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Blog

Medicaid managed care enrollment update—Q4 2023

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This week, our In Focus section reviews recent Medicaid enrollment trends in capitated, risk-based managed care in 30 states.1 Many state Medicaid agencies post monthly enrollment figures by health plan for their Medicaid managed care population on their websites. These data allow for timely analysis of enrollment trends across states and managed care organizations. All 30 states highlighted in this review have released monthly Medicaid managed care enrollment data into quarter four (Q4) of 2023. The analysis that follows reflects the most recent data posted. HMA continues tracking enrollment as states work towards concluding their Public Health Emergency (PHE) unwinding-related redeterminations and resuming normal eligibility operations. 

Health Management Associates, Inc., (HMA) has reviewed the Q4 enrollment data (see Table 1) and offers the following observations:  

  • Across the 30 states tracked in this report, Medicaid managed care enrollment declined by 7.3 percent year-over-year as of December 2023. 
  • Of the 30 states, 26 experienced decreased enrollment in December 2023, compared with the previous year, as the result of Medicaid redeterminations. 
  • A total of 23 of the states—Arizona, California, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, Washington, and West Virginia—saw net Medicaid managed care enrollment decrease by 469,000 (0.9%) to 51.5 million members at the end of Q4 2023. (Note: North Carolina expanded Medicaid in December 2023 and was added to the expansion group, in part inflating the change). 
  • The seven states that had yet to expand Medicaid as of December 2022—Florida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and Wisconsin—have seen Medicaid managed care enrollment decrease 25.2 percent to 13.9 million members at the end of Q4 2023.  

Table 1. Monthly MCO Enrollment by State, October 2023−December 2023 

Note: In Table 1, “+/- m/m” refers to the enrollment change from the previous month. “% y/y” refers to the percentage change in enrollment from the same month in the previous year.

It is important to note the limitations of the data presented. First, not all states report the data at the same time during the month. Some of these figures reflect beginning of the month totals, whereas others provide an end of the month snapshot. Second, in some cases the data are comprehensive in that they cover all state-sponsored health programs offering managed care; in other cases, the data reflect only a subset of the broader managed Medicaid population, making it the key limitation to comparing the data described below and figures that publicly traded Medicaid MCOs report. Consequently, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be developed based on publicly available monthly enrollment information. 

Expand Your Awareness about Medicaid and Medicare Advantage via HMAIS 

If you are interested in gaining access to detailed information on the Medicaid managed care landscape, an HMAIS subscription is the key to unlock important data. The HMA Information Services (HMAIS) collects Medicaid and Medicare Advantage Special Needs Plan (SNP) enrollment data, health plan financials, as well as developments on expansions, waivers, and demonstrations. Your HMAIS login also provides access to a library of public documents all in one place, including Medicaid RFPs, responses, model contracts, scoring sheets and other procurement related materials. HMAIS combines this publicly available information along with HMA expert insights on the structure of Medicaid in each state, as well as a proprietary HMA Medicaid Managed Care Opportunity Assessment. 

For information on how to subscribe to HMA Information Services, contact Andrea Maresca.

Blog

HMA offers a new way to approach grant funding for behavioral health providers

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Grants from both government and foundations can be an essential component of a community behavioral health provider’s growth strategy. Every year billions of dollars are distributed to support program growth, quality improvement, training, and other essential needs. Finding the right opportunities and applying for grants that are aligned with your organization’s strategic growth interests can be an essential catalyst for organizational development, service continuum growth, and quality improvements.

Behavioral health providers often struggle with identifying and applying for the right grant opportunities. It is time consuming and takes resources away from your mission to serve your communities. The deluge of notices of funding opportunities, requests for proposals, requests for applications, and requests for expressions of interest can overwhelm even the most sophisticated and well-resourced provider. Few organizations have the internal capacity to devote to wading through the hundreds of opportunities that are published each week.

That is why we created HMA Grant Prospector. HMA will do the work, so you don’t have to.

The HMA Grant Prospector is a tool that combines HMA’s deep subject matter expertise in community behavioral health care with understanding of the process of grant procurement. We have embedded this expertise in proprietary software that can sift through grant opportunities and pick out the gold nuggets from the mountain of information.

When your organization subscribes to Grant Prospector, we interview you to find out what services you have, the communities you serve, and what gaps in your care continuum you seek funding to fill. We collect information on grant opportunities as they are released, and the Grant Prospector matches your organization’s criteria with funding opportunities. We’ll send you only those opportunities for which your organization is eligible, that are aligned with your strategy and organizational objectives, and targeted to your population. You can rely on HMA to do the legwork so you can focus your efforts on improving lives in your community.

CLICK HERE TO LEARN MORE ABOUT THIS SERVICE

“HMA has helped us quickly and easily identify the best opportunities for grants for Horizon Health Services. With their help, we have been able to find the right opportunities, apply with precision, and expand our service continuum.”

– Erin DiGirolamo, CEO and Brandy Vandermark-Murray, President, Horizon Health Services, Buffalo, NY

Blog

Announcing HMA’s new value-based payment (VBP) readiness assessment tool for behavioral health providers

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Dollars and Sense: Is Your Organization Positioned to Thrive in the World of Value-Based Payments?

As the healthcare system in the U.S. moves away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality, every Behavioral Health organization finds itself with challenges ahead. Whether your organization stands at the forefront, poised for a full dive into value-based payment implementation, or is tentatively exploring initial steps, understanding your organization’s readiness on the VBP spectrum is paramount to success. Health Management Associates (HMA) is helping provider organizations in every phase of readiness move forward. We understand the detailed steps to help you focus on value, change payment structures, adapt clinical and operation workflows, and prepare and train your workforce to improve quality. Our tool is not just a promise but a practical solution to assess your current organizational readiness, providing valuable insights to focus your attention toward the next level of value.

