HMA Insights: Your source for healthcare news, ideas and analysis.

HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

Show All | Podcast | Blogs | Webinars | Weekly Roundup | Videos | Case Studies | Reports | News | Solutions

Filter by topic:

Receive timely expert insights on topics you care about.

Select Topics

1852 Results found.


HMA, Wakely, The Focus Group Consultants Available for Meetings at the JPM Healthcare Conference in January 2024

Read Blog

Health Management Associates consultants, including colleagues from Wakely and The Focus Group, will be attending the JP Morgan Healthcare Investor conference in San Francisco, January 8-10, 2024. In addition to meeting with clients, HMA will be cosponsoring a reception with Shepherd Mullin as well as participating on a panel hosted by KPMG.

“While we’ve acclimated to a more virtual business world, the JP Morgan conference represents a unique opportunity to get together in person with valued clients and partners to discuss healthcare policy dynamics, emerging investment themes, and the exciting capabilities HMA has added over the last year to support its investment clients,” said Greg Nersessian, Managing Director of HMA Investment Services. “Rain or shine, we look forward to getting together and learning more about the trends that will shape healthcare investing in 2024.”

Tim Murray, a former JPM analyst, and now a Principal and healthcare actuary at Wakely Consulting Group, an HMA Company, says “The one inalienable truth about JPM’s annual event is that it sets the stage and tone for health care investing in the upcoming year…I’ll be focused intensely on how investors see the myriad headwinds facing government-sponsored healthcare programs playing out in ’24…they will surely inhibit growth but may also set the stage for opportunistic deal flow.”

The Focus Group is a strategic consulting firm working on business transformation in healthcare and private equity portfolios, acquired by HMA in late 2021. Its Managing Director Alex Rich added “our team is eager to reflect on recent deals and provide perspectives on new theses. Based on our wide array of recent projects and experiences, we’re excited to share and prepare creative strategies for portfolio value creation in the year ahead.”

Also in attendance will be the following HMA consultants:

To set up a meeting with any of our team, please click here. For further information on HMA Investment Services, please contact Greg Nersessian.


Medicaid Business Transformation DC: recommendations for technical assistance

Read Blog

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

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

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

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

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

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

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


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

Read Blog

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

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

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

Model Overview

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

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

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

The Model will have two phases for participating SMAs:

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

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

TMaH Opportunities and Considerations

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

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

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

What’s next?

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

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


Opportunities for local and regional managed care organizations with justice-involved services

Read Blog

Previously, HMA developed a comprehensive series of webinars reviewing the potential for using 1115 waivers to expand and improve health care services for the justice-involved population. With California becoming the first state earlier in 2023 to receive approval for the authority to provide a specific set of Medicaid services for up to 90 days in advance of release to youth and adults in state prisons, county jails, and youth correctional facilities, and many other states with pending waivers of a similar type, this blog post considers the implications of this emerging policy trend for local and regional managed care organizations (MCOs) in 2024.

The Opportunity

Delivering Medicaid services through MCOs has become the dominant strategy employed by states with 41 states (including the District of Columbia) using managed care for at least certain Medicaid populations. Local and regional MCOs represent a key component in this landscape across the country and often are deeply rooted in the states and communities they serve because of their specific focus on a single or limited number of markets.

With the precedent now in place for federal authority (and federal financial participation) to provide services such as reentry case management, behavioral health and physical health consultation services (in-person or via telehealth), laboratory and radiology services, medications as well as medication administration, medication assisted therapy inclusive of counseling, and community health worker services, states have a clear pathway toward pursuing the ability to provide services for the justice-involved population prior to release. Among the many important implementation questions states will need to consider as they continue to pursue the authority to provide these services is how the specific services will be delivered and financed. Given the dominance of Medicaid managed care, states will have to grapple with how MCOs can be leveraged to support a successful implementation of the delivery of services to the justice-involved population. The strong community presence of local and regional MCOs within the Medicaid managed care ecosystem makes these MCOs important entities for states to consider. Local and regional MCOs should consider what role they believe they can play as partners to states in these initiatives to serve justice-involved populations as successfully as they have served other Medicaid populations.

