Insights

Filter by topic:

Receive timely expert insights on topics you care about.

547 Results found.

CMS proposes regulation for Rural Emergency Hospitals

On June 30, 2022, the Centers for Medicare & Medicaid Services (CMS) released a proposed regulation establishing the Conditions of Participation (CoPs) for a new hospital provider type, Rural Emergency Hospitals (REHs). The REH concept was first developed by the Medicare Payment Advisory Commission (MedPAC) and subsequently mandated by Congress through the Consolidated Appropriations Act (CAA) of 2021 to address the growing concern over closures of rural hospitals.

REHs provide an opportunity for Critical Access Hospitals (CAHs) and rural hospitals to improve the way care is delivered in their communities, maintain access, and avert potential closure by choosing to focus on the service offerings that are most essential to their communities, such as emergency services, observation care, and additional medical, behavioral, and maternal outpatient services. Importantly, the REH concept enables facilities to maintain a hospital designation absent inpatient capacity thereby ensuring that rural communities retain access to services. This proposed regulation is a significant milestone in CMS’ work to implement the REH designation and their novel payment methodology by their mandated start date of January 1, 2023.

The REH concept is expected to help address the observed health inequities that arise when rural communities lack access to hospitals and other providers. Obtaining an REH designation could be an opportunity for many independent hospitals and delivery systems to strategically reshape themselves in line with their community’s needs while receiving payments from Medicare for doing so.

Within CMS’ proposed regulation, the agency proposes to establish a novel set of REH CoPs which will define the parameters of the REH designation. The REH CoPs closely align with the current CAH CoPs in most cases, while considering the uniqueness of REHs and the statutory requirements. In some instances, the proposed REH policies closely align to the current hospital and ambulatory surgical center standards, such as the polices for outpatient services’ requirements and life safety code, respectively.

As a part of this proposed regulation, CMS seeks input from the rural community on a few key aspects of the REH designation, including:

The specific proposed REH standards, including the ability of an REH to provide low-risk childbirth-related labor and delivery services and whether the agency should require REHs to provide outpatient surgical services in the event that surgical labor and delivery intervention is necessary.
Whether it is appropriate for an REH to allow a physician, physician associate, nurse practitioner, or clinical nurse specialist, with training or experience in emergency medicine, to be on call and immediately available by telephone or radio contact and available on site within specified timeframes.

Updates to CoPs for Critical Access Hospitals

Also within this draft regulation CMS proposes to update the CoPs for CAHs by: (1) adding a definition of primary roads to the location and distance requirements; (2) establishing a patient’s rights CoP; and (3) allowing CAHs that are a part of a larger health system (containing other hospitals and/or CAHs) to unify and integrate their infection control and prevention and antibiotic stewardship programs, medical staff, and quality assessment and performance improvement programs (known as QAPI) to ensure consistent and safe care.

What’s Next

CMS is accepting comments on this rule until August 29, 2022. CMS intends to propose additional policies related to Medicare enrollment, payment, and quality reporting in the upcoming Calendar Year 2023 Outpatient Prospective Payment System/Ambulatory Surgery Center proposed rule. CMS will develop final policies for this program later this year.

For more information about this proposed regulation including how to submit comments and how the REH concept may impact the hospital industry and patients in rural communities please contact our Medicare team who have knowledge in Congressional, MedPAC and CMS policy and operations – Zach Gaumer (HMA Principal) ([email protected]), Amy Bassano (HMA Managing Director, lMedicare) ([email protected]), or Andrea Maresca (HMA Principal) ([email protected]). To access CMS’s proposed Rural Emergency Hospital and Critical Access Hospital Conditions of Participation, visit: https://www.federalregister.gov/public-inspection/current.

Ohio releases next generation MyCare Ohio program RFA

Read Blog

This week’s In Focus section delves into the Next Generation MyCare Ohio managed care program, spotlighting the request for applications (RFA) that the Ohio Department of Medicaid (ODM) released on May 31, 2024. The MyCare Ohio Program, which serves people who are dually eligible for both Medicaid and Medicare, is undergoing a substantial transformation. Transitioning from the financial alignment initiative (FAI) demonstration model used in 29 counties, it is evolving into a statewide, fully integrated dual eligible special needs plan (FIDE-SNP) model. This shift is more than procedural; it signifies a pivotal moment of transition to new federal D-SNP requirements.

Background

The MyCare Ohio Program launched in May 2014 as a Centers for Medicare & Medicaid Services (CMS) FAI demonstration. MyCare Ohio integrates Medicare and Medicaid benefits for dually eligible members enrolled in competitively selected MyCare Ohio managed care plans, providing one care coordinator and streamlined communication and services. It serves 150,000 individuals in 29 counties.

CMS is sunsetting all FAI demonstration programs on December 31, 2025, prompting ODM to convert to the FIDE-SNP model.