VBP Readiness Assessment Tool

HMA’s VBP Readiness Assessment is a free, online survey tool that can help you gauge your organization’s preparedness across six pivotal domains of core functions necessary for successful participation in payment reform models. Completing the survey will provide a snapshot about a single provider or an entire organization and determine where you stand on the value-based payment spectrum.  The six domains encompass measuring outcomes, evaluating board and leadership readiness, assessing technological capabilities for capturing and sharing data, gauging partnerships, payer engagement strategies, and financial alignment.

Readiness Assessment Results

VBP graphic 1
VBP graphic 2

Example plot of a readiness assessment showing an organization’s scores on the VBP spectrum.
This organization has an overall Intermediate level of readiness with the highest levels demonstrated in
Board & Leadership Readiness and Partnership and lowest levels in Financial Readiness.

The journey toward successfully navigating the realm of value-based payments demands a strategic and informed approach. The crucial first step is a comprehensive assessment of organizational readiness, and the HMA VBP Readiness Assessment Tool stands as a valuable resource for this purpose. The ever-changing landscape of healthcare payments requires organizations to be adaptive and forward-thinking. With HMA’s team of experts offering guidance at every stage, providers, associations, health plans, and states can gain a profound understanding of the necessary organizational efforts required to engage in VBP successfully. The current landscape increasingly emphasizes value, therefore, the importance of transitioning from fee-for-service to value-based models cannot be overstated. As the demand for value continues to grow, organizations that proactively position themselves to meet these evolving expectations will not only thrive but contribute significantly to shaping the future of healthcare delivery. The HMA VBP Readiness Assessment Tool is not just a survey; it’s a compass guiding you through the dynamic terrain of value-based payments, serving as a way to identify meaningful progressive steps you can take to strengthen your organizational position within the VBP space.

Taking the survey and receiving one analyzed response is free, but you may find value in contracting with HMA for a more in-depth analysis of your organization. Click below for more details and to access the survey.

learn more about the Assessment Tool

For more information, please contact Rachel Bembas, PhD, Principal.

Blog

Medicaid managed care final rule: what to watch for

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Our second In Focus section provides a refresher on the Medicaid and Children’s Health Insurance Program managed care access, finance, and quality proposed rule that the Centers for Medicare & Medicaid Services (CMS) published in May 2023. As Health Management Associates, Inc. (HMA), has noted, the final rule is expected to be published later this month. If finalized as proposed, several provisions in the rule will signal the start of a new era of accountability and transparency for the Medicaid program. 

The policy changes are expected to fall into the following major categories: in lieu of services (ILOS), the Medicaid and CHIP Quality Rating System (MAC QRS), medical loss ratios (MLRs), network adequacy, and state directed payments (SDPs). These revised policies will affect Medicaid coverage and reimbursement for years to come. Following is a summary of the proposed policy changes to watch for in the final rule.  

ILOS 

CMS has proposed to expand upon and codify the sub-regulatory guidance around ILOS outlined in State Medicaid Director Letter #23-001. The letter advised state that they have the option to use the ILOS authority in Medicaid managed care programs to reduce health disparities and address unmet health-related social needs, such as housing instability and nutrition insecurity. The final rule would expand upon and codify that guidance. 

For example, although the ILOS proposal adds reporting requirements and guardrails to address fiscal accountability, the proposed rule also noted that the substitution of an ILOS for a state plan service or setting should be cost-effective but does not need to meet budget neutrality requirements. States are also permitted to specify that an ILOS can be an immediate or longer-term substitute for a state plan service or setting. 

MAC QRS 

CMS has proposed a MAC QRS framework that includes: (1) mandatory quality measures, (2) a quality rating methodology, and (3) a mandatory website display format. State Medicaid agencies and managed care organizations (MCOs) will be required to adopt and implement the MAC QRS framework that CMS develops or adopt and implement an alternative but equivalent managed care quality rating system. CMS will update the mandatory measure set at least every two years. Any planned modifications to measures will be announced publicly through a call letter or similar guidance, with measures based on: (1) value in choosing an MCO; (2) alignment with other CMS programs; (3) the relationship to enrollee experience, access, health outcomes, quality of care, MCO administration, or health equity; (4) MCO performance; (5) data availability; and (6) scientific acceptability. 

State Medicaid agencies will be required to collect from MCOs the data necessary to calculate ratings for each measure and ensure that all data collected are validated. In addition, state Medicaid agencies will be expected to calculate and issue ratings to each MCO for each measure. 

Lastly, state websites will be required to contain the following elements: (1) clear information that is understandable and usable for navigating the website itself; (2) interactive features that allow users to tailor specific information, such as formulary, provider directory, and ratings based on their entered data; (3) standardized information so that users can compare MCOs; (4) information that promotes beneficiary understanding of and trust in the displayed ratings, such as data collection timeframes and validation confirmation; and (5) access to Medicaid and CHIP enrollment and eligibility information, either directly on the website or through external resources. 

MLRs 

CMS has proposed three areas for revision to its existing MLR standards, which require MCOs to submit annual MLR reports to states, which, in turn, must provide CMS with an annual summary of those reports. Areas for revision include: (1) requirements for clinical or quality improvement standards for provider incentive arrangements, (2) prohibited administrative costs in quality improvement activity (QIA) reporting, and (3) additional requirements for expense allocation methodology reporting. 