While the opportunities for local and regional MCOs will evolve over time, initial opportunities to contemplate are as follows:

  1. Serving as a Thought Partner: There is already significant interest across states in pursuing the ability to deliver services in advance of release but local and regional MCOs can support state officials looking to develop in greater detail the most viable path forward to do so. Local and regional MCOs can be well positioned serve as thought partners to states by educating themselves about California’s 1115 waiver approval and engaging state officials in their markets as partners to think through how the approach taken by California can be adapted to a given state’s goals and environment.
  2. Serving as the Lead Case Manager: Providing reentry case management to coordinate the reentry process for the justice-involved population is likely to be a key service in any service array from this population. To ensure the complex coordination related to this process occurs successfully across multiple organizations, local and regional MCOs can explore working with states to serve as the lead entity for case management as individuals are enrolled (or reenrolled) in managed care.
  3. Facilitating Enrollment Continuity and Continuity of Care: The process for transitioning to Medicaid coverage and care after these have been interrupted as a result of incarceration can be daunting for both the justice-involved population and well as state administrators and providers. Local and regional MCOs can play an intervening role here to provide support to all parties involved to produce a result where the enrollment process is as seamless as possible and critical care delivery is maintained specific to an individual’s health and social needs.
  4. Providing Infrastructure Funding: In partnership with states, local and regional MCOs can infrastructure funding to build capacity to support many of these entities who will be involved with the reentry process. Such entities can include, for example, behavioral health providers, community-based organizations, primary care providers, and social service providers. The type of capacity needed will likely include data sharing, technology changes, and workforce development.
  5. Providing Technical Assistance: In addition to supporting capacity-building, local and regional MCOs can provide technical assistance to entities involved with the reentry process. Complex operational, policy, and technology issues will arise during the reentry process that are specific to a given entity. Local and regional MCOs, because of their focused knowledge and experience in specific markets, are well positioned to provide expertise and guidance on issues ranging from care management to claims submission.

What’s Next?

As more states with pending 1115 waivers for reentry services for the justice-involved population gain approval, local and regional MCOs should anticipate engagement from states on planning and implementation in in 2024. Given this, taking action early to engage state partners and prepare your organization to serve this population is a prudent step to consider now.

For More Information

If you have questions about how HMA can support your efforts related to the Medicaid services for justice-involved populations and local and regional MCOs, please contact Michael Engelhard, managing director, Linda Follenweider, managing director, or Patrick Tigue, managing director.

HMA News

Fueling Change: Reflecting on a Year of Successful Collaboration

Read News

While 2023 was challenging for many, it was also a year of successful partnerships and action that fueled positive change in the lives of individuals and within communities nationwide. This short video highlights just a few examples of that critical work that happens every day.

At HMA, we are honored to serve as trusted advisors to our clients and partners as we work side by side to tackle the most complex health and human services challenges. We look forward to creating even more positive change in 2024, together.


Future-Ready: Is Your MCO Equipped for Change?

Read Blog

Government Funded Programs and Readiness

As a local or regional managed care organization (LRMCO), being “ready” means proactively addressing all the areas where your organization can get tripped up, or worse, lose your contract with a state Medicaid agency. LRMCOs are heavily reliant upon government funded programs. These include Medicaid, Medicare, and Marketplace business. Most LRMCOs are not as heavily involved in the commercial market, either on a fully insured or self-insured basis, and even when they are, these areas comprise smaller parts of their overall product offerings. National MCOs have looked to Medicaid managed care to fuel growth, strengthen relationships with government partners, and leverage infrastructure.

In any government program, “readiness” is a critical capability that often gets overlooked due to the daily pressures of running the organization. It’s often said that “you should always be audit ready.” The meaning of this is that you and your organization should always be prepared to undergo an outside audit from your regulator, financial auditor, or other entity such as the National Committee for Quality Assurance. Having a well-run organization allows you to not only be ready to respond to regulators or auditors but also to be able to demonstrate stable financial, operational, and compliance performance.  Having this stable base of performance allows for more meaningful strategic planning, innovation, and state and federal partnership.

In Medicaid and other government programs, where public purchasers follow stringent purchasing rules, perhaps another way to think of your MCO’s operations is to always be “procurement ready.” But what does it mean to be “procurement ready” for your MCO? Today, managed care is the primary Medicaid delivery system vehicle for most states across the country. While some states procure all Medicaid managed care services in single, comprehensive contracts, many states procure for services via specific programs. Managed long-term services and supports, behavioral health, dental, and other programs are examples of specific programs that states procure alongside those that states have procured historically including low-income children and their parents, pregnant women, people with disabilities, people aged 65 and older, and, with advent of the Affordable Care Act, low-income adults without dependent children. State Medicaid managed care contracts are typically three to five years in duration, often with single or multiple year optional extensions. What this means is that in any given year there are approximately 10 Medicaid managed care program procurements. Moreover, these procurements are now among the largest contracts awarded by states, often exceeding billions of dollars per year. As a result, the importance of being ready for these events has grown substantially over the years.

