HMA Insights: Your source for healthcare news, ideas and analysis.
HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.
The Nevada Division of Health Care Financing and Policy (DHCFP) engaged HMA to evaluate Nevada’s Medical Assistance for the Aged, Blind, and Disabled (MAABD) program and the needs of its participants. A targeted focus of the evaluation was on home and community-based services (HCBS) within the Nevada MAABD population, including Nevada’s Frail Elderly (FE) and Physically Disabled (PD) waiver.
The project included:
Data analyses of Nevada’s population and long term services and supports (LTSS) landscape, the state’s ongoing efforts to rebalance LTSS dollars from institutional to HCBS services and demographic and other information about the MAABD population
Stakeholder engagement, including three focus groups that engaged 55 stakeholders and individual interviews, to provide stakeholders a greater voice in the MAABD improvement process
Evaluation of the MAABD structure and administration
Program recommendations to help inform and guide DHCFP’s considerations for better serving the FE and PD MAABD populations throughout the state
The report made recommendations to enroll the MAABD population aged 65 and older into a combination MLTSS/FIDE-SNP (managed long-term services and supports/fully integrated dual eligible special needs plan) program, implement Program of All-Inclusive Care for the Elderly (PACE) as a targeted nursing home diversion strategy and strengthen Nevada’s Medicaid quality framework to better deliver and ensure improved quality of care for the MAABD population.
“Public health problems pose special challenges. They are generally enormous in scale, stem from numerous and highly complex causes, play out in the public eye, impact a vast array of stakeholders, and require unusually long-term solutions. The massive scope and complexity of such problems, including conditions such as uncontrolled childhood mortality, suboptimal maternal health, HIV/AIDS, cardiovascular disease, and cancer, among others, affect millions worldwide. Furthermore, the health issues quickly trigger a host of other family, economic, and social problems that ruin lives, erode communities, and weaken countries.”
– Journal of Public Health, Fostering public health leadership article
Concerned about another crisis?
Health departments play a critical role in achieving health security, including preparing communities for potential threats, mitigating those threats, responding to emergencies, and aiding in the recovery process. Over the past few years, public health has been faced with heightened scrutiny, lack of trust, and the need to evolve and keep up with the latest natural disasters, environmental, and infectious disease threats.
How HMA can help
HMA assists state, local, territorial, and tribal health departments with:
Plan writing, including emergency operations, hazard mitigation, medical counter measures, mass fatality, pandemic, continuity of operations, and crisis communications.
Reviewing and synthesizing emergency plans, policies, and procedures into actionable and meaningful abbreviated checklists.
Training and exercise development, including tabletop exercises, full scale exercises, hot wash debrief facilitation, after action report writing.
Workforce analyses, including determining if your health department is adequately staffed to respond to an emergency and maintain the foundational public health functions.
Capacity building and strategic infrastructure investment, including spending plans, funding, and development of action plans.
Staff/workforce resilience and morale, including team building, workforce assessments, and strategic planning.
Equity and Inclusion, including access and functional needs.
Infection control, including facilitating trainings, plan writing, and compliance.
Our Colleagues and Expertise
HMA public health preparedness experts applicable experience and expertise to assist public health agencies in preparing, mitigating, responding to, and recovering from public health emergencies.
Managing and coordinating Public Health Emergency Preparedness (PHEP) grants and emergency response and recovery activities at state, local and territorial health departments.
Developing emergency operation plans, procedures, and guidelines for emergency response projects.
Multifaceted public health strategic planning, which incorporates health services access, social service integration, workforce sustainability, data modernization, and environmental considerations.
Former staff from the National Association of County and City Health Officials (NACCHO)’s public health preparedness program.
Supply chain management of medicines and other health technology resources.
Development of evidence-based infection control practice, policy, and procedures.
Colleagues educated via the Association of Professionals in Infection Control and Epidemiology (APIC) in infection control prevention practices and public policy.