Next Generation RFA

The MyCare Ohio Program will convert to the Next Generation MyCare Ohio Program in January 2026. ODM is modeling portions of the program after the state’s Next Generation Medicaid managed care program. The Next Generation MyCare Ohio Program initially will be implemented in the 29 currently participating counties and then expand statewide, covering a total of 250,000 eligible individuals. Medicaid managed care organizations (MCOs) that serve the program will need to become CMS-approved FIDE-SNPs. MCOs awarded a Next Generation MyCare Ohio contract will need to notify CMS of their intent to establish a statewide FIDE-SNP in Ohio by fall 2024 to begin operations in January 2026.

ODM anticipates selecting up to four Next Generation MyCare Ohio MCOs to serve enrollees statewide, though a decision on the number of plans will be finalized as awards are made and based on what is most advantageous to the state.

MCOs will need to develop a member-focused strategy with care coordination as a priority. MCOs will also increase focus on behavioral health coordination. According to ODM, goals for the Next Generation program include:

Focusing on the individual
Improving individual and population wellness and health outcomes
Creating a personalized care experience
Supporting providers in continuously improving care
Improving care for people with complex needs to promote independence in the community
Increasing program transparency and accountability

Next Generation MyCare will advance these goals through a population health approach, designed to address inequities and disparities in care.

The program will enroll dually eligible individuals ages 21 and older. This is a change from the current program, which enrolls dual eligibles who are 18 years old and older. The eligible age increase is being made to align with the Medicaid early and periodic screening, diagnostic, and treatment (EPSDT) benefit.

The new program also will continue to offer all the same services available through Ohio’s home care, PASSPORT (long-term services and supports), and assisted living waivers.

Evaluation

Applications initially will be reviewed to confirm the applicant meets the mandatory requirements. Applicants who meet the mandatory requirements will proceed to review and evaluation of responses to application questions that fall into seven topic areas, with a total of 1,000 available points (see Table 1). Of note, if an applicant is not currently serving as either a Next Generation MCO or a MyCare Ohio MCO, the applicant will receive zero points for qualifications and experience. Organizations that have yet to participate in at least one of these programs should consider the effect on their total score.

Table 1

Current Market

Five MCOs—CVS/Aetna, CareSource, Centene/Buckeye, Molina, and United—participate in the current MCOP, with two or three of them participating in each of the seven regions.

Timeline

MCOs should submit a notice of intent to apply by June 21. Proposals are due August 2, and awards will be issued October 8. Implementation is scheduled for January 1, 2026.

Link to RFP

Connect With Us

Ohio is one of several states transitioning from a FAI demonstration at the end of December 2025. Additionally, the 2025 Medicare Advantage Final Rule includes new policies affecting D-SNPs that could reshape the integrated care plan landscape in many states.

Health Management Associates (HMA) will host a webinar June 20, 2024, to review the current landscape and federal changes that will affect D-SNPs in 2025 and beyond. The session will feature an analysis of the new regulations and a discussion of the critical strategic and product impacts on Medicare organizations that offer D-SNPs or are considering offering D-SNPs. Attendees also will have the opportunity to engage with the panelists during a Q&A session.

More information on the webinar is available here. Contact HMA expert Sukey Barnum to learn more about the Ohio RFA and Holly Michaels Fischer, Greg Gierer, Dara Smith, and Tim Murray for details about the nationwide D-SNP rules and landscape.

Federal healthcare quality initiatives: recent developments reshaping the landscape

Read Blog

This week, our In Focus section considers the increasing emphasis on quality at all levels of our healthcare system, especially for work that affects federally funded health insurance programs.

The Universal Foundation Measure Set

The 2024 Centers for Medicare & Medicaid Services (CMS) Quality Conference, April 8−10, in Baltimore, MD, continued to highlight the harmonizing of quality measures across CMS programs and promotion of CMS’s universal foundation measures. These metrics capture quality across six domains for adults and four domains for children. By promoting and integrating these well-established measures across all CMS programs, end users can align priorities across programs and help to reduce burden on providers and health plans being assessed.

Medicaid has long been a leader in incorporating the universal foundation measures, having used many of them in managed care contracts, health homes, and other arrangements that include a quality assessment component for the past 20 years. Earlier this year, many universal foundation measures, including those pertaining to behavioral health, became part of the mandatory core measure set that all states must report to CMS as required in the SUPPORT for Patients and Communities Act—comprehensive federal legislation that addresses the opioid epidemic. Mandatory reporting will allow Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC), and other stakeholders to better understand the impact of federal investments on quality of care for Medicaid and CHIP enrollees.

New Developments in Medicaid’s Approach to Quality

Forward momentum is evident in other areas of healthcare quality as well. A significant federal milestone in quality of care was included in the Medicaid Managed Care Rule released in April 2024, which required states to design a quality rating system (QRS) and submit their methodology to CMS for approval. The QRS is intended to be user-friendly and help Medicaid members to pick a plan and monitor its quality performance. States will be able to use the QRS as a monitoring and oversight tool to compare plan performance. Not only will a QRS help improve Medicaid’s accountability to states, enrollees, and policymakers, but it also promotes transparency for all end users and the public. At present, Medicaid quality measures are reported by state rather than by plan. Plan performance in Medicaid is typically captured in a state’s external quality review organization (EQRO) annual report, which may impede the ability of most users to extract, compare, and digest information.