With regard to provider incentive arrangements, CMS proposes to require that contracts between MCOs and providers: (1) have a defined performance period that can be tied to the applicable MLR reporting period(s), (2) include well-defined quality improvement or performance metrics that the provider must meet to receive the incentive payment, and (3) specify a dollar amount that can be clearly linked to successful completion of these metrics as well as a date of payment. MCOs would be required to maintain documentation that supports these arrangements beyond attestations. 

In terms of QIA reporting, CMS proposes to explicitly prohibit MCOs from including indirect or overhead expenses when reporting QIA costs in the MLR. CMS also intends to add requirements regarding how MCOs can allocate expenses for the purpose of calculating the MLR by requiring MCOs to offer a detailed description of their methodology. 

Network Adequacy 

CMS has proposed a range of new network adequacy requirements intended to improve timely access to care for managed care enrollees. Those related to appointment wait time standards and secret shopper surveys are among the most prominent. 

For appointment wait time standards, CMS proposes that state Medicaid agencies develop and enforce wait times associated with routine appointments for four types of services: (1) outpatient mental health and substance use disorder (SUD) for adults and children, (2) primary care for adults and children, (3) obstetrics and gynecology (OB/GYN), and (4) an additional service type determined by each state Medicaid agency using an evidence-based approach. The maximum wait times must be no longer than 10 business days for routine outpatient mental health and SUD appointments and no more than 15 business days for routine primary care and OB/GYN appointments. State Medicaid agencies could impose stricter wait time standards but not more lax ones. The wait time standard for the fourth service type will be determined at the state level. 

State Medicaid agencies also will be required to engage an independent entity to conduct annual secret shopper surveys to validate MCO compliance with appointment wait time standards and the accuracy of provider directories to identify errors, as well as providers that do not offer appointments. For an MCO to be compliant with the wait time standards, as assessed through the secret shopper surveys, it would need to demonstrate a rate of appointment availability that meets the wait time standards at least 90 percent of the time.  

SDPs 

CMS has proposed several important changes to the requirements governing the use of SDPs, strengthening both the accountability required of and flexibility afforded to states. For example, CMS proposes to require that provider payment levels for inpatient and outpatient hospital services, nursing facility services, and the professional services at an academic medical center not exceed the average commercial rate. Furthermore, states would be required to condition SDPs upon the delivery of services within a contract rating period and prohibited from using post-payment reconciliation processes. 

With regard to flexibility, CMS proposes to remove unnecessary regulatory barriers to support the use of SDPs by states to implement value-based payment arrangements and include non-network providers in SDPs. The proposal also permits states to implement, without prior approval, minimum fee schedules in Medicaid consistent with Medicare provider rates. 

What’s Next  

CMS is expected to publish the final rule in April. In addition, CMS plans to publish a separate final rule addressing new regulations pertaining to access to care, which will have equally significant impacts on states, MCOs, and providers. If you have questions about how HMA can support your efforts related to the managed care final rule’s implications and the context of other federal regulations for states, MCOs, or providers, contact Michael Engelhard, Managing Director, Regional Managed Care Organizations, and Andrea Maresca, Managing Director, Information Services.

Blog

CMS finalizes significant changes to Medicare Advantage and Medicare Part D programs for 2025

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This week, our In Focus section reviews a wide-ranging and comprehensive final rule released April 4, 2024, by the Centers for Medicare & Medicaid Services (CMS). The regulation revises and updates policies that affect Medicare Advantage (MA) and Medicare Part D coverage beginning in the upcoming plan year. 

The policies adopted in the final rule aim to strengthen consumer protections and guardrails, promote fair competition, and ensure MA and Part D plans can best meet the healthcare needs of Medicare beneficiaries, including individuals dually eligible for Medicare and Medicaid. In addition, the final rule includes important new policies to expand access to behavioral health providers, promote equity in healthcare coverage, and improve access to and use of Medicare Advantage supplemental benefits. These policy changes complement payment policy changes that were recently finalized in the April 1, 2024, CMS CY 2025 Rate Announcement and will take effect June 3, 2024.  

Below HMA experts walk through the major policies CMS finalized. 

Expanding Access to Behavioral Health Providers 

CMS finalized several regulatory changes to improve Medicare beneficiaries’ access to behavioral health services through strengthened MA network adequacy standards. These changes include: 

  • Establishing network evaluation standards for a new facility-specialty provider category, called outpatient behavioral health. This category includes a range of behavioral health providers, including marriage and family therapists (MFTs), mental health counselors (MHCs), opioid treatment programs, community mental health centers, addiction medicine specialists and facilities. Outpatient behavioral health will be included in network adequacy evaluations. 
  • Permitting MFTs and MHCs to enroll and start billing Medicare—as a result of statutory changes established in the Consolidated Appropriations Act (CAA) of 2023—and establishing corresponding changes to network adequacy standards for MA plans. 
  • Requiring MA plans to independently verify that behavioral health providers added to their network furnish services to at least 20 patients within a 12-month period. 
  • Adding outpatient behavioral health facility-specialty to the list of the specialties that will receive a 10 percent credit toward meeting network adequacy time and distance standards. 

Impact: Adding the outpatient behavioral health category is expected to enhance Medicare beneficiaries’ access to a broader scope of behavioral health specialists. As result of the new policy and network expectations, MA plans may need broaden their networks, and providers that contract with MA plans may need to strengthen their capacity to address Medicare billing and reporting requirements, including quality reporting initiatives.  