Being “Ready” Means Being Prepared and Planning in Advance

A critical element of being “procurement ready” is not to rely upon fixing issues when a Medicaid request for proposal (RFP) appears likely; it is to be on top of requirements on an ongoing basis, address issues quickly, and capture success stories as they happen. Too often, LRMCOs don’t look to begin this process until it is too late—a small issue has become a big problem and remediation is expensive, time-consuming, and painful. Even the best proposal will struggle to win in the face of a record of real or perceived suboptimal performance.

The reality is that states are asking for MCO results (Healthcare Effectiveness Data and Information Set scores, state audit findings, Health Insurance Portability and Accountability Act breaches, etc.) as part of RFPs. These data points are hard to hide even with great writing and presentation. States are also more frequently including member or case “scenarios” in RFPs, which are specific in nature and are designed to have the MCO describe exact steps, processes, and outcomes. It is therefore important to monitor and measure for performance year-round.

For incumbent LRMCOs, the best way to maximize your chances of winning a renewal is to deliver effectively—and to be seen as delivering effectively—on your existing contract. A well performing incumbent LRMCO has tremendous advantages because:

  1. Switching vendors is risky and painful for states, even under the best of circumstances.
  2. Competitors are less likely to bid when they know the incumbent is well-regarded by the state.
  3. The key to delivering effectively is continuous assessment and adjustment, so LRMCOs identify potential issues early and can address them before they mushroom into bigger problems.

The time to begin preparing for your next procurement is while you begin to deliver under the existing procurement, not three months before a new procurement.

Best practice is to begin RFP planning 18 months to 24 months in advance of the anticipated issuance date. That planning should include developing “win strategies,” competitive assessments, and proposal logistics. Putting remediation initiatives on top of these areas adds unnecessary stress and strain on the LRMCO and the teams responsible for delivering a winning proposal. Therefore, being “procurement ready” is an important and often critical element in ultimately preparing winning proposals.

States look for “partners” not just contractors. LRMCOs can serve as invaluable thought partners to help inform how states can meet their stated policy aims. This not only puts LRMCOs in good standing with state leaders, but it also means they are well informed about state thinking so they won’t be caught by surprise if new requirements appear in the next RFP.

States frequently provide vague guidance on when RFPs will be released (“early next year,” “in the second quarter”, etc.) Some states have published concrete schedules for their multiple RFPs, but this is the exception. The implication for LRMCOs is that it is very difficult to “time” when to get your operations optimally ready for a forthcoming RFP. A wiser approach is to always be ready for an RFP to drop (again, like being audit ready). Some operational, performance, or compliance issues can be addressed in fairly short time frames. Other areas, such as quality reporting, require about a two-year lead time to fix any problems, gather the data, and exhibit optimal performance due to data/reporting lag. Other areas that require longer lead times are claims, encounter data reporting, risk adjustment, delegation oversight, and many others. Due to the lead times required, to be always “procurement ready,” LRMCOs need to have robust operational readiness and monitoring programs established as part of daily operations.

Strategies for Achieving and Maintaining Audit Readiness and Contract Compliance

As noted earlier, strong performance on audits and a consistent record of impressive compliance is an advantage when participating in RFP processes. States prefer to contract with MCOs that have a robust track record of compliance and can persuasively demonstrate their ability to consistently meet the needs of members. Strategies that LRMCOs can employ to develop such a track record include:

  1. Develop Robust Compliance Programs: LRMCOs should establish comprehensive compliance programs that include policies and procedures, training, monitoring, and auditing. These programs should address all aspects of contract compliance and the specific requirements of the state’s program.
  2. Internal Controls and Documentation: LRMCOs should implement internal controls to monitor and measure contract compliance regularly. In addition, organizations should maintain thorough documentation of all activities, decisions, and communication. This documentation serves as evidence during audits and demonstrates a commitment to compliance.
  3. Regular Audits and Self-Assessments: LRMCOs should conduct regular self-assessments and internal audits to identify and rectify potential compliance issues before external audits occur. This proactive approach helps mitigate risks and ensures continuous improvement.
  4. Data Management and Reporting: LRMCOs should develop robust data management systems to collect, store, and report the necessary data. Accurate and timely reporting is essential for demonstrating compliance with performance measures and outcomes.
  5. Staff Training and Awareness: LRMCOs should ensure that staff members are well-trained and aware of their roles in maintaining contract compliance. Regular training sessions can keep employees updated on changing regulations and requirements.
  6. External Auditors and Consultants: LRMCOs should consider engaging external auditors and consultants with expertise in compliance to conduct independent reviews and provide recommendations for improvement.
  7. Continuous Quality Improvement: LRMCOs should implement continuous quality improvement processes to enhance the quality of care delivered to members. This demonstrates a commitment to improving health outcomes and can positively influence contract awards.