Another federal initiative is the Medicaid Access Rule, also released in April 2024, to help state Medicaid programs move toward public reporting of quality and compliance measures in home and community-based services (HCBS). In 2022, CMS released more than 90 measures that could be used to assess quality of care in Medicaid HCBS waiver populations. Under the rule, CMS will identify a subset of HCBS quality measures in 2026 and the technical specifications for these measures will be made available publicly and updated as needed. Similar to the CMS Child and Adult Core Sets, states will have an opportunity to implement these measures and CMS can use those outcomes to create HCBS scorecards by state.

Medicare Advantage Star Ratings Program

Finally, CMS is incorporating the health equity index (HEI) into the Medicare Advantage Star Rating system. The HEI contributes to a plan’s potential bonus and helps level the playing field for plans that enroll and provide services to underrepresented or at-risk populations. The HEI will account for enrollees who are dually eligible for Medicare and Medicaid, individuals with disabilities, or members with a low-income subsidy (LIS). The HEI also assesses plan-level performance for these specialized populations. Allowing plans to earn a better bonus for delivering high-quality services to these populations helps to mitigate adverse selection and reward plans for care that may be resource intensive.

What’s Next

Accountability for quality is beginning to emerge in the form of value-based contracting, incentive payments, and other forms of reimbursement focused on reducing disparities and improving outcomes. Health plans, providers, state agencies, vendors and other interested stakeholders need to have a strategy for quality improvement that reflects evolving federal and state quality priorities, reporting systems, and improvement processes.

HMA’s quality and accreditation team includes experts in the quality space from a variety of backgrounds, including National Committee for Quality Assurance (NCQA) surveyors, former HEDIS auditors, health plan and provider senior quality staff (vice presidents and chief quality officers), and former Medicare/Medicaid leaders. To learn more about implementing quality programs or to explore options for leveraging quality measures to maximize your organization’s value-based contracts, win requests for proposals, increase membership, and optimize member experience, contact Caprice Knapp, PhD, Managing Director, Quality Accreditation.

Crosswalk of 400 recommendations on behavioral health workforce

Read Blog

The Center for Workforce Solutions (CWS) complied more than 400 recommendations for dealing with behavioral health workforce issues, from publicly available reports by federal and state policymakers, national associations, foundations and other partners and stakeholders. The summary of that report can be found below.

READ THE REPORT SUMMARY

The CWS is a partnership between the National Council for Mental Wellbeing (National Council), Health Management Associates (HMA) and The College for Behavioral Health Leadership (CBHL). The CWS is invested in creating a national platform that supports cross-sector partners working at multiple levels of the system to execute solutions in concert to tackle complex recommendations and achieve meaningful impact. They want to elevate workforce solutions that exist and can scale as well as build the pathways for overcoming barriers to implementation.

In an effort to understand what recommendations exist and what initiatives are suggested as solutions for the workforce crisis, the CWS reviewed recommendations and cross-walked them to the CWS levers of change as a way of building an actionable roadmap for addressing the behavioral health workforce crisis and to support cross-sector action towards creating a stronger, more equitable workforce.

Learn more about HMA’s work with the CWS and on Collective Impact at https://www.healthmanagement.com/blog/advancing-workforce-through-collective-impact/

If you want to learn more about how HMA can help your organization with behavioral health workforce issues, contact our experts below.

Election-driven shifts in healthcare innovation

Read Blog

Innovation is the source of progress, driving advancements across industries and shaping the way we live, work, and interact. However, the landscape of innovation is not static—it ebbs and flows, influenced by various factors including political leadership. This year’s presidential election may bring forth significant shifts in priorities, policies, and funding that directly impact innovation efforts like Center for Medicare & Medicaid Innovation (CMMI), state waivers and the Advanced Research Projects Agency for Health (ARPA-H).

CMMI serves as a catalyst for testing innovative payment and service delivery models within Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). With a new administration comes the potential for shifts in CMMI’s focus and funding priorities. For instance, a president (or his/her appointees) can direct CMMI to design payment models, reimbursement structures that can lead to higher quality outcomes and more cost-effective healthcare delivery. The policy priorities and values that undergird a president’s healthcare agenda can shape the kinds of innovation that CMMI drives. Current CMMI initiatives have prioritized value-based care approaches linking payment to outcomes, improving equity of care across race, gender, and geography, and patient-centered care models designed to support particularly high cost, complex conditions; the priorities of the previous administration included focus on substance abuse disorders, kidney disease, and diabetes.

CMS also grants waivers to states, such as Section 1115 waivers for Medicaid or 1332 waivers for insurance marketplaces, that offer flexibility to experiment with innovative healthcare solutions. The values and policy approaches of a new president will influence the degree of regulatory flexibility and the types of experimentation that will be approved. For example, several states have recently received approval on Medicaid waivers that encourage community-based approaches to whole person care, wrapping together healthcare coverage, benefits, delivery, with new support services that address upstream barriers to health.

