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Blog

Advancing health equity and integrated care for rural dual eligibles

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This week, our In Focus section highlights the Health Affairs article, Advancing Health Equity and Integrated Care for Rural Dual Eligibles, authored by  Ellen Breslin, Samantha Di Paola, Susan McGeehan, Rebecca Kellenberg, and Andrea Maresca, Health Management Associates.

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.

Link to Health Affairs article.

Blog

HMA consultants pen Health Affairs blog post, “Advancing Health Equity And Integrated Care For Rural Dual Eligibles”

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HMA Consultants Ellen Breslin, Samantha Di PaolaSusan McGeehanRebecca Kellenberg, and Andrea Maresca recently wrote the Health Affairs blog post, “Advancing Health Equity And Integrated Care For Rural Dual Eligibles.”

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.

Read the full article here.

Blog

West Virginia releases RFP for foster children, youth in Medicaid Managed Care

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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.

Market

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.

Timeline

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.

Evaluation

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.

Mountain Health Promise RFP

Blog

SAMHSA releases CCBHC planning grants opportunity for states

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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[1]:

  • 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.[2] 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.

Should you have questions or want to learn more about HMA’s available support related to this and other CCBHC opportunities, contact Kristan McIntosh at [email protected].  


[1] https://www.thenationalcouncil.org/wp-content/uploads/2022/06/22.06.06_HillDayAtHome_CCBHC_FactSheets.pdf

[2] https://www.congress.gov/117/plaws/publ159/PLAW-117publ159.pdf

Blog

HMA identifies key trends for emerging Medicaid Section 1115 demonstration proposals

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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:

  1. Addressing health inequities
  2. Improving access and coverage
  3. 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 earlier In 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.

Conclusion

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.

Blog

New Mexico releases Medicaid Managed Care RFP

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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.

RFP

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
    • Justice-involved individuals

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).

Eligibility

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.

Timeline

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.

Current Market

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.

Evaluation

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.

New Mexico Turquoise Care RFP

Blog

Funding and strategies to address the youth behavioral health crisis

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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[1]. 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%[2].

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.[3] 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.[4]

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[5] 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.

Multi-Tiered System of Supports (MTSS) framework

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[6], and it successfully engages young people[7].

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[8].

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:

Heidi Arthur, Principal [email protected]

Michael Butler, Principal [email protected]

You can also contact DBT in Schools, LLC for information about DBT-STEPS-A [email protected].


[1] 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

[2] 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

[3] Protecting youth mental health – hhs.gov. (n.d.). Retrieved from https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

[4] 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

[5] Excellence in Mental Health Act. (2013, February 7). http://www.congress.gov/

[6] McCauley E, Berk MS, Asarnow JR, et al. Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA Psychiatry. 2018;75(8):777–785. doi:10.1001/jamapsychiatry.2018.1109 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2685324#:~:text=Given%20its%20effectiveness%20with%20adults,suicidal%20youths%20with%20promising%20results.&text=A%20recent%20RCT%20with%20self,1%2Dyear%20follow%2Dup.

[7] Rathus, Jill H. ( 2014). DBT skills manual for adolescents. New York :The Guilford Press,

[8] Elizabeth T. Dexter-Mazza, James J. Mazza, Alec L. Miller, Kelly Graling, Elizabeth Courtney-Seidler, and Dawn Cattuchi (2022). Application of DBT in a School-Based Setting. Pending publication

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HMA perspectives on the 2022 federal policy landscape

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This week, our In Focus section looks at the current federal policy landscape and trends and the legislative outlook for the remainder of 2022 and beyond. Experts from HMA continue to monitor developments in this area and provide additional updates as more information becomes available.

Legislative Branch

To date in 2022, Congress passed multiple comprehensive bills, including the Inflation Reduction Act (IRA), which was signed by President Biden on August 16, 2022. The IRA extends Exchange plan premium tax subsidies through 2025, institutes an out-of-pocket drug spending cap for Medicare beneficiaries, expands Medicare, Medicaid, and CHIP coverage protections for certain vaccines, allows Medicare to negotiate drug prices, and implements a penalty payment in the Medicare program for prescription drug prices that rise faster than the rate of inflation.