Require Mid-Year Enrollee Notification of Supplemental Benefits 

The number of MA plans that offer supplemental benefits to beneficiaries is increasing, with the most frequently offered supplemental benefits including coverage for vision, dental, and hearing services.  Moreover, many MA plans also are offering supplemental benefits to address unmet social determinants of health needs, including home meal delivery, transportation, and in-home services and supports. At the same time, use of these benefits is reportedly low, and there are gaps in research and data analysis about how these benefit offerings are affecting beneficiaries’ cost and health outcomes.   

As a result, CMS is finalizing policies that require MA plans to engage in outreach to beneficiaries. Specifically, the final rule requires MA plans to send enrollees a mid-year notification regarding their unused supplemental benefits. The notification must include information on the scope of the benefit, patient cost-sharing, and detailed instructions on how beneficiaries can access their unused benefits.  

Impact: This change is intended to improve beneficiary awareness of plans’ supplemental benefit offerings and encourage greater use of these benefits. As a result of the regulatory changes, MA plans may look to further refine and adjust their MA supplemental benefit offerings to further improve the healthcare experience for Medicare beneficiaries. 

New Standards for Supplemental Benefits under SSBCI 

MA plans also offer supplemental benefits to beneficiaries through the Special Supplemental Benefits for the Chronically Ill (SSBCI) program, whereby people with ongoing and complex chronic conditions can receive supplemental benefits that are tailored to their specific health and social needs. In the final rule, CMS establishes new requirements for MA plans to demonstrate the value of these services by submitting evidence that the item or service will improve or maintain the overall health of chronically ill beneficiaries.   

Impact: This new reporting requirement is intended to ensure that SSBCI items and services are evidence-based and meaningful. As these regulatory changes are implemented under tight timelines, plans will need to move quickly to compile clinical data and evidence on the effectiveness of these targeted benefits, while also considering changes in their benefit offerings to better meet the needs of beneficiaries with complex and chronic conditions. 

MA Star Rating Changes 

In the final rule, CMS describes its ongoing work to streamline quality measures, including the agency’s progress in moving toward the Universal Foundation of core quality measures that are aligned across CMS’s quality and value-based programs. CMS notes that MA plans are beginning to report additional measures that are part of the Universal Foundation. Under previous regulations, CMS proposed to make the following changes to specific measures in the Star Ratings system: 

  • Remove the standalone Part C medication reconciliation post-discharge measure
  • Add the updated Part C colorectal cancer screening measure with the NCQA (National Committee for Quality Assurance) specification change 
  • Add the updated Part C care for older adults−functional status measure with the NCQA specification change. 

Impact: These changes build on earlier CMS efforts to improve the Star Rating system, including adding a health equity index and reducing the weight of patient experience and access measures to better align with the CMS Quality Strategy. 

Ensure More Dual-Eligible Managed Care Beneficiaries Receive Medicare and Medicaid Services from the Same Organization 

CMS finalized several significant changes designed to improve access to integrated care for dually eligible beneficiaries, including the following:  

  • CMS is limiting enrollment in certain Dual Eligible Special Needs Plans (D-SNPs) to individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO).  
  • CMS also limits the number of D-SNP benefit packages that an MA organization can offer in the same service area as an affiliated Medicaid MCO. If a state Medicaid agency requires it, MA plans may offer more than one D-SNP for full-benefit dually eligible individuals in the same service area as the MA organization’s affiliated Medicaid MCO.  
  • Dually eligible beneficiaries will have an opportunity to enroll in an integrated D-SNP monthly under a new integrated care special enrollment period (SEP). 
  • CMS is lowering the D-SNP look-alike threshold from 80 percent to 70 percent for plan year 2025 and to 60 percent for plan year 2026 and into the future.  

Impact: These are considerable changes that are designed to increase the percentage of dually eligible beneficiaries enrolled in MA plans that also are contracted to cover Medicaid benefits. In addition, these changes will expand access to integrated member materials, unified appeals processes across Medicare and Medicaid, and continued beneficiary access to Medicare services during an appeal.  

Require Health Equity Assessments of Utilization Management Practices and Procedures 

CMS finalized several regulatory changes to the composition and responsibilities of MA plans’ utilization management (UM) committees, including the following:  

  • At least one member of the UM committee must have expertise in heath equity. 
  • The UM committee must conduct an annual assessment of UM practices and procedures on health equity, with a particular focus on the impact on beneficiaries who are low-income, dually eligible for Medicare and Medicaid, or have a disability. 
  • MA plans must make the health equity analysis publicly available on the plan’s website. 

Impact: These policy changes are aimed at assessing the impact of utilization management through a health equity lens and ensuring that these policies and procedures do not have a disproportionate impact on access to medically necessary care for underserved populations.  

Other Provisions 

The final rule makes several other notable regulatory changes to MA and Part D, which include: 

  • Allowing Part D plans to substitute biosimilars for the reference biologic product during the plan year as part of formulary maintenance changes, which is expected to expand access to lower cost biosimilars for Medicare beneficiaries  
  • Limiting out-of-network cost sharing for D-SNP PPOs 
  • Standardizing the MA risk adjustment data validation appeals process 
  • Establishing new guardrails for plan compensation to agents and brokers to prevent anti-competitive steering of beneficiaries and new requirements to third-party marketing organizations   
  • Changes to Medicare Part D medication therapy management (MTM) eligibility criteria 

What’s Next  

CMS continues its work to incorporate requirements for consumer engagement and transparency of data to address health equity. This final rule is poised to have a significant impact on plan benefit design and the landscape of health insurance markets in states and regions of states. CMS has created additional opportunities for states to advance integrated care initiatives that align with Medicaid, which will have downstream implications for MA and Medicaid plans, providers, and partnering organizations.  