ARPA-H, a new unit within the National Institutes of Health focuses on investments in “break-through technologies and broadly applicable platforms, capabilities, resources, and solutions that have the potential to transform important areas of medicine and health for the benefit of all patients,” holds immense potential for driving breakthroughs in healthcare by funding innovation that “cannot readily be accomplished through traditional research or commercial activity.” The types of projects funded by ARPA-H could be directly impacted by the policy and budget priorities of whomever is president in 2025 and their interest in promoting collaboration between government, academia, and industry to address complex health challenges. A prime example of a potentially impacted area is the emphasis on cancer research by the Biden Administration. This focus may shift drastically with a change in leadership.

For healthcare innovators looking to stay informed and adaptable amidst these potential policy changes, HMA has two opportunities of interest: The HMA Fall conference, and a DC Direct subscription. On October 7-9, healthcare leaders and HMA experts will gather for the 2024 Fall Conference: Unlocking Solutions in Medicaid, Medicare and Marketplace, focused on innovation in public programs. Our keynote speaker Darshak Sanghavi, MD is, a foundational leader at ARPA-H tasked with developing health programs that challenge how we think about healthcare innovation inside and outside government. Conference registration is open and can be found here.

Leavitt Partners (LP), an HMA Company, guides clients who need to more closely track federal policy and regulatory activity and know when and how to influence the process. DC Direct, an exclusive offering from LP, provides timely information and insights to elevate your knowledge from simply scratching the surface of understanding to becoming part of the fabric of change.

Texas releases STAR Kids RFP

Read Blog

This week’s second In Focus reviews the Texas STAR Kids request for proposals (RFP), which the Texas Health and Human Services Commission released on May 10, 2024. The STAR Kids Medicaid managed care program provides coverage to children and youth ages 20 and younger with disabilities. Nine plans currently participate in the program, with contracts worth approximately $4 billion annually.

STAR Kids Overview

The STAR Kids program operates under the Texas Healthcare Transformation and Quality Improvement Program 1115 demonstration project. To be eligible, individuals must receive Supplemental Security Income (SSI) and SSI-related Medicaid, participate in the Medically Dependent Children Program (MDCP) Section 1915(c) waiver, live in a community-based intermediate care facility, or participate in an intellectual or developmental disability (I/DD) waiver program.

Medicaid managed care organizations (MCOs) provide acute, behavioral, and long-term services and supports (LTSS) to children in the MDCP program and acute services only to children covered under the other home and community-based services/IDD waivers.

RFP

Texas plans to award contracts to at least two MCOs for each of the 13 service areas (SAs). Each MCO can be awarded up to six SAs.

MCOs will need to describe reimbursement strategies that incentivize high-quality and cost-effective healthcare while controlling spending and reducing ineffective service utilization in their proposals.

MCOs must demonstrate progress toward advancing alternative payment model (APM) initiatives within an APM performance framework. MCOs will need to provide a proposed APM and a means of tracking its effectiveness, including implementation of processes that support and incentivize providers to apply value-based care models and reward high performers.

Evaluation

Technical questions in the proposals are divided into five broad categories, representing a total of 1,800 points. Plans can score up to 2,000 points, including oral presentations (see table below).

Timeline

Proposals are due July 11, with awards expected to be made between December 2025 and February 2026. The contract start date is anticipated to begin between December 2026 and February 2027. Contracts will run for six years with three two-year renewal options.

Current Market

Incumbents CVS/Aetna, Elevance/WellPoint, Blue Cross Blue Shield of Texas, Centene/Superior Health Plan, Community First Health Plan, Cook Children’s Health Plan, Driscoll Children’s Health Plan, Texas Children’s Health Plan, and UnitedHealthcare served 150,000 beneficiaries as of November 2023.

Connect With Us

Texas has an active Medicaid procurement schedule, with key deadlines and additional developments expected in the coming months. HMA experts in Texas are monitoring these activities as the state works to reprocure all its Medicaid managed care contracts. These programs include the State of Texas Access Reform (STAR) and CHIP for traditional Medicaid members, STAR+PLUS for members who are aged and disabled, and STAR Kids for individuals younger than 20 years old with disabilities.

Through HMA’s Information Services, subscribers gain access to detailed information about the Texas and other state RFP landscapes and procurement documents, as well as historical data about plan contracts, enrollment, and financials.

For more information about HMA’s work in Texas and our HMAIS resources contact Stephen Palmer, Alona Nenko, and Andrea Maresca.

Minnesota’s initiative to build a stronger substance use disorder ecosystem

Read Blog

This week, our In Focus section spotlights Minnesota’s innovative efforts to develop a comprehensive ecosystem that addresses substance use disorder (SUD).

Overview

Like many states, Minnesota experienced a significant surge in overdose deaths between 2018 and 2021, magnifying disparities in health outcomes linked to SUD and fatalities. For example, in 2021, Native American Minnesotans were 10 times more likely to succumb to a drug overdose than their white counterparts. Similarly, Black Minnesotans faced over three times the risk of dying from a drug overdose compared with White Minnesotans.

How do you create a more effective SUD prevention and treatment system? By fostering collaboration among the people who are directly affected, service providers, advocates, policymakers, and payors so they can learn from one another, offer support, and collectively commit to advancing change.