Going forward, stakeholders have an extensive list of immediate Medicare payment issues for Congress to tackle while lawmakers continue to consider fundamental reforms to the program. Priorities include mitigating Medicare payment reductions scheduled for 2023; providing relief to address inflationary cost pressures; extending the 5 percent bonus for physicians participating in Advanced Alternative Payment Models (APMs), which expires at the end of 2022 for Accountable Care Organizations (ACOs); and permanently expanding telehealth access and payment policies after the federal COVID-19 public health emergency (PHE) declaration expires. Many stakeholder groups are also urging the Senate to act on the House-approved legislation, Improving Seniors Timely Access to Care Act (H.R. 3173), to reform Medicare Advantage prior authorization policies.

Congress did not include major Medicaid proposals in the Inflation Reduction Act. Medicaid stakeholders want Congress to revisit certain Medicaid policies in one of the remaining legislative vehicles this year. Significant proposals of interest include closing the Medicaid coverage gap in non-expansion states, enhanced coverage for justice involved populations, and expanding support for home and community-based services (HCBS). States and some stakeholders have also sought more certainty in the timing and guardrails for ending the COVID-19 Public Health Emergency (PHE) policy that links enhanced federal Medicaid funding with the requirement for continuous Medicaid coverage.

Congressional leaders and key influencers are laying the groundwork for 2023 legislative efforts. Congress is likely to defer action on most major legislative issues until after the November mid-terms, including finalizing federal fiscal year 2023 funding for most departments. A change in control of either or both chambers of Congress will likely lead to greater scrutiny of the Biden Administration’s health care policies and actions, which have largely gone untested by this Congress.

Executive Branch

Executive orders have been a major source in driving federal workstreams in 2022. Following enactment of several major bills, implementation responsibilities have shifted to the Executive Branch and stakeholders will have multiple opportunities to further shape and support new programs, regulatory and policy updates, and funding opportunities. Executive orders passed include:

  • Advancing Racial Equity and Support for Underserved Communities, January 21, 2021
  • Promoting Competition in the American Economy, July 9, 2021
  • Improving the Customer Experience, December 13, 2021
  • Access to Affordable, Quality Health Coverage, April 5, 2022
  • Equality for LGBTQI Individuals, June 15, 2022
  • Protecting Access to Reproductive Healthcare Services, July 8, 2022

The Administration will continue to address COVID-19 emergency needs while stepping up efforts to support states, health plans, providers and other stakeholders as they prepare for the post-COVID environment. The current PHE declaration expires October 13, 2022, but since HHS has not signaled that it plans to end the PHE in October, another extension is likely until January 11, 2023. The next advance notification about the end of the PHE would be Nov. 12, 2022. Once the PHE declaration expires, numerous Medicare and Medicaid, TANF, and SNAP flexibilities will end, including Medicaid’s continuous coverage requirement and certain telehealth flexibilities, among others. Additional federal agency guidance is expected to support post-PHE transitions.

The Centers for Medicare & Medicaid Services (CMS) plans to advance new policy direction across several service and delivery areas, including strengthening long-term services and support and innovations via Section 1115 demonstration programs. CMS is expected to approve transformational 1115 proposals in additional states. Several state proposals focus, in part, on building capacity among local and regional entities and community-based organizations to address social drivers of health. Many state proposals are also strengthening behavioral health delivery systems and seek to meet enrollees’ urgent behavioral health needs. Additionally will want to monitor CMS’ regulatory efforts to align and strengthen managed care and fee-for-service (FFS) access and network adequacy policies as well as updates to the agency’s in lieu of services policy in managed care programs.

The Administration is also expected to accelerate work on its top policy priorities and regulatory agenda in advance of the next Presidential election, and this will require ongoing engagement among health care stakeholders.

For additional information on these and other policies, please contact Andrea MarescaAmy BassanoZach GaumerJon Kromm, or Kevin Kirby.