The Value of a Proactive Approach

To be continuously “procurement ready,” LRMCOs must be forward-thinking and adaptive. Embracing change, data-driven decision making, quality improvement, building strong provider networks, investing in technology, engaging stakeholders, and maintaining financial stability are all essential steps to ensure the sustainability and success of these organizations in the intervening years between state-issued RFPs. By taking a proactive approach to addressing these needs, LRMCOs can position themselves as leaders in providing high-quality health care services for the members they serve.

For More Information

If you have questions about how HMA can support your efforts to be ready, please contact Michael Engelhard, Managing Director or Patrick Tigue, Managing Director.


The role of specialized managed care in addressing the intersection of child welfare reform and behavioral health transformation

Read Blog

This week, our In Focus section highlights the efforts of Health Management Associates (HMA) and partner organizations to better coordinate services for children in foster care and for children with behavioral health needs.

First, HMA released an issue brief on November 6, 2023, as part of a partnership between HMA and the National Association of State Mental Health Program Directors (NASMHPD) Technical Assistance Coalition. Together HMA and NASMHPD experts wrote a series of five briefs on children’s behavioral health.

The brief released last month, “The Role of Specialized Managed Care,” written by HMA experts Heidi Arthur and Angela Bergefurd, with input from Caitlin Thomas-Henkel and Uma Ahluwalia, centered on the intersection of child welfare reform and behavioral health transformation. More specifically, it described how specialized Medicaid managed care plans can ensure better alignment between child welfare and behavioral healthcare services.

The paper emphasizes the role of state-level special needs plans (SNPs) in the delivery of coordinated care and examines the opportunities afforded to states seeking to leverage specialty managed care plans.

Specialized managed care plans can help fill the void by incentivizing the provision of services for children in foster care and specialty services for children with behavioral health needs. Plans in three states — Washington, Arizona, and Ohio — are highlighted, and can serve as examples of how state Medicaid SNPs can be implemented.

Link to Issue Brief

This paper is part of a larger effort that HMA and several partner organizations are supporting. Stakeholders include:

  • The Annie E. Casey Foundation
  • Casey Family Programs
  • National Association of Medicaid Directors (NAMD)
  • Child Welfare League of America (CWLA)
  • Administration for Children and Families
  • Substance Abuse and Mental Health Services Administration

The goal of these collaborations is to foster dialog between state agencies and stakeholders working to improve the well-being of children and youth with complex needs.

Most recently, HMA hosted a webinar December 12, 2023, featuring speakers from the partner organizations to discuss insights from a federal meeting that took place in November. Webinar speakers also informed participants about plans for a multistate policy lab scheduled for February 2024, where representatives of up to eight state child welfare agencies will participate in a two-day workshop on improving the children’s behavioral health continuum of care in their states. The webinar focused on the overall effort and provided a forum for states to hear from this partnership on the importance of collaborating to strengthen the children’s behavioral health system. Watch the webinar here.

For questions about the brief, please contact Heidi Arthur or Angela Bergefurd. For questions about the webinar or the larger effort, please contact Caitlin Thomas-Henkel or Uma Ahluwalia.

HMA News

New experts join HMA in October 2023

Read News

HMA is pleased to welcome new experts to our family of companies in October 2023.

Anika Alvanzo- Principal

Dr. Anika Alvanzo is a distinguished healthcare executive with over 20 years of experience in specialty addiction treatment, behavioral health integration and quality improvement.

Kristine Malana Barrientos – Senior Consultant

Kristine Malana Barrientos brings expertise in the Program of All-inclusive Care for the Elderly (PACE) senior leadership and operational experience from her work in California’s PACE market.