The Minnesota Department of Human Services (DHS) Behavioral Health Division has enlisted Health Management Associates, Inc. (HMA), to facilitate the Minnesota SUD Community of Practice (CoP), with the goal of creating a culturally responsive system of care. A CoP has three primary elements:

A common identity, purpose, or value that encourages engagement and mutual exploration
A community that establishes a culture of learning and willingness to share, ask, and listen
The cultivation of practices where the community develops, shares, and maintains frameworks, tools, and ideas that are evidence-based and usedii

HMA understands that a well-established CoP, supported by solid processes, tools, resources, and expertise, is essential to realize and sustain a strong CoP foundation for translating knowledge into action.

Many states, including Minnesota, are using the American Society of Addiction Medicine (ASAM) criteria as the guidepost of their efforts to improve the addiction treatment system. To develop a road map on how to implement the ASAM Fourth Edition Levels of Care in Minnesota, HMA convened workgroups to collect firsthand information about services available in participants’ communities, whether they can deliver services at the ASAM level, and the barriers to providing this level of care.

The Approach

To authentically engage the community, HMA has partnered with three community advisors, each representing communities with the most significant disparities. The community advisors are integral to ensuring all CoP efforts incorporate a cultural lens that is responsive to the needs of communities facing health inequities. They do so by amplifying the voices and experiences of individuals in populations disproportionately affected by SUDs. In addition, the community advisors provide tailored facilitation, training, and resources within their respective CoPs to promote culturally specific and responsive practices. This approach seeks to increase treatment engagement and reduce disparities in treatment outcomes.

HMA is working with the CoP to create a report on SUD treatment gaps, a strategic planning and implementation summary, an ASAM implementation road map, a community advocacy capacity-building report, and an overview of culturally specific and responsive models of care.

Connect with Us

HMA brings experience in helping to build systems of care and expertise in assisting states with assessing ASAM levels of care and developing strategies, plans, and training to bolster these efforts. HMA is committed to empowering individuals with lived experience and people underserved by existing systems to play key roles in shaping new systems aimed at fostering equitable care.

The May 2024 edition of HMA’s Podcast, Vital Viewpoints, features a discussion with HMA Principal Debbi Witham about her insights on the ASAM levels and the impact on systems of care. She shares her in-depth understanding of the complexities of SUD and underscores the crucial need for quality measures and sustainable healthcare funding while warning against investing in ineffective systems. Ms. Witham further emphasizes how states might correct course now to ensure equitable distribution of funding and offers insights into the essential steps for coordinating a community response that enhances outcomes.

For more information about HMA’s work in Minnesota and similar projects in other states contact Paul Fleissner, Boyd Brown, and Debbi Witham.

SAMHSA’s next chapter: priorities, programs, and possibilities

Read Blog

The prospect of new leadership due to a presidential election brings with it the potential for significant shifts in priorities, policies, and programs within federal agencies. The Substance Abuse and Mental Health Services Administration (SAMHSA) plays an increasingly critical role in shaping the nation’s mental health and substance use disorder services in the United States. Mental health and the opioid crisis are a salient political issue that will receive some attention on the campaign trail, but candidates are unlikely to detail the specifics on how the rhetoric becomes reality.

SAMHSA’s budget could see adjustments, channeling resources toward initiatives that align with the new administration’s vision. This could mean increased funding for specific programs deemed critical under the new leadership and decreases for other programs. Any major shifts in funding will require the support of Congress. Also possible with new leadership are changes to programmatic approaches that revolve around the introduction of novel interventions, expansion of access to treatments, and addressing emerging challenges such as the opioid crisis with renewed vigor.

The intersection of technology and mental health is likely to receive heightened attention. Telehealth expansions, digital tools for prevention and intervention, and data-driven innovations may become focal points of SAMHSA’s strategy.

As SAMHSA adapts to new leadership, the opportunity arises to forge innovative pathways toward improved mental health outcomes and enhanced support for individuals and communities affected by substance use disorders. By embracing whatever change may come, SAMHSA can continue its vital mission of promoting behavioral health and resilience across the nation. The results of the 2024 election will have a significant impact on federal mental health policy in the coming years; DC Direct subscribers get a steady stream of insight to stay on top of what’s coming next.

Takeaways from the ensuring access to Medicaid services final rule

Read Blog

This week’s second In Focus section delves into the Ensuring Access to Medicaid Services final rule. The Centers for Medicare & Medicaid Services (CMS) published the access rule May 10, 2024, alongside the similarly significant Medicaid managed care final rule. The two rules include new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and the Children’s Health Insurance Program (CHIP) across the fee-for-service (FFS) and managed care delivery systems and provide targeted regulatory flexibility in support of this goal.

Five Takeaways from the CMS Medicaid Managed Care Final Rule, which Health Management Associates, Inc. (HMA), published April 24, 2024, outlined key issues and implications that CMS advanced in the Medicaid managed care program. The Ensuring Access to Medicaid Services final rule, meanwhile, focuses on the following:

Payment adequacy for direct care workers (80/20 rule)
The role of self-direction and the 80/20 rule
Establishment of a pathway to national benchmarking of Medicaid rates
Potential impacts of the rule on programs that serve individuals with dual eligibility

Overview

The Ensuring Access to Medicaid Services finalized policies are designed to create an updated federal framework for Medicaid’s home and community-based services (HCBS) programs. These changes come at a pivotal time, as states are facing workforce shortages, particularly among HCBS direct care workers (DCWs). Table 1 provides an overview of several significant final policies.

