Insights

This week, our In Focus section reviews the New Hampshire Medicaid Care Management (MCM) request for proposals (RFP), which the state’s Department of Health and Human Services released on September 8, 2023. The new contracts will be worth approximately $1.1 billion and will provide full-risk, fully capitated Medicaid managed care services to approximately 190,000 beneficiaries. Implementation will begin September 2024.

MCM Program

The MCM program covers traditional Medicaid, the Children’s Health Insurance Program (CHIP), and the state’s adult Medicaid expansion Granite Advantage Health Care Program. MCM provides integrated acute care, behavioral health, and pharmacy services. Managed long-term services and supports are not included in the program.

Incumbents are AmeriHealth Caritas, Boston Medical Center/WellSense, and Centene/New Hampshire Healthy Families.

RFP

New Hampshire will award contracts to three Medicaid managed care organizations (MCOs). MCOs will cover the populations outlined in Table 1.

Table 1. New Hampshire MCM Program Enrollment as of July 1

The state outlines several key areas of focus within the RFP, including introducing a primary care and preventive services model of care—an approach centered on patient-provider relationships and provider-delivered care coordination. The RFP also will have a greater emphasis on priority populations, such as individuals with inpatient admissions for behavioral health diagnoses; children in the child welfare system; babies with low weight or neonatal abstinence syndrome; and people who are incarcerated and eligible for the Community Reentry demonstration program, pending approval from the Centers for Medicare & Medicaid Services.

Timeline

Mandatory letters of intent are due September 18, 2023, and a mandatory conference will take place September 21. Proposals are due October 30, 2023. An award date has yet to be announced, but the state contract discussions with selected MCOs will occur November 20−December 11, 2023. Contracts will run from September 1, 2024, through August 31, 2029.

Evaluation

MCOs will be scored on their ability to meet a possible 2,160 points. The technical proposal comprises a possible 1,510 points, as shown in Table 2.

Table 2. Technical Proposal Scoring

The cost component sections will make up 650 points, as shown in Table 3.

Table 3. Cost Component Scoring

Link to RFP

This week, our In Focus section reviews the request for proposals (RFP) for the Virginia Cardinal Care Medicaid managed care program, released by the Department of Medical Assistance Services (DMAS) on August 31, 2023. The RFP includes a new foster care specialty plan. Implementation is scheduled to begin July 1, 2024.

Cardinal Care

Cardinal Care launched in January 2023 as a rebranding of the state’s Medicaid program and Children’s Health Insurance Program—Family Access to Medical Insurance Security Plan (FAMIS). Cardinal Care Managed Care (CCMC) will combine the state’s existing Medallion 4.0 managed care program for traditional Medicaid and the Commonwealth Coordinated Care Plus (CCC Plus) managed long-term services and supports (MLTSS) program to serve 1.9 million Medicaid managed care members.

RFP

The state will award statewide fully capitated, risk-based contracts to a maximum of five health plans. A separate foster care specialty plan contract will also be awarded to one of the winners. If none of the plans win the separate foster care specialty program, all plans awarded a CCMC contract will be required to cover all services.

Selected plans will provide acute care, behavioral health, and MLTSS services to all Virginians who are eligible for Medicaid, including children, adults, and pregnant women in low-income households; children and adults with disabilities; low-income older adults; and individuals receiving LTSS, including dual-eligible populations. The foster care plan will cover children in foster care, individuals younger than 26 years old who were formerly in foster care, and children eligible for adoption assistance.

The RFP contains several targeted focus areas and changes to the managed care program. For example, it emphasizes improvements to the state’s behavioral health care system and improved health outcomes through a focus on health-related social needs such as housing stability and food insecurity for CCMC members.

Contracted plans will be required to operate a dual-eligible special needs plan (DSNP) in Virginia.

Market

CVS/Aetna, Elevance/Anthem, Sentara/Optima Health, Molina, and UnitedHealthcare are the current incumbents. Effective with the new RFP, DMAS intends to reassign most CCMC members as part of an enrollment process. At present, Optima holds the largest market share of enrollment at 37 percent, followed by Anthem at 30 percent.

Timeline

Letters of intent are due by September 20 and proposals are due on October 27. As previously mentioned, new contracts will begin July 1, 2024. Contracts will have a six-year initial term, with two two-year renewal options. Award dates have not been announced.

Evaluation

Plans will be awarded up to 1,000 points during the evaluation process based on the categories shown below.