Craig Cartossa – Consulting Actuary II

Craig Cartossa, ASA, MAAA, has expertise in Advanced Analytics, Healthcare Economics, Medicare Part D, Value Based Contracting, and Disease Management and Care Management Predictive Modeling and ID/Stratification. Read more about Craig.

Shannon Mayer – Principal

Shannon Mayer is an impactful healthcare executive with over 30 years of experience. She is recognized for attaining results in Medicaid and Medicare Advantage’s highly regulated environments.

Cotrina McGue – Senior Consultant

Cotrina McGue is a highly skilled information technology (IT) professional with over 35 years of experience and over 25 years specializing in healthcare systems.

Patricia Miles – Senior Consultant

Patricia Miles is a performance-driven managed care leader with over 25 years of experience in the Medicaid and Medicare markets.

Jason Pettry – Senior Consultant

Jason Pettry is a dedicated healthcare executive with over 10 years of experience with the Programs of All-Inclusive Care for the Elderly (PACE).

Corrie Piontak – Principal

Corrie Piontak is a skilled healthcare professional with over 15 years of focused experience in management consulting, payer and provider strategy, and partnership strategy.

Aaron Ramthun – Associate Principal

Aaron Ramthun is a financial professional with more than 20 years of experience working across the healthcare finance field, including Medicare bids, Medicaid rate book reviews, and budgeting. Aaron has a demonstrated track record of improving operational efficiency and implementing innovative forecasting practices.

Matt Smith – Consulting Actuary I

Matt Smith, ASA, has experience with population health analytics, total cost of care analysis, value-based care contracts, financial modeling, pricing and reserving, and risk adjustment. Read more about Matt.

Read more about our new HMA colleagues

Anika Alvanzo

Anika Alvanzo


Cotrina McGue

Cotrina McGue

Senior Consultant

Patricia Miles

Patricia Miles

Senior Consultant

Jason Pettry

Jason Pettry

Senior Consultant

Aaron Ramthun

Aaron Ramthun

Associate Principal


Massachusetts releases RFR for One Care and Senior Care Options

Read Blog

This week, our In Focus section reviews the request for responses (RFR) for the Massachusetts One Care and Senior Care Options (SCO) programs, released by the Massachusetts Executive Office of Health and Human Services (EOHHS) on November 30, 2023. The programs provide physical, behavioral, long-term services and supports (LTSS), and other community services to Medicare and Medicaid dual-eligible beneficiaries. Implementation is set to begin January 1, 2026.

One Care

One Care launched in 2013 as a Section 1115 Medicare-Medicaid Plan (MMP) program dual demonstration waiver. It operates under a financial alignment initiative (FAI) capitated model. The program provides integrated care to dual eligible adults ages 21 to 64. Individuals may remain enrolled in One Care when they turn 65 years old as long as they continue to meet all other requirements. Members can also access an independent LTSS coordinator.

As the Centers for Medicare & Medicaid Services (CMS) sunsets the FAI dual demonstrations, One Care will shift to a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) beginning in 2026, pending federal approval of the Section 1115 amendment request. Members will have exclusively aligned enrollment with the same plan for both Medicare and Medicaid coverage.


SCO launched in 2004 and is currently a FIDE SNP with exclusively aligned enrollment. Medicaid enrollees ages 65 and older with or without Medicare are eligible. Enrollment in this managed care program is voluntary. Individuals on the Frail Elder Waiver can only join SCO.


Massachusetts will award separate contracts for One Care and SCO but may prefer bids from plans seeking to operate both; however, plans may submit bids to operate one type of plan. The state seeks to offer both One Care and SCO coverage for eligible individuals in as many counties as possible, and ideally statewide. Plans must propose to cover people in at least six counties for each type of plan.

To be selected, plans will need to have a contract with CMS to operate a FIDE SNP in Massachusetts in 2026. Applications must be submitted to CMS by February 2025.


Letters of intent are due February 15, 2024, and the deadline for responses is March 22, 2024. Plans will be selected by November 1, 2024. Implementation is set to begin January 1, 2026. Contracts will run an initial five-year term through December 31, 2030. Contracts may be renewed for up to five years in any increment.

Current Market

Commonwealth Care Alliance, Tufts, and UnitedHealthcare serve 43,000 One Care members.

SCO incumbents WellSense Senior Care Options (formerly BMC Healthnet), Commonwealth Care Alliance, Fallon Health, Molina/Senior Whole Health, Tufts, and UnitedHealthcare serve 77,000 members.

Link to RFP