Table 1. Ensuring Access to Medicaid Services: Overview of Final Rule Policies

Below HMA reviews several key questions we are fielding regarding the impact of the rule.

Ensuring Payment Adequacy: How will states demonstrate that 80 percent of Medicaid payments go to direct care workers?

The final rule requires at least 80 percent of Medicaid payments be spent on compensation for DCWs workers, including homemaker, home health aide, and personal care services. In response to public comment, CMS adjusted the final rule to include some employer costs in the 80 percent calculation.

Recognizing it will take substantial time for providers to establish the necessary systems, data collection tools, and processes to collect the required information to report to states, CMS is providing states six years to implement the HCBS Payment Adequacy policy, and four years for reporting requirements. States and providers must ensure that that they are prepared to meet the payment adequacy requirements in the final rule. Being successful will require collaboration between states and providers, investments in systems, and analysis of – and potentially changes to – reimbursement levels.

How does the 80/20 rule apply to self-directed care?

CMS finalized its proposal to require that at least 80 percent of all payments for homemaker, home health aide, and personal care services in HCBS programs, including managed care programs, be spent on compensation for DCWs. In a change from its proposed policy, CMS limits the 80/20 compensation mandate to certain types of self-directed models. Specifically, the 80/20 rule will apply to models in which the beneficiary directing services does not set the payment rate for the worker, such as Agency with Choice and other self-directed models that use a fiscal intermediary or fiscal employer agent, in both managed care and FFS delivery systems. The compensation rule does not apply to self-directed models in which the beneficiary sets the rates paid to workers.

CMS will hold states accountable for compliance with the 80/20 rule, regardless of whether their HCBS are delivered through an FFS delivery system, managed care delivery system, or both. States will need to determine an approach to track compliance with the minimum performance requirement at the provider level, not the managed care plan level. States and managed care plans should collaborate to determine their respective roles in activities such as the data collection and mandatory reporting, and they should continue to seek and monitor clarifying guidance from CMS.

How will the Ensuring Access final rule affect national benchmarks in Medicaid rates? State Medicaid programs have many nuances that make it difficult to obtain applicable comparison data and best practices. Beginning July 1, 2026, the final rule requires that states publish their payment rates, specifically the average hourly Medicaid FFS fee schedule payment rates, separately identified for payments made to individual providers and provider agencies, if the rates vary. States also must conduct a comparative analysis of their base Medicaid FFS fee schedule payment rates with the Medicare non-facility payment rate. CMS does not, however, require that states change their payment rates based on the comparative analysis.

Payment rate transparency publications, comparative payment rate analyses, and payment rate disclosures present opportunities for states, MCOs, and providers to assess the adequacy of payment rates and their impact on access to services. The forthcoming data also will help federal and state level policymakers in their efforts to improve quality, access, and affordability. States will need to do baseline assessments comparing Medicaid and Medicare rates. States, managed care plans, and providers should monitor for CMS sub-regulatory guidance, including hypothetical examples of the service codes that would be subject to the comparative payment rate analysis.

Does the final rule affect integrated models of care for people who are dually eligible for Medicaid and Medicare? CMS finalizes policies that will have a variable impact on states and individuals dually eligible for Medicare and Medicaid because of differences in state approaches to integrated care for this population. For example, the new grievance system policies apply differently depending on the level of integration the state requires of Medicare Advantage (MA) dual-eligible special needs plans (D-SNPs) programs. Like grievance systems, states, providers, and MCOs should monitor how states address the final rules for critical incidents for individuals with dual eligibility when a Medicaid managed care plan is unable to access Medicare data.

CMS intends to provide additional sub-regulatory guidance and technical assistance to support implementation of policies that affect dually eligible individuals. States should verify their access to and readiness to use Medicare data related to the new requirements, and seek technical assistance to maximize use of these data for individuals enrolled in non-integrated D-SNPs. Commentors have also asked how the changes to the HCBS quality measure set may work in programs for dually eligible members.

Connect with Us 

HMA is ready to support your efforts to understand and take action to account for the Ensuring Access to Medicaid Services final rule’s effects on your state’s or organization’s strategy and operations. Our experts are developing policies and procedures at the intersection of the access and managed care final rules. Please contact Susan McGeehan, Dari Pogach, and Patrick Tigue to connect with our expert team members on this vital set of issues.

HMA opens registration for fall conference: Unlocking Solutions in Medicaid, Medicare, and Marketplace

Read Blog

Unlock Solutions in Medicaid, Medicare, and the Marketplace at HMA’s Fall Conference, October 7−9

This week, we preview what to expect at the 7th annual Health Management Associates, Inc. (HMA) Fall Conference “Unlocking Solutions in Medicaid, Medicare, and Marketplace,” October 7−9, 2024, at the Marriott Marquis Chicago, IL. Learn more about our Keynote Speaker and take advantage of our Early Bird Registration.