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The basics of evaluating PBM contracts

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This week, our In Focus section highlights an issue brief from Wakely, an HMA Company, The Basics of Evaluating PBM Contracts, published September 2022. The brief provides an overview of the basic financial elements of a pharmacy benefit manager (PBM) contract. Evaluation of a traditional request for proposals (RFP) or PBM contract should begin with financial analysis of the following four key elements: discount guarantees (typically understood as point-of-sale ingredient costs), dispensing fees, rebate guarantees, and PBM administrative fees. This paper addresses various points of consideration when attempting a financial analysis of these contract elements.

Payors today face unprecedented degrees of complexity when conducting a PBM RFP or evaluating PBM contracts. To stay competitive, payors must navigate an ambiguous and changing pricing environment. That requires a solid understanding of PBM contracting. In a proposal, some PBMs may offer better AWP discounts while other PBMs offer better rebate guarantees. Alternatively, a payor may find a PBM that offers the best discounts and rebates but charges significantly higher administrative fees. Such analysis will consider the impacts of these key components together with historical and projected drug mix. While any PBM analysis must start with the elements discussed in this paper, a complete analysis must dive below the surface and into the fine print underlying these items.

Link to Issue Brief

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Delaware substance use disorder treatment system needs assessment

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This week, our In Focus highlights a Health Management Associates Institute on Addiction (HMA IOA) report, Delaware Substance Use Disorder Treatment System Needs Assessment, published in June 2022. HMA IOA conducted a statewide three-county substance use disorder (SUD) treatment system needs assessment in Delaware. This project began in November 2021 and was primarily funded by New Castle County with contributions from Kent and Sussex counties. The goal was to review the current state of the SUD treatment ecosystem, identify strengths and gaps collecting input from as many Delawareans across multiple sectors as possible, and make actionable recommendations to build a more robust and sustainable future state system.

The final analysis included interviews with key stakeholders, focus groups, a survey of all licensed SUD providers, claims data analysis, and a comparison of Delaware’s public (e.g., Medicaid) outpatient and residential SUD reimbursement rates with selected regional states. This approach provided a unique cross-sector view of where the most significant opportunities for improvement and investment may rest.

The areas of greatest experienced need in the system were reported as: inadequate treatment beds, especially for some populations, like children and youth; lack of residential services for adults, especially those on Medicare and without insurance; needed supports for those experiencing negative impacts from social determinants of health (SDOH), like transportation and housing needs; lack of consistent access and care coordination; lack of adequate reimbursement to sustain the system or expand the treatment system; the need for trauma-informed care (TIC); and the need for more harm reduction and prevention strategies, including greater access specifically to Narcan 4mg Nasal Spray or its generic equivalent.

The study found that Delaware is meeting only 15 percent of SUD treatment needs and only meeting five percent of the need for the highest-intensity services, including inpatient treatment.

The results also showed an apparent discrepancy between what the state is working hard to implement to address the SUD and overdose crisis in Delaware and the community’s perception of, or lived experience with, those SUD treatment services and supports. Additionally, HMA IOA heard about many treatment system strengths from interviewees, town hall participants, and focus groups and included recommendations that are meant to leverage those existing strengths in the future treatment system.

Click here to read the report.

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How can Medicare and Medicaid providers utilize CMS’ COVID-19 roadmap?

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On August 18, 2022, the Centers for Medicare and Medicaid Services (CMS) released a roadmap to support healthcare providers with preparing for the eventual end of the COVID-19 public health emergency (PHE) declaration. CMS also published a series of fact sheets summarizing the status of Medicare Blanket waivers and flexibilities by provider type as well as flexibilities applicable to the Medicaid providers and stakeholders.

In its announcement, CMS expressed concern that the continued PHE flexibilities could contribute to further decline in patient, resident, and client safety beyond what has already been observed. As a result, the agency is cautiously working to balance ongoing PHE needs while conveying more urgency for providers to prepare for the eventual end of the PHE flexibilities and waivers.

CMS has already ended certain flexibilities and waivers. The agency could phase out other flexibilities as it prepares to let the PHE declaration lapse. This means that providers and health plans should act now to assess flexibilities and waivers in use and develop a plan to transition to post-PHE environment.