Link to RFP

This week, our In Focus section reviews the Centers for Medicare & Medicaid Services (CMS) report to Congress on Non-emergency Medical Transportation (NEMT) in Medicaid, released June 20, 2023. CMS found that approximately 3 million to 4 million Medicaid beneficiaries used NEMT services annually between 2018 and 2021 and made recommendations related to Medicaid coverage of NEMT for medically necessary services.

Background

NEMT includes transportation services not limited to public transport, taxis, personal vehicle transport, non-emergency ambulances, air transport, and transportation network companies. Medicaid, unlike private insurers and Medicare, covers NEMT for any covered medical service for beneficiaries with an unmet transportation need. NEMT program administration varies from state to state and can be on a fee-for-service basis, carved out with third-party transportation brokers, or carved into the Medicaid risk-based managed care contracts. Under the Consolidated Appropriations Act, 2021, which made NEMT a statutory requirement, HHS must conduct and submit an analysis of nationwide Medicaid NEMT services to Congress. An initial report was submitted in June 2022.

Table 1. NEMT Service Delivery Models by State, 2018−2021

CMS conducted the analysis using Transformed Medicaid Statistical Information System (T-MSIS) data for calendar years 2018−2021. The analysis covered the number and percentage of Medicaid beneficiaries using NEMT, the average number of NEMT ride days, the types of medical services beneficiaries accessed when using NEMT, monthly trends in use of NEMT versus telehealth services before and during the COVID-19 public health emergency (PHE), and a comparison of the volume of NEMT services used by delivery model and state.

The T-MSIS data has some limitations and may not capture all Medicaid NEMT provided to beneficiaries due to differences in billing practices across states and providers. For example, if states claim certain medical service expenditures as administrative expenditures, T-MSIS will not capture it. Further, the number of ride days undercounts the total number of NEMT rides, as beneficiaries may receive multiple NEMT rides in a day. Because of these and other limitations, the data represents a subset of the NEMT that the Medicaid program covers.

Findings

Approximately 3−4 million Medicaid beneficiaries used NEMT annually in 2018−2021, representing 4−5 percent of Medicaid beneficiaries. Alaska, Minnesota, Arizona, Maine, and Wisconsin had the highest percentage of Medicaid beneficiaries who used NEMT, with up to nearly 11 percent in Alaska in 2021.

States that used a capitated broker model to deliver NEMT saw the highest use of these services. However, on average, states that used in-house NEMT delivery model claimed a relatively high percentage of NEMT expenditures as administrative expenditures, and NEMT administrative expenditures generally are not captured in the T-MSIS data.

Figure 1. Number of NEMT Ride Days per 10,000 Beneficiaries, by Delivery Model and Beneficiary Subgroup, 2021

Medicaid enrollees with the highest NEMT usage rates included individuals in Money Follows the Person, receiving Section 1915c home- and community-based services, dually eligible for Medicare and Medicaid, and aging adults and people with disabilities. In addition, Medicaid members with certain physical and mental health conditions and those with a substance use disorder had higher rates of usage compared with the average Medicaid members. Medicaid enrollees in remote areas also used NEMT at the highest rates.

During the COVID-19 PHE, rates of NEMT dropped from 3.9 million beneficiaries, or 5 percent of all Medicaid members in 2019, to 3.5 million (4 percent) in 2020 and 3.3 million (4 percent) in 2021. In 2019−2020, the total number of annual NEMT ride days dropped by 37 percent, from 81.3 million to 53.1 million, but increased by more than 4 percent (to 55.5 million) in 2021. On average, the monthly number of NEMT ride days in 2021 remained about 30 percent below pre-PHE levels, and the number of beneficiaries using NEMT remained 23 percent below pre-PHE levels. The COVID-19 PHE caused telehealth to sharply increase. Throughout the PHE, telehealth was used more frequently than NEMT to access certain services.

Recommendations

CMS found that public transit was rarely used for NEMT, even though more than one-third of beneficiaries live in large, urban areas. In the report, CMS recommends that states should find opportunities to improve operations between NEMT and public transit networks to better coordinate services for beneficiaries.

CMS also recommends that states further examine the role of NEMT in improving the use of timely preventive care. Beneficiaries used NEMT to access preventive services at the highest rate of all service types examined. The analysis found some evidence that use of NEMT increases access to preventive services and is cost-effective, implying that increasing the uptake of NEMT may confer cost savings to states and the federal government.

Finally, CMS recommends that states increase awareness of the NEMT benefit. Medicaid beneficiaries’ knowledge of the benefit is low. CMS urges states to work with health plans and providers to share information with beneficiaries about the availability of NEMT.

Link to report