Keynote Speaker Announced

We are pleased to announce our Keynote Speaker will be Darshak Sanghavi, MD, program manager at the Advanced Research Projects Agency for Health (ARPA-H)—a newly created multibillion dollar federal agency tasked with developing health programs that are “so bold no one else, not even the private sector, is willing to give them a chance.” His talk, “Unlocking Health Solutions through Innovation,” will highlight the innovative collaborations and projects ARPA-H is advancing. A trained clinician who has served in high level public and private sector advisory roles, Dr. Sanghavi will discuss how this new wave of research and innovations is changing how we think about healthcare’s challenges and will address why the agency is so important at this time. He will highlight ARPA-H investments and commitments and the timeline for impact, including how healthcare systems and states should be thinking about ARPA-H funded innovations and preparing for scaling breakthroughs that improve outcomes.

Before joining ARPA-H, Dr. Sanghavi was global chief medical and clinical operating officer for Babylon, the global end-to-end digital healthcare provider serving more than a dozen countries and 24 million-plus people, with the mission of bringing “affordable and accessible healthcare to everyone on earth.” He also has served in senior roles at UnitedHealthcare’s Medicare & Retirement, OptumLabs, the R&D hub of UnitedHealth Group, and in the Obama Administration as the Director of Preventive and Population Health at the Center for Medicare and Medicaid Innovation, where he directed the development of large pilot programs designed to improve the nation’s healthcare costs and quality. He is an award-winning medical educator, who has worked in medical settings around the world. He will draw on these diverse experiences to inspire and challenge attendees to unlock solutions to some of our healthcare system’s most complex issues.

Network with Leaders in Healthcare

This is an important moment for ever-changing publicly sponsored healthcare programs like Medicaid, Medicare, and the Marketplace, with greater focus on value and federal initiatives that encourage improved health equity, affordability, quality, and outcomes. Don’t miss out on this opportunity to form new partnerships as you dig into today’s urgent issues and immerse yourself in insightful discussions, networking opportunities, and engaging workshops on the new Medicaid managed care rule, applications for AI in healthcare, approaches to meet rural workforce needs, value-based care contracting, and insights from state Medicaid services.

Preconference tactical workshops will focus on exclusive tools, insights, and strategies to guide program design, navigate new regulatory frameworks, and advance value-based care. HMA’s premier national conference plenary and breakout sessions will focus on the landscape for innovation in healthcare, emerging service delivery models, and growth strategies in pursuit of improved value, quality, and better outcomes.

Who should attend?

Executives and leaders from federal, state, and local government agencies, health plans, payers, managed care, hospitals and health systems, provider and provider enablement organizations, community-based organizations, IT companies, life sciences organizations, investment firms, foundations, and associations.

CLICK HERE TO REGISTER

The 2024 Presidential Election and its long-term impact on Medicaid

Read Blog

The prospect of new leadership due to a presidential election brings with it the potential for significant shifts in priorities, policies, and programs within federal agencies. Medicaid now provides healthcare coverage for more than 84 million Americans. Since 2010, Medicaid has been subject to significant federal policy changes, starting with expansion as part of the Affordable Care Act, pandemic-related continuous eligibility provisions, expanded coverage for postpartum women, and just recently updated rules for managed care plans. The 2024 election will have a significant impact on Medicaid in the coming years, although you won’t hear much about it on the campaign trail (but our DC Direct subscribers get a steady stream of insight to stay on top of what’s coming next).

Medicaid’s political salience has been quiet but steadily increasing since 2010, with now 41 states (including DC) having expanded access, changing the political narrative about the program. Medicaid coverage churn due to the unwinding of the pandemic related continuing-coverage provisions has been politically fraught for governors and legislatures, even bringing some states like Mississippi to finally consider the expansion opportunity to improve stability of coverage.

States each have their own approach to designing Medicaid coverage, but federal rules set the parameters within which they choose how to maintain access and quality of healthcare for low-income individuals and families. New CMS rules are requiring require more from managed care plans who contract to administer Medicaid in many states, increasing network adequacy, quality measurement standards, consumer protections and tailored approaches for long-term services and supports. These changes will shape the future of procurements for managed care services.

The election is very likely to touch on broad issues of affordability and equity, which are relevant to all healthcare programs but especially to Medicaid. Current policy priorities that center on equity have resulted in program design features that can impact the social determinants of health, including initiatives to address housing insecurity, food access, and mental health services. Increasingly these concerns have been bipartisan, although the proposed approaches will differ based on who is in charge.

Changes in national leadership – whether at CMS, HHS, or in the White House – will inevitably result in changes to the Medicaid program that impacts states and the agencies that serve the millions of Americans who rely on the program for essential healthcare services. Our Leavitt Partners colleagues provide regular intelligence on all the federal activity in D.C. that impacts Medicaid and other state health programs. Learn more about DC Direct and how this steady stream of insight can help inform your strategic decisions.