Phase-out of COVID-19 Flexibilities

During the COVID-19 PHE, CMS has utilized Medicare and Medicaid waivers and flexibilities extensively. For example, Medicare has not enforced certain federal requirements during this time to allow hospitals to utilize off-site locations to screen and treat patients when needed as well as to minimize certain reporting requirements. The agency’s flexibilities also have accelerated adoption of telehealth and audio only services, particularly for behavioral health services.

Medicare and Medicaid providers across the states utilized PHE flexibilities to varying degrees, in part depending on experiences in individual communities, capacity, and other provider specific factors. Additionally, over the course of the PHE health plan and provider staffing and workflows have changed dramatically. This means health plans and providers will need a tailored plan to support the transition to the post PHE environment.

HMA’s experts are working with hospitals, health systems, clinics, and other providers as well as health plans on the steps they need to take now to prepare for multiple transitions. Our experts identified six immediate steps that Medicare and Medicaid plans and providers can be undertaking now to ensure they can effectively return to normal operations, including:  

  • Review performance on the patient and clinician safety metrics cited in the new CMS resources. In instances where providers have gaps and suboptimal safety and quality outcomes they will need assistance developing and implementing mitigation and quality improvement plans.
  • Utilize CMS’ tailored fact sheets to identify specific flexibilities and waivers in use now and the “normal” federal regulations that will be in effect once the PHE lapses. This assessment should include the blanket waivers and provider specific flexibilities, including:
    • Flexibilities around the requirements and timing for practitioner training
    • Expansion of allowable sites of service that permitted more expansive use of telehealth and virtual services as well as screening and treatment provided at alternative sites
    • Relaxation of federal requirements pertaining to surge capacity protocols
    • Flexibilities for staffing requirements, including medical records departments, nursing facilities, among others
    • Waiver of requirement for hospitals to submit occupational mix surveys and to have a utilization review plan with a UR committee focused on services furnished to Medicare and Medicaid enrollees
    • Applicable of the Extreme and Uncontrollable Circumstances Policy in Medicare’s Shared Savings Program and use of other flexibilities for MSSP Accountable Care Organizations (ACOs)
    • Non enforcement of certain physician self-referral laws
    • Waiver of numerous reporting requirements including those pertaining to verbal orders, discharge planning, HEDIS and STARs measure reporting, among others
  • Project impact of ending Medicaid’s continuous coverage policy and support individuals with actions they may need to take at the end of the PHE. Once the PHE ends, Medicaid’s enhanced federal funding for states and continuous coverage policy will end. HMA is working with health plans, providers and other stakeholders to project how this change will impact the enrollment and payer mix on state and local levels. Additionally, patients and their caregivers will need support from plans, providers, and consumer groups to ensure they renew their coverage or transition to other coverage programs when needed.HMA’s experts have written extensively about our work to support the Medicaid unwinding activities here and here.
  • Develop a plan to transition from “PHE” to “post-PHE” expectations that is informed by the assessment of flexibilities in use. Key components of the plan include:
    • Anticipated resource needs to reflect changes in staffing and workflows during the PHE
    • Articulation of specific compliance procedures and regular reporting requirements that will resume and the process for this transition
    • Develop training and education opportunities for staff that may be new or need refresher on normal policies and procedures as well as timeframes for making these changes
  • Update budgets projections to account for changes in reimbursement rates for certain services post-PHE. Certain reimbursement amounts and payment methodologies will change post-PHE, such as payment for administering the COVID-19 vaccine in a Medicare patient’s home among other changes. Providers will need to project the financial impact of these payment changes and update coding and billing manuals and procedures where applicable.
  • Build strategies to sustain changes to care models implemented during the COVID-19 PHE while also addressing health disparities. Some providers and facilities adopted care models and modified existing ones during the PHE that may have improved patient outcomes and experiences, maximized expertise of practitioners, and improved value-based care. For example, some providers have embraced the Medicare Hospital Without Walls Initiative and will need to assess their options as some of those flexibilities are phased out. Other federal opportunities have newly emerged during the pandemic, such as the Rural Emergency Hospital designation and pending changes to the Medicare Shared Savings Program (MSSP).