Project Spotlight
HMA worked with El Paso County Public Health (EPCPH) leadership to extend the reach of EPCPH staff during this pandemic and support the quick development of a COVID-19 recovery plan and an After Action Report (AAR). HMA gathered background information, intelligence, and templates from EPCPH staff, drawing from the prior COVID-19 plans. HMA documented best practices from other counties where HMA currently supported COVID-19 response planning and conducted interviews with EPCPH staff as needed to provide input into the plans. HMA drafted two plans: 1) a COVID-19 recovery plan, including a review of the transition back after COVID-19, health department continuity of operations (COOP) as it moved back to normal and indicators for return to work, and 2) an AAR for EPCPH’s positives and negatives related to the following: variances, EH (masks, capacity) compliance (masks, capacity), case investigation/contract tracing, and data analytics as well as med surge.
HMA evaluated COVID-19 response activities within the Hospital Association of California (HASC) member facilities and partners across the regions served. HMA reviewed a representative sample of member facility and partner agency plans developed and utilized during the response. We reviewed relevant annexes, guidance from local and state public health, member facilities, and federal agencies activated, alongside open-source information. HMA also examined documentation developed during response and recovery, including situation reports, memorandums of understanding, messaging to facilities, memos about response, training, and exercise events to perform an analysis of activities and references. In addition, this project garnered input from other key healthcare and government stakeholders in the regional market, including emergency medical services, public health, city and county governments, transportation, and others via online surveys and small group interviews. The creation of a Mid-Action Report/Best Practices Plan was particularly important to document lessons learned, best practices, and improvement items to inform ongoing efforts and future readiness initiatives to improve HASC’s capabilities and the planning needs of its members.
Hannah Savage is an experienced public health professional with skills in program evaluation, data analysis, survey development, survey analysis, and … Read more
A multi-disciplinary public health leader, Emily Wilson is passionate about bringing people together to solve the most pressing problems in … Read more
Over the past decade, the U.S. has seen significant federal and state policy initiatives to improve and expand assistance for the millions of family members who help care for older adults, and those who support people with intellectual and developmental disabilities (I/DD) across the lifespan. The pandemic, combined with workforce shortages, accelerated these efforts. In this webinar with national family caregiving experts, we discussed policy and practice advances and their potential impact on enabling more Americans to live at home and in the community.
Learning Objectives:
Review evidence that supporting family members improves outcomes for older adults and people with I/DD.
An overview of current federal and state implementation of the 2022 National Strategy to Support Family Caregivers and the 2022 National Agenda for Supporting Families with a Member with I/DD.
Share evolving opportunities for improving policy and practice in family caregiving initiatives.
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.
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 on June 20, 2024 titled “D-SNP growth and integration: key implications of the 2025 CMS final rule” 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. Watch the replay now.
Contact our experts below for details about the nationwide D-SNP rules and landscape.
Watch our informative webinar where HMA experts reviewed the upcoming changes from the 2025 Final Rule that will impact Dual Special Needs Plans (D-SNPs) in 2025 and beyond. The session featured an analysis of the new regulations and a discussion of the critical strategic and product impacts on Medicare organizations offering D-SNPs or considering offering D-SNPs. Attendees also had the opportunity to engage with the panelists during a Q&A session.
Learning Objectives
Understand the impact of the 2025 Final Rule on D-SNPs as CMS promotes the integration of Medicare and Medicaid for dually eligible individuals.
Gain a high-level understanding of the federal changes, the timelines for implementation, and the impact on your D-SNP strategy and growth opportunities.
On May 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F).
CMS created a fact sheet which concisely reviews the final rule’s key provisions, as well as an applicability dates chart, which serves as a reference guide to the various applicability dates for different provisions in the final rule. The final rule creates new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and CHIP by principally addressing these topic areas:
ILOSs are defined as substitute services or settings for a service or setting covered under the state plan and can be leveraged by Managed Care Organizations (MCOs) to address unmet health-related social needs (HRSNs).
They must be offered to all members and must be voluntary as well as documented in MCO contracts.
ILOSs cannot exceed 5% of total capitation.
If ILOS costs exceed 1.5% of total capitation, states must provide additional documentation to CMS to demonstrate medical appropriateness and cost-effectiveness.