The Health Management Associates team will continue to analyze and assess these regulatory changes that CMS has finalized. We have the depth, experience, and expertise to assist in tailored analysis and model policy impacts of the recently finalized changes.  For more information or questions about the policies described, contact Amy Bassano, Julie Faulhaber, Andrea Maresca, or Greg Gierer.

Blog

Opportunities for continued certified community behavioral health clinic expansion and enhancement

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Opportunities related to Certified Community Behavioral Health Clinics (CCBHCs) continue to expand for both states and providers. With this increased investment in the model comes the need for continued refinement and improvement. CCBHCs enable government and other payors and providers to increase capacity and move towards a transformed behavioral health system that is responsive to local community needs. This article summarizes a number of new developments that will impact CCBHCs, including a few opportunities for expansion that you may not want to miss.

Background

CCBHCs provide integrated and coordinated community-based care for individuals across the lifespan who are living with and/or at risk for behavioral health conditions. 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 positive outcomes, such as: [i]

  • Significant reductions in client hospitalizations
  • Increased access to high quality community-based care, including services like Medication Assisted Treatment and care coordination
  • Mitigation of the challenges related to the national health care workforce shortage
  • Innovative and strengthened partnerships with cross-system partners, such as law enforcement, schools, and hospitals

SAMHSA CCBHC Demonstration Grant Opportunity Releases for States

Earlier this month, SAMHSA released its CCBHC Demonstration Program opportunity for states who currently or have previously held a CCBHC Planning Grant. The Demonstration RFP (request for proposals) will allow selected states to initiate a CCBHC Demonstration Program starting on July 1, 2024. In 2016, Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania were selected by the U.S. Department of Health and Human Services (HHS) to participate in the initial CCBHC Demonstration Program. In August 2020, Kentucky and Michigan were selected as two new CCBHC Demonstration States through the Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136). Through this most recent 2024 CCBHC Demonstration opportunity, SAMHSA will select up to 10 additional states to participate in the CCBHC Demonstration, as outlined by the Bipartisan Safer Communities Act of 2022 (P.L. 117-259).

For those interested in this RFP:

  • Eligibility: States selected for the 2016 or 2023 CCBHC Planning Grant (that are not currently participating in the Demonstration Program) are eligible to apply for this RFP.
  • Due Date: Applications are due March 20, 2024, at 11:59pm EST and must be submitted by email to [email protected]. Awarded states will be announced in June 2024.  
  • Evaluation Criteria: As outlined in the Protecting Access to Medicare Act (PAMA) of 2014, state applications will be scored on their ability to:
    • Provide the most complete scope of services
    • Improve availability of, access to, and participation in, CCBHC services
    • Improve availability of, access to, and participation in assisted outpatient mental health treatment in the state
    • Demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net federal spending

For additional context and background on this opportunity, 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.

Other CCBHC Updates of Note

In addition to this state Demonstration RFP, there have been several recent updates to CCBHC-related guidance documents that are worth noting for anyone who is currently participating and/or interested in the CCBHC model:

Updates to the Prospective Payment System (PPS) Guidance

Under the state CCBHC Demonstration Program, CCBHCs are paid a daily or monthly Prospective Payment System (PPS) rate. In 2023, in preparation for issuing an updated guidance, CMS held a forum for states, providers, and other stakeholder input on newly proposed PPS changes. In February 2024, the updated PPS Guidance was released, reflecting gathered feedback incorporating payment flexibilities and alignment with revisions to the CCBHC criteria. One major change was the addition of two PPS options for states, which addresses the high-cost and specialized care delivered through mobile and on-site crisis intervention services provided directly to individuals. Specifically:

  • PPS-3 offers states the option to reimburse CCBHCs on a daily basis, including daily Special Crisis Services rates, which allow states to set separate PPS rates for crisis services provided by CCBHCs.
  • PPS-4 offers states the option to reimburse CCBHCs on a monthly basis, including monthly Special Crisis Services rates. Quality Bonus Payments are also required under this PPS-4 structure.

Additionally, the metrics for Quality Bonus Payments (which are required as part of the PPS-2 and PPS-4 monthly rate structures and optional for the PPS-1 and PPS-3 daily rate structures) have been modified to align with the revised CCBHC Quality Metrics. Additionally, CMS added new guidance related to payments to CCBHCs that are also certified as FQHCs (Federally Qualified Health Centers) and other provider types operating within the Medicaid program.

Overall, this updated PPS Guidance is effective on or after January 1, 2024 for existing CCBHC Demonstration States and on or after July 1, 2024 for newly selected states added to the program under the above CCBHC Demonstration Program RFP.

CCBHC Quality Metrics: Final Specifications Released

Further, when SAMHSA revised the CCBHC criteria in March of last year, they also updated the required and optional quality measures for both CCBHC providers and states operating a Demonstration program. The revised guidance specifies that all CCBHCs, including those participating in a State Demonstration Program as well as providers funded by a SAMHSA CCBHC Grant, must begin collecting and reporting on the required provider-specific measures starting in calendar year 2025. Similarly, states participating in the CCBHC Demonstration Program must transition to reporting on the new state-specific measures as well, with their first measurement year for the new measures running from January 1, 2025 – December 31, 2025.

Earlier this month, SAMHSA released the final specifications for each of the required and optional CCBHC quality measures. Providers and states alike are currently working hard to prepare their quality processes and systems to report on these new measures. With the inclusion of SAMHSA-funded CCBHCs in these quality measure reporting requirements, the hope is that the expanded data will assist us all in better understanding the impact of the CCBHC initiative as it relates to access to care and outcomes.