What’s Next

The COVID-19 PHE declaration next expires on October 12, 2022. While a renewal of the PHE declaration is possible into early 2023, providers should be using this time to prepare for resumption of normal policies and procedures.

The expiration of PHE flexibilities and waivers are not, however, happening in a vacuum. Providers need to make this transition amidst a dynamic healthcare sector with high expectations for continuous improvement in quality, patient experiences, and value. During this transitional period HMA’s experts are working with health plans and providers to develop or revisit strategic plans and investments to refocus attention on improving models of care and value-based payment approaches, including strategies that will help mitigate health disparities.

For questions, please contact Melinda Estep, Mary Walter, and Andrea Maresca.

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Medicaid managed care spending tops $420 billion in 2021

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This week, our In Focus section reviews preliminary 2021 Medicaid spending data collected in the annual CMS-64 Medicaid expenditure report. After submitting a Freedom of Information Act request to the Centers for Medicare & Medicaid Services (CMS), HMA received a draft version of the CMS-64 report that is based on preliminary estimates of Medicaid spending by state for federal fiscal year (FFY) 2021. Based on the preliminary estimates, Medicaid expenditures on medical services across all 50 states and six territories in FFY 2021 was nearly $710.2 billion, with over 59 percent of the total now flowing through Medicaid managed care programs. In addition, total Medicaid spending on administrative services was $30.8 billion, bringing total program expenditures to $741 billion.

Total Medicaid Managed Care Spending

Total Medicaid managed care spending (including the federal and state share) in FFY 2021 across all 50 states and six territories was $420.5 billion, up from $359.6 billion in FFY 2020. This figure includes spending on comprehensive risk-based managed care programs as well as prepaid inpatient health plans (PIHPs) and prepaid ambulatory health plans (PAHPs). PIHPs and PAHPs refer to prepaid health plans that provide only certain services, such as dental services or behavioral health care. Fee-based programs such as primary care case management (PCCM) models are not counted in this total. Below we highlight some key observations:

  • Total Medicaid managed care spending grew 16.9 percent in FFY 2021. The rate of growth has been increasing since the COVID-19 pandemic. Prior to 2020, the rate had decelerated since FFY 2016.
  • Managed care spending growth was due in large part to the COVID-19 pandemic and the resulting higher Medicaid enrollment.
  • In terms of dollars, the increase in Medicaid managed care spending from FFY 2020 to FFY 2021 was $60.9 billion, compared to $46.1 billion from FFY 2019 to FFY 2020.
  • Medicaid managed care spending has increased at a compounded annual growth rate (CAGR) of 16.1 percent since FFY 2007, compared to a 6.6 percent growth in total Medicaid spending.
  • Compared to FFY 2020, Medicaid managed care spending as a percent of total Medicaid spending in FFY 2021 increased by 3.8 percentage points to 59.2 percent.

Figure 1: Medicaid MCO Expenditures as a Percentage of Total Medicaid Expenditures FFY 2007-2021 ($M)

As the table below indicates, 69.4 percent of FFY 2021 spending came from federal sources, which is 12 percentage points higher than the pre-Medicaid expansion share in FFY 2013, and 1.8 percentage points higher than FFY 2020.

Figure 2: Federal vs. States Share of Medicaid Expenditures, FFY 2013-2021 ($M)

State-specific Growth Trends

Forty-five states and territories report managed care organization (MCO) spending on the CMS-64 report, including Alaska, which utilizes a PIHP/PAHP model exclusively. Oklahoma is expected to implement a Medicaid managed care program in 2023. Of the remaining 44 states and territories that contract with risk-based MCOs, average MCO spending in FFY 2021 increased 17.6 percent. On a percentage basis, North Carolina experienced the highest year-over-year growth in Medicaid managed care spending at 63.3 percent due to the implementation of its risk-based Medicaid managed care program. Among states with more mature programs, Colorado experienced the fastest growth in FFY 2021 at 59 percent, followed by Nebraska at 55.6 percent.