Succeeding in the world of value-based payments: assess your organization’s VBP readiness

Read Blog

In the ever-evolving landscape of healthcare, the shift towards value-based care (VBC) has emerged as a transformative force, promising improved outcomes, reduced costs, and enhanced patient experiences. While the benefits of VBC are clear, the path to implementation can be complex and challenging, particularly for behavioral health (BH) providers. In this blog post, we delve into the significance of assessing readiness for VBC and value-based payment (VBP) systems, with a specific focus on BH providers, and why it serves as a crucial step towards success.

Behavioral health plays a pivotal role in holistic patient care, addressing mental health and substance use disorders that significantly impact overall well-being. However, traditional fee-for-service models often inadequately incentivize preventive and coordinated care, leading to fragmented services and suboptimal outcomes. Recognizing this gap, the transition to VBC offers a promising avenue to realign incentives, improve care coordination, and enhance patient outcomes in the realm of behavioral health.

Insights from the HMA Spring Workshop

In March 2024, HMA hosted a workshop on value-based care, (you can read more of the key takeaways here). A consensus emerged on the indispensable role of data and technology in driving informed decision-making. Dr. Katie Kaney’s keynote address on innovative approaches to holistic care metrics resonated with attendees, highlighting the need to move beyond conventional measurements towards a comprehensive understanding of patient well-being.

A pivotal aspect of VBC lies in the collaborative effort between payers and providers to align measures and incentives while ensuring these measures hold significance for all stakeholders, including payers, providers, and patients. The conversations with attendees on Empowering Care Delivery through Tangible Measures underscored the imperative of clinician involvement in outcome measurement establishment. We discussed the importance of meaningful measurement for state-level initiatives and local strategies, all aimed at achieving better outcomes for our communities.

The Importance of Readiness Assessment

Embarking on the journey towards VBC demands a comprehensive understanding of organizational strengths, challenges, and readiness to embrace change. As we navigate the transition to value-based care, understanding where your organization stands is key. This is where readiness assessment tools play a pivotal role. By systematically evaluating various aspects of organizational preparedness, such as infrastructure, data capabilities, care delivery models, and cultural readiness, organizations can identify areas for improvement and tailor strategies to navigate the transition effectively.

Tailoring Strategies for Success

Assessing readiness enables organizations to tailor strategies that align with their unique circumstances and challenges. For instance, organizations lacking robust data infrastructure may prioritize investments in health information technology and analytics capabilities to support population health management and outcome measurement. Similarly, addressing workforce training and cultural transformation can foster a patient-centric approach and promote collaboration across care teams.

Mitigating Risks and Maximizing Opportunities

VBC presents both opportunities and risks for organizations. While it offers incentives for preventive care, care coordination, and improved outcomes, it also requires operational and cultural shifts that may pose challenges. Readiness assessment enables organizations to identify potential risks, such as inadequate data systems, reimbursement uncertainties, or staff resistance, and develop mitigation strategies to address them proactively. Moreover, it empowers organizations to capitalize on opportunities, such as alternative payment models, partnerships with primary care providers, and value-based contracting, to enhance sustainability and growth.

Driving Quality and Equity in Behavioral Health

At its core, VBC embodies a commitment to delivering high-quality, equitable care that addresses the diverse needs of patients. By assessing readiness and embracing VBC principles, BH providers can enhance care delivery, improve outcomes, and reduce disparities in access and quality of care. Furthermore, by integrating behavioral health into broader care delivery models and payment structures, organizations can foster a more holistic approach to health and well-being, promoting resilience and recovery for individuals and communities alike.

Moving Forward with Confidence

As organizations navigate the complexities of VBC, assessing readiness serves as a guiding compass, illuminating the path forward and empowering organizations to embrace change with confidence. By leveraging readiness assessment tools, organizations can identify strengths, address weaknesses, and chart a course towards sustainable, value-driven care delivery. In doing so, they not only enhance their own viability and success but also contribute to a more resilient, equitable healthcare system that prioritizes the well-being of all individuals.

How HMA Can Help

There are many tools online that offer to help organizations determine their readiness for implementing VBC. By using HMA’s new VBP Readiness Assessment tool, you also can gain access to the experts on HMA’s behavioral health and VBC teams. Meticulously crafted to gauge your organization’s preparedness, HMA’s value-based payment readiness assessment surveys six domains of core functions necessary for successful payment reform models.

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.

Assessing readiness for VBC is not merely a preparatory step but a fundamental aspect of organizational transformation. For behavioral health providers, it represents a critical opportunity to reshape care delivery, drive quality and equity, and ultimately, improve the lives of those served. As the healthcare landscape continues to evolve, readiness assessment will remain an indispensable tool for navigating change, fostering innovation, and realizing the full potential of value-based care in behavioral health.

TAKE THE SURVEY AND LEARN MORE

Featured Services:

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

Receive timely expert insights on topics you care about.

547 Results found.

Insights from the HMA Spring Workshop

The Importance of Readiness Assessment

Mitigating Risks and Maximizing Opportunities

Driving Quality and Equity in Behavioral Health

Moving Forward with Confidence

How HMA Can Help