Guidance for States on CCBHC Criteria Customizations

Finally, SAMHSA recently released updated guidance for states looking to customize the federal CCBHC criteria as part of their CCBHC Demonstration Programs, to align with updates they made to the federal criteria in March of 2023. The guidance outlines, for a variety of criteria, how states may add or customize the requirements. Importantly, all CCBHCs operating either under a SAMHSA CCBHC Grant Program or a state-run CCBHC Demonstration Program must meet all of the revised federal CCBHC Criteria on or before July 1, 2024. Building on the federal criteria, many states are strategically taking advantage of customization opportunities to better align the CCBHC model with their system-wide goals and address gaps within their current behavioral health system’s capacity.

Upcoming opportunities for CCBHC expansion

In addition, there are several upcoming opportunities on the horizon for both states and providers looking to enter the CCBHC space.

New CCBHC-Expansion Grants for Behavioral Health Providers

SAMHSA’s Fiscal YeaGr 2024 budget requested $552.5 million for the CCBHC Expansion Program, which is a $167.5 million increase above the FY 2023 enacted level. The CCBHC-Expansion Grant Program includes both “Improvement and Advancement” grants for existing CCBHCs looking to enhance their programs, as well as “Planning, Development, and Implementation” grants for providers looking to establish a new grant-funded CCBHC.

SAMHSA’s FY24 funding will support 360 continuation grants, as well as award a new cohort of 158 grants, and a technical training assistance center grant to continue the improvement of mental disorder treatment, services, and interventions for children and adults. The budget also proposes to establish “an accreditation process [that] would ensure consistent adherence to the CCBHC model and create capacity to confirm adherence to the criteria and the model.”

While the new CCBHC-Expansion Grant RFPs are not currently posted on SAMHSA’s list of projected RFPs, we can expect (based on prior rounds) they are likely to be released sometime in the spring.

Expected Upcoming CCBHC Planning Grant for States

In addition to seeding the selection of a new cohort of 10 states to participate in the CCBHC Demonstration Program starting through the above Demonstration Program RFP and then every two years thereafter, the 2022 Bipartisan Safer Communities Act also earmarked funding for SAMHSA Planning Grants to support states looking to join the Demonstration. For states who are not selected to participate in the CCBHC Demonstration Program starting on July 1, 2024, we expect another CCBHC Planning Grant RFP to be released in the fourth quarter of this calendar year, with another round of 15 Planning Grants to be awarded to selected states in 2025.

States looking to prepare for the next Planning Gant RFP can review HMA’s summary of the most recent Planning Grant opportunity and watch HMA’s webinar co-hosted with the National Council for Mental Wellbeing that provides an overview of the previous RFP.

Interested in Learning More?

Reach out to our experts! HMA offers a deeply informed yet neutral perspective on CCBHC development, with team members who specialize in operations, quality, and fiscal components of the CCBHC model. We have helped 17 states successfully write their CCBHC Planning Grant applications, and in 2023 alone, we helped behavioral health providers secure approximately $80 million in expansion grant funding they are using to support their communities. Our team of experts brings extensive experience supporting both states and providers to leverage the CCBHC model to support their overall system transformation goals.

Click here to learn more about our work with CCBHCs or contact:

Heidi Arthur, Principal
Kristan McIntosh, Principal
Josh Rubin, Principal


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

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Substance Use Disorder (SUD) Ecosystem of Care Webinar Series: Pivoting to Save Lives

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Over the coming weeks, HMA is presenting a 3-part webinar series describing a whole person, integrated, solutions-based approach to the ongoing overdose epidemic. It is time to reconsider standard attempts to solve this crisis. Leaders need to be willing to pivot away from approaches that have not yielded the level of impact that this crisis demands, and to be ready to try new ideas and solutions.

“An ideal Ecosystem of Care is person-centered, and parts of the system work together to eliminate stigma, overcome barriers, and prevent people from falling through the cracks that are currently pervasive,” says Dr. Jean Glossa, Managing Director. “Stakeholders participating in SUD care, prevention, and treatment may need to expand their services and work together with other partners in ways they have not before.” 

Each webinar in this series will share HMA’s nuanced understanding of the many paths available for those seeking recovery or a different relationship to addictive behaviors. Experts in the field will share valuable insights, shedding light on the various interventions and strategies that contribute to a holistic and effective approach to supporting individuals on their journey to lasting recovery. Whether you are a healthcare professional, caregiver, or someone personally affected by substance use, this webinar offers a roadmap for navigating the complexities of the Substance Use Care Continuum, fostering hope and resilience in the pursuit of sustained well-being.

By attending this series of webinars, you will learn how to:

  • Describe ongoing overdose crisis as a national public health emergency.
  • Recognize where certain solutions didn’t create the desired impact.
  • Consider new approaches and solutions to overcome ingrained stigma.

Part 1: Overview and The Role of Health Promotion and Harm Reduction Strategies
Part 2: Empowering Change in the SUD Ecosystem
Part 3: Building Systems-Thinking in the SUD Ecosystem

HMA expert consultants have deep expertise, and professional on-the-ground lived experience, with supporting efforts nationwide to build an evidence-based, patient-centered, and sustainable addiction treatment ecosystem. No matter the scope or size of the project, HMA has experience working with states, and community organizations to develop impactful, sustainable responses to SUD. Our team is ready to help clients create, disseminate, and implement actionable and sustainable programs, to address substance use, overdose, and addiction.

Check out these related resources:

If you have other questions or want to speak to someone about how HMA can help your organization with some of these ideas, please contact Jean Glossa or Erin Russell.