The chart below provides additional detail on Medicaid managed care spending growth in states with risk-based managed care programs in FFY 2021.

Figure 3: Medicaid Managed Care Spending Growth on a Percentage Basis by State FFY 2020-21

Source: CMS-64; *Note: Not all states are included in the table.

Looking at year-over-year spending growth in dollar terms, Illinois experienced the largest increase in Medicaid managed care spending at $5.5 billion. Other states with significant year-over-year spending increases in dollar terms included Texas ($5.2 billion), California ($5.2 billion), and New York ($5.1 billion). The chart below illustrates the year over year change in spending across the states.

Figure 4: Medicaid Managed Care Spending Growth on a Dollar Basis by State FFY 2020-21 ($M)

Source: CMS-64; *Note: Not all states are included in the table.

The percentage of Medicaid expenditures directed through risk-based Medicaid MCOs increased by more than  five percentage points in 14 states from FFY 2020 to FFY 2021. The managed care spending penetration rate rose 13.4 percentage points in the District of Columbia, 9.7 percentage points in Indiana, 9.5 percentage points in Nebraska, 9.2 percentage points in North Carolina, and 9.1 percentage points in Illinois.

Figure 5: Medicaid MCO Expenditures as a Percentage of Total Medicaid Expenditures in States with a 5 percent or Greater Increase from FFY 2020 to FFY 2021 ($M)

Source: CMS-64

The table below ranks the states and territories by the percentage of total Medicaid spending through Medicaid MCOs. Iowa reported the highest percentage at 97.2 percent, followed by Puerto Rico at 95 percent, and Hawaii at 94.4 percent.

We note that in many states, there are certain payment mechanisms which may never be directed through managed care, such as supplemental funding sources for institutional providers and spending on retroactively eligible beneficiaries. As a result, the maximum achievable penetration rate in each state will vary and may be below that achieved in other states. The Medicaid managed care spending penetration rate is greatly influenced by the degree to which states have implemented managed long-term services and supports (MLTSS) programs.

Figure 6: Medicaid MCO Expenditures as a Percent of Total Medicaid Expenditures, FFY 2016-2021

Non-MCO Expenditures

Despite the rapid growth in Medicaid managed care over the last 10 years, program spending still represented approximately 59 percent of total Medicaid expenditures in FFY 2021. So where is the remaining fee-for-service (FFS) spending (approximately $291 billion) going? First, as noted above, there are many states/territories with Medicaid managed care programs in which certain beneficiaries or services are carved-out of the program, and these are typically associated with high-cost populations. The total amount of non-MCO spending in the 44 states with risk-based managed care in FFY 2021 was $260.4 billion. Assuming an average “full penetration” of 85 percent of total Medicaid spending, then HMA estimates that an additional $221 billion in current FFS spending could shift to a managed care model just in the states that already employ managed care for a subset of services and/or beneficiaries.

Thirteen states/territories did not utilize a comprehensive risk-based managed care model in FFY 2020. In general, the 13 states/territories that do not utilize managed care today are smaller states. Oklahoma, with $5.3 billion in Medicaid spending is expected to shift to risk-based Medicaid managed care in 2023. Total Medicaid spending across all 13 non-managed care states/territories was $29.8 billion. The 13 states/territories that did not employ a risk-based comprehensive Medicaid managed care model in FFY 2021 were Alabama, Alaska, American Samoa, Connecticut, Guam, Maine, Montana, Northern Mariana Islands, Oklahoma, South Dakota, Vermont, Virgin Islands, and Wyoming.

In terms of spending by service line, the largest remaining FFS category is home and community-based services at $69.5 billion, which accounts for 24 percent of FFS spending. Inpatient hospital services represent 21 percent of FFS spending at $60.8 billion.

Figure 7: Fee-for-Service Medicaid Expenditures by Service Line, FFY 2021

While the CMS-64 report provides valuable detail by service line for all FFS expenditures, it does not capture how spending directed to Medicaid MCOs is allocated by category of service. Therefore, it is not possible to calculate total MCO spending by service line, a challenge that will only intensify as more spending runs through MCOs.