches, and equity in communities that have recently faced civil unrest, community violence, and/or collective trauma within the past 24 months; and to assist high-risk youth and families through the implementation of evidence-based violence prevention, and community youth engagement programs. SAMHSA expects ReCAST to be guided by a community-based coalition of residents, non-profit organizations, and other entities (e.g., health and human service providers, schools, institutions of higher education, faith-based organizations, businesses, state and local government, law enforcement, and employment, housing, and transportation services agencies). Applications are due October 17th.
In addition to these two grants, there will be an expansion of the Certified Community Behavioral Health Center (CCBHC) Demonstration for States that is expected to be released later this month. The Excellence in Mental Health Act established a federal definition and criteria for CCBHCs. These centers are a provider type that delivers a comprehensive range of mental health and SUD services to vulnerable individuals. They meet people where they are, which can include school-based services, and act as a critical partner in ensuring people have access to quality, affordable, and accessible mental health care.
School-based Mental Health Services
School-based mental health services, delivered within a Multi-Tiered System of Supports (MTSS) framework, can be supported by the aforementioned funding opportunities. The MTSS framework is currently used in public schools to target services and supports to students. As shown below, MTSS addresses universal prevention and progressively targeted support for students and families. It also aligns well with partnerships with community providers to establish an authentic community response that addresses the continuum of mental health needs.
The key to a successfully implemented MTSS framework is a strong partnership between the school staff, parents/guardians, children, and community partners. This partnership works well when anchored to an evidence-based socio-emotional curriculum that is reinforced across all Tiers and familiar to all parties.
Suicide and Self Harm Prevention
Dialectical Behavioral Therapy (DBT) was recently identified by the New York Times as “the Best Tool We Have’ for Self-Harming and Suicidal Teens,” because it is one of the only interventions found to reduce self-harm and suicidal ideation, its effects are maintained at one-year follow-up, and it successfully engages young people.
Curriculum developers Drs. Lizz Dexter-Mazza and James Mazza worked with Marsha Linehan, the DBT treatment developer, to adapt DBT Skills into a universal school-based social emotional learning curriculum, called DBT-STEPS-A. This approach is designed to help schools intervene and support well-being and resiliency before kids are suicidal or self-harming. It trains existing school personnel to integrate skill-building into the school program, universally or as a stand-alone option for youth in 6-12th grade (an elementary version is in development). As such, it is a viable approach, despite the current shortage of mental health care professionals in school-based settings.
In addition, DBT provides a shared language and strategies across all three MTSS tiers so that everyone (students, school staff, teachers, providers, and parents/guardians) can benefit. Because DBT is also commonly provided in inpatient, outpatient, and residential behavioral health programs, the value of extending this approach into school settings is further magnified for youth who transition from the highest levels of care.
A DBT STEPS-A program taught at the universal level provides the broadest application within school-based settings, supports uptake that leads to peer-to-peer coaching and support, along with shifting the school environment and culture to promote mental wellbeing and reinforce the skills via a shared language and common strategies. In Tier 2, students are supported to practice skills and decision-making strategies in smaller group or individual psychotherapy sessions as needed. The third tier is more intensive support for students experiencing ongoing emotional and behavioral difficulties for whom Tier 2–level support is not sufficient. It is designed to supplement individual psychotherapy for those in need of a higher level of care. Parent/guardian skills-training seminars are recommended, so they can learn about the skills their child is acquiring and how best to support them while they are practicing. Engaging parents/guardians proactively helps to increase adaption of the skills across both home and school contexts.
A matched sample of adolescents who received the DBT STEPS-A curriculum demonstrated lower scores on the BASC-2 Emotion Symptom Index and on the BASC-2 Internalizing Problems, indicating fewer mental health difficulties, compared to peers who did not receive the curriculum (Cohen’s F squared equal to 0.65 and 0.83, respectively.
The DBT curriculum is accessible via a $50 manual. All handouts for kids are available in English and Spanish and can be printed from a web-based link for free. An array of trainings are available to support rapid school-based service delivery.
To learn more about current and upcoming funding for enhanced school and community-based mental health care or DBT-STEPS-A, contact:
 National Vital Statistics reports – Centers for Disease Control and … (n.d.). Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr-69-11-508.pdf
 Richtel, M. (2021, December 7). Surgeon general warns of Youth Mental Health Crisis. The New York Times. Retrieved from https://www.nytimes.com/2021/12/07/science/pandemic-adolescents-depression-anxiety.html
 Protecting youth mental health – hhs.gov. (n.d.). Retrieved from https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf
 Sheryl H. Kataoka, M.D., M.S.H.S., Lily Zhang, M.S., and Kenneth B. Wells, M.D., M.P.H. (2002). Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. The American Journal of Psychiatry: https://doi.org/10.1176/appi.ajp.159.9.1548
 Excellence in Mental Health Act. (2013, February 7). http://www.congress.gov/