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Advancing workforce through Collective Impact

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The National Council for Mental Wellbeing (NCMW) launched the Center for Workforce Solutions in 2023 in partnership with The College for Behavioral Health Leadership (CBHL) and Health Management Associates (HMA). The partnership is leveraging Collective Impact to address the workforce crisis, and using a cross-sector approach to address the long-standing challenges for expanding and solidifying the behavioral health workforce. The partners identified a gap in advancing workforce solutions with many national convenings creating various sets of recommendations without a coordinated or clear approach to moving recommendations to action.

Why use Collective Impact?

  • Workforce challenges and solutions require a cross-sector approach including changes in Federal and State regulations as well as at the provider level. Need a coordinated approach to truly reach change.
  • There are a lot of recommendations nationally with stalled action in many cases because the recommendations require other implementers to act.
  • No single accountable entity to ensure recommendations move forward
  • Need for cross-sector agreement on strategies and then cross-sector implementation
  • Scale of the challenge can create overwhelm and inertia to address big gaps
  • Leverage the work being done across partners while building a coordinated effort

Check out this webinar recording to learn more about the history of this effort.

Link to the Webinar

2023 Progress

The partnership was busy in 2023 with activities to build multiple avenues for change:

  • Building a robust partnership and backbone for the collective impact approach which is working seamlessly to support a national and cross-sector group of leaders to support implementation of recommendations that often require multiple levels of the system and cross-sector engagement.
  • Developing a draft framework for the complexity of the workforce challenges and solutions and thinking about the implementers (regulators, policy makers, providers, and others) that are needed to implement recommendations.
  • Cross-walking more than 400 recommendations from national sources including national and state approaches as well as provider lessons using the framework to understand consistent recommendations, identify themes and prioritize where to focus moving recommendations to action.
  • Launching a Behavioral Health Provider and Association ECHO on workforce building a network of providers to share case studies and learn from each other and discuss innovative solutions for addressing workforce challenges.
  • Continuing to identify funding support to move the collective impact approach forward.

What’s Coming in 2024?

  • National Workforce Conversation—a virtual meeting open to all interested nationally to communicate and share information broadly and to collectively track what’s working and lessons learned in workforce efforts.
  • Launch Steering Committee and Working Groups—which will include national key decision makers who will guide a coordinated approach to implementing recommendations and working cross-sector to be accountable to change.
  • Launch Second ECHO for Providers and Associations to continue to share what’s working and improve the immediate workforce crisis at the provider level. Stay Tuned https://www.thenationalcouncil.org/program/center-for-workforce-solutions/engage/echo/
  • NatCon’24: Register and join the Workforce Development and Talent Management Track (April 15 – 17, 2024)
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Collaborating to improve children’s behavioral health

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

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

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

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

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

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

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

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

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

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

Timeline of Key Events

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

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HMA has previously reviewed and discussed some of the implications of provisions put forward in the Medicaid and Children’s Health Insurance Program managed care access, finance, and quality proposed rule published by the Centers for Medicare & Medicaid Services (CMS) back in May 2023. It is now anticipated that the final rule will be published later this month in April 2024. Given that the final rule, if it codifies many of the proposed provisions as written, will have a significant impact across Medicaid stakeholders including states, managed care organizations (MCOs), and providers, and that its publication appears imminent, it is valuable to recall the major areas that the final rule will likely address.

The final rule is anticipated to include policy changes in several major areas. These include in lieu of services (ILOS), the Medicaid and CHIP Quality Rating System (MAC QRS), medical loss ratios (MLRs), network adequacy, and state directed payments. When taken together, the policymaking in each of these areas represents the start of a new era of accountability and transparency in the Medicaid program and will affect Medicaid coverage and reimbursement for years to come.

HMA is on the alert for the final rule and will provide analysis and expertise relevant to states, MCOs, and providers, both before and following its release. Whether it is understanding the opportunities to leverage ILOS to address health-related social needs, ensuring operational readiness for data collection and calculation obligations for the MAC QRS, or preparing to comply with MLR requirements related to provider incentive arrangements and quality improvement activity reporting, as well as a host of other topics, HMA will be able to provide insight.

For More Information

If you have questions about how HMA can support your efforts related to the final rule’s implications for states, MCOs, or providers, please contact Michael Engelhard, Managing Director, Regional Managed Care Organizations and Andrea Maresca, Managing Director, Information Services.

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HMA experts drawing on own lived experience to present on “Lifting Voices” project: Navigating the Children’s System of Care at NATCON24 in St. Louis, April 15-17

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At the upcoming NATCON24 convention, HMA principals Heidi Arthur and Ellen Breslin will conduct a motivating workshop called “Lifting Voices for Meaningful, Actionable Change: Insights from Navigating the Children’s System of Care.” During this workshop, Heidi and Ellen will discuss how their own journeys as mothers of children with significant behavioral health needs have informed their work as policy and practice advisors to state and local authorities. They will lift up the voices of their fellow parents and youth, whose insights they sought in order to inform improvements to behavioral health care and access at the state and local levels around the country. Heidi and Ellen seek to make this an engaging workshop for attendees and encourage all to join the call to action. 

Please join their workshop at NATCON24 on Monday, April 15, 2024 from 10:30– 11:30 AM CT in room 132, Level 1, ACCC.

As longtime leaders in health and human services, HMA’s behavioral health experts bring front line and leadership experience to their work supporting behavioral health authorities, child welfare programs and community and school-based providers of all kinds. We consult with public and private sector entities who serve children and families in order to improve access, streamline, and integrate care. We aim to advance equity and improve quality in state, county, and local program development. Contact us to learn more.