When an ILOS is terminated, states must develop a transition plan to arrange for state plan services and settings to be provided in a timely manner.
States must make available online a “one-stop-shop” where members can learn about and compare MCOs based on quality and other variables.
Mandatory quality measures are established.
The methodology for calculating the quality ratings displayed on each state’s MAC QRS is also established.
Although guidelines exist, states can submit their own version of a MAC QRS to CMS for approval.
Provider incentive payments must be tied to clearly defined, objectively measurable, and well-documented clinical or quality improvement standards to be classified as incurred claims (in alignment with private market MLR regulations).
Prohibits the inclusion of indirect administrative costs that are not directly related to improving quality as QIAs as incurred claims in the numerator (in alignment with private market MLR regulations).
Imposes additional expense allocation methodology requirements (in alignment with private market MLR regulations).
Requires SDPs to be included as both incurred claims (for payments made by MCOs to providers) and premium revenue (for payments made by states to MCOs).
Sets maximum appointment wait time standards of no more than 15 business days for routine primary care (adult and pediatric) and obstetric/gynecological services and 10 business days for mental health and substance use disorder services (adult and pediatric).
Enforces these standards using secret shopper surveys and requires states to contract for the secret shopper surveys.
Requires states to post the appointment wait time standards as well secret shopper survey results.
A remedy plan must be implemented for any MCO that fails to meet these required standards for access.
States must also conduct an annual enrollee experience survey for each MCO.
Codifies ACR payment ceiling, which applies to hospitals, practitioner services at academic medical, and nursing facility services.
Requires “hold harmless” attestation.
Allows for SDPs at 100% of Medicare without prior written approval.
Removes network provider requirement to receive payment.
Prohibits use of interim payments based on prior period data even if ultimately reconciled.
Prohibits use of separate payment term where SDPs are paid separate from capitation rates.
Explicitly states that SDPs must result in “stated goals and objectives.”
Requires states to submit detailed, provider level SDP data to the Transformed Medicaid Statistical Information System.
Implications for States
The final rule creates opportunities for states to leverage new flexibilities to further policy goals but also creates new administrative burdens. MCOs and providers will look to states to comprehensively understand final rule’s requirements and be prepared to manage the steps necessary to achieve compliance over a multiyear implementation process.
Implications for MCOs
As states move to comply with the final rule, MCOs will be immediately downstream from the steps taken by states to do so and MCOs need to prepare accordingly. Proactive actions by MCOs to not only engage with states early but also to prepare financially and operationally for the different provisions of the final rule over time will put them in the best position possible.
Implications for Providers
The most significant implications for providers in the final rule are related to SDPs, where a new level of accountability will be required. All topics covered by the final rule, however, have provider implications.
Looking ahead
The provisions of the final rule range in their effective dates from as early as the final rule’s effective date, July 9, 2024, to as late as the first rating period on or after four years after July 9, 2024.
Because of these variable effective dates, states, MCOs, and providers will need to comply with the final rule immediately in some cases, while having significant lead time to do so in other areas. Sub regulatory guidance is also forthcoming and must be monitored for and digested.
HMA stands ready to support states, MCOs, and providers in analyzing and responding to the strategic, financial, and operational impacts of the final rule’s provisions in specific markets and organizational contexts.
If you have questions or want to connect with our expert team members, e-mail [email protected].
HMA recently released a report on the Medicare Physician Fee Schedule (PFS) with background on the structure of the program, and recommendations for reforms that could be considered. This webinar provided background and context about the PFS for interested parties who may be less familiar with the payment system and why the stakeholder community got to the point of needing to “fix” the fee schedule. We discussed pressing policy and payment concerns, provided an overview of key structural issues within the PFS that should be considered and balanced when making policy changes to the payment system, highlighted different stakeholder perspectives, and offered recommendations within CMS authority.
Learning Objectives:
Understand the background, context and function of the PFS including its relationship to other payment systems.
Highlight key policy developments over time leading to the current focus on “fixing” the payment system.
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 our featured expert below.