Learn more about the foundations of this project by accessing the Lifting Voices report from October 2023 below.

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CMS releases Medicare Advantage and Part D payment policies for CY 2025

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This week, our In Focus section reviews the recently announced policy and payment updates from the Centers for Medicare & Medicaid Services (CMS) that will affect Medicare Advantage (MA) and Medicare Part D programs in calendar year (CY) 2025. We also take a look at the CY 2025 Part D Redesign Program Instructions

Both the rate announcement and program instructions include important technical updates and payment policy changes that will affect MA and Part D plans. CMS previously released a proposed rule in November 2023 that included proposed policy changes to MA and Part D. Health Management Associates, Inc., colleagues are closely monitoring how the final Rate Notice will shape the industry’s approach to the separately proposed policies for supplemental benefits, integrated dual eligible special needs plans (D-SNPs), and encounter data policies among others.  

The following are highlights from the CY 2025 Rate Announcement and significant changes CMS made from the Advance Notice released earlier this year. 

Payment Impact on MA 

CMS estimates that the final ate announcement will lead to a 3.70 percent increase in average payments to MA plans in CY 2025. This reflects the net payment impact of policy changes and updates to MA plan payments relative to 2024 and is the same amount as proposed in the CY 2025 Advance Notice released on January 31, 2024. As a result, MA plans will receive an estimated $16 billion increase in payments for CY 2025, and according to CMS, the federal government is expected to make $500−$600 billion in payments to MA plans in 2025. This reimbursement increase—which include all the various elements affecting MA plan payments, including the MA risk score trend—represents the average payment increase across all MA plans, although the actual impact on each plan will vary. 

Effective Growth Rate 

The effective growth rate finalized in the CY 2025 rate announcement is 2.33 percent, down slightly from 2.44 percent in the advance notice. The effective growth rate is driven largely by growth in Medicare fee-for-service expenditures, and the CY 2025 Rate Announcement was updated to include program payments during the fourth quarter of 2023. In addition, the technical medical education adjustment has declined from 67 percent in the Advance Notice to 52 percent in the Rate Announcement. 

Medicare Advantage Risk Adjustment and Coding 

The rate announcement continues to phase in the updated risk adjustment model by blending 67 percent of the risk score calculated using the updated 2024 MA risk adjustment model with 33 percent of the risk score calculated using the 2020 MA risk adjustment model.  These revisions to the MA risk adjustment model, which include important technical updates to improve the model’s predictive accuracy, were finalized last year under the CY 2024 Rate Announcement with a three-year phase-in. The Rate Announcement also finalizes that CMS will adopt a new methodology for normalizing risk scores to more accurately address the effects of the COVID-19 pandemic. 

Consistent with what the agency proposed in the Advance Notice, in CY 2025, CMS will apply the statutory minimum 5.90 percent MA coding pattern difference adjustment. 

Star Ratings 

CMS continues work toward implementing the “Universal Foundation” of quality measures—a subset of metrics aligned across public programs. CMS invites stakeholder feedback as it continues to explore adding measures to the Star Ratings, which are components of the Universal Foundation. 

For the CY 2025 rate announcement, Star Ratings changes include the types disasters that are included in the adjustment, updates to the non-substantive measure specification, and the list of metrics for inclusion in the MA and Part D improvement measures and Categorical Adjustment Index for 2025 Star Ratings. 

Part D Design and Part D Risk Adjustment Changes 

The Rate Announcement details several important changes to the standard Part D drug benefit for CY 2025 as required by the Inflation Reduction Act (IRA). These adjustments include eliminating the coverage gap phase from a three-phase benefit (deductible, initial coverage, and catastrophic) and setting the annual cap on patient out-of-pocket prescription drug costs at $2,000. The changes in Part D coverage design will have a significant impact on liability for Medicare beneficiaries, Part D plans, drug manufacturers, and CMS.  

CMS also finalized updates to the Part D risk-adjustment model to reflect Part D design changes included in the IRA and to ensure Part D plan sponsors can develop accurate bids for CY 2025. These changes include calibrating the Part D risk model using more recent data years and updating the normalization factor to reflect differences between MA-PD plan and standalone Part D plan risk score trends. 

Key Considerations 

Overall the final rate notice maintains stability and the opportunity for beneficiary choices in the MA program even as it continues to implement noteworthy changes in risk adjustment. The payment policies finalized in the CY 2025 Rate Announcement will have varying effects across MA plans, with some experiencing larger or smaller impacts in CY 2025. Plans should assess these effects as they prepare their bid submissions for 2025. 

In the CY 2025 rate announcement, CMS indicates that the 3.70 percent increase will provide continued stability in beneficiary access, choice, and benefits while ensuring accurate, appropriate payments to Medicare Advantage organizations. 

Looking ahead, CMS also has proposed policy and technical changes to the MA and Part D programs, which are expected to be finalized in the coming days. HMA’s summary analysis homes in on key issues that likely will be included in the final rule. CMS continues to solicit feedback from stakeholders on ways to reinforce and improve transparency in the MA program through the CMS Request for Information on MA data collection. Comments are due May 29, 2024. 

The HMA team will continue to analyze the important payment and technical changes finalized in the CY 2025 rate announcement. We have the depth, experience, and subject matter expertise to assist with tailored analysis and the modeling capabilities to assess the policy impacts across the multiple rules and guidance. 

If you have questions about the comments of the CY 2025 Rate Announcement and payment policies that impact MA plans, providers, and beneficiaries, contact Julie Faulhaber ([email protected]), Amy Bassano ([email protected]), Andrea Maresca ([email protected]), or Greg Gierer ([email protected]).