Insights

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

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

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

Filter by topic:

Receive timely expert insights on topics you care about.

Select Topics

1852 Results found.

HMA News

HMA pre-conference workshop focuses on behavioral health innovation and new solutions at the intersection of health and human services

Read News

The demand for behavioral health services has never been greater than it is in 2023. Broad focus on mental wellness and pandemic-driven trauma have increased demand for lower acuity care, while significant spikes in overdoses and suicides have increased demand for higher acuity care, including inpatient treatment. Dramatic increases in government funding and policies to expand access have run up against an overburdened and fragmented behavioral health delivery system and a shortage of clinicians, creating an urgent need for innovative workforce and technology solutions that better integrate behavioral, physical, and public health systems. 

HMA’s 6th annual conference, “Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth” is putting a special focus on behavioral health through a half-day pre-conference workshop as well as topics throughout the regular conference sessions that highlight how these services and programs are becoming more integrated. 

Pre-Conference Workshop 

Join us on Sunday, October 29th at the Fairmont Chicago, Millennium Park for a deep dive into how behavioral health sits at the intersection of health care and the social services that are critical to achieving positive health outcomes: 

  • An opening panel on behavioral health system redesign and how states are leveraging new policies, waivers, and funding streams to improve access to services. This panel will feature Monica Johnson from SAMHSA and leaders from Massachusetts, Iowa, and New York. 
  • A panel on complex populations and how states are connecting these patients to address health related social needs that can impede progress. This panel will feature examples from Ohio, Wisconsin, New York, and California. 
  • The preconference will feature two World Café style discussions where participants break into groups to explore new solutions around the behavioral health workforce and how states are redesigning systems to improve network adequacy.  

More Insights and Expertise 

In addition, our main conference will feature a session on crisis system development and sustainability, looking at how states are creating and funding crisis systems to reduce disparities in access to behavioral health services, featuring case studies on newly implemented 988 hotlines, mobile crisis units, and other innovations in crisis stabilization. 

We are looking forward to hearing from panelists about the important work they are doing to bring forward new solutions, new collaborations, and new uses of federal funds to better serve the behavioral health needs in our communities across America. We’ll create a follow up blog on the learnings and insights shared in both sessions.  

To learn more about HMA’s efforts to support behavioral health, contact Gina Lasky or Gina Eckhart, managing directors of HMA’s behavioral health team, and be sure to register by July 31 to get the early bird rate. For additional insights, join the conversation with #HMACon2023. 

Blog

CMS releases report on nonemergency medical transportation in Medicaid

Read Blog

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

Background

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

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

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

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

Findings

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

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

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

Source: The Centers for Medicare & Medicaid Services

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

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

Recommendations

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

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

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

Link to report

Webinar

Webinar replay: new tools for Medicare policy changes impacting behavioral health services

Watch Now

This webinar was held on July 26, 2023.

In light of the recent Medicare regulatory and statutory expansion of behavioral health services and providers, this webinar focused on how those changes will impact the demand, delivery, and availability of behavioral health services. Experts covered how changes in Medicare coverage will affect different behavioral health provider types, improve access to opioid/SUD treatment, and improve flexibility with telehealth/digital service delivery. At a time when behavioral health access is strained, and workforce shortages are reported nation-wide, this new Medicare coverage (expected rules to be announced soon) presents both a significant opportunity as well as a challenge to the delivery system.

Learning Objectives:

  • Understand the recent Medicare regulatory and statutory changes impacting behavioral health providers, services, and reimbursement.
  • Anticipate changes in demand for behavioral health services and the impact on your local market.
  • Plan for the impact of regulation changes on demand for opioid/SUD treatment and telehealth/digital service delivery.
Blog

The CMS managed care proposed rule: three implications for local and regional MCOs

Read Blog

Previously, HMA reviewed the provisions of the Medicaid and Children’s Health Insurance Program (CHIP) managed care access, finance, and quality proposed rule published by the Centers for Medicare & Medicaid Services (CMS) on May 3, 2023. CMS is accepting comments on the proposed rule through July 3, 2023. While the proposed rule, if finalized as put forward, will have a significant impact across Medicaid stakeholders including enrollees, managed care organizations (MCOs), providers, and state Medicaid agencies, this blog post outlines three specific aspects of the proposed the rule and their implications for a subset of MCOs: regional and local MCOs.

Medical Loss Ratio (MLR) Standards

In the proposed rule, CMS outlines three areas for revisions to its existing MLR standards which require MCOs to annually submit MLR reports to states and require states, in turn, to annually provide a summary of those reports to CMS. An MLR is calculated by adding the expenditures for incurred claims to the expenditures for activities that improve health care quality and fraud prevention activities (the numerator) and dividing this by adjusted premium revenue (the denominator). The three areas where CMS proposes revisions 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.

Related to provider incentive arrangements (which are considered part of incurred claims), 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. Furthermore, MCOs would be required to maintain documentation to support these arrangements and cannot rely upon attestations as documentation of compliance.

Related to QIA reporting, CMS proposes to explicitly prohibit MCOs from including indirect or overhead expenses when reporting QIA costs in the MLR. CMS notes that today, for example, expenditures for facility maintenance, marketing, or utilities may be included in the MLR even though such expenses do not directly improve health care quality. From the perspective of CMS, the inclusion of such expenditures in the MLR numerator may be resulting an inflated MLRs that then provide a distorted view of MCO performance.

Related to expense allocating reporting, CMS proposes to add requirements regarding how MCOs can allocate expenses for the purpose of calculating the MLR. Specifically, MCOs would need to describe in their methodology a detailed description of the methods used to allocate expenses, including incurred claims, quality improvement expenses, federal and state taxes and licensing or regulatory fees, and other non-claims costs. The goal of requiring this additional detail is to give state Medicaid agencies the ability to assess whether MLRs are accurately represented as a result of the methodology employed by an MCO to allocate expenses across lines of business (e.g., Marketplace, Medicaid, and Medicare).

For local and regional MCOs, the changes to MLR standards proposed by CMS will require meaningful efforts to ensure compliance. Provider incentive arrangements, most expansively, may need to be renegotiated to conform to the requirements and, at a minimum, may need to be documented in a more robust fashion to ensure evidence of compliance can be furnished upon request. The impact of QIA expenditures that are no longer able to be included in the MLR numerator will need to be modeled to ensure that a resulting failure to meet any minimum MLR requirements does not occur and, if this is projected to occur, a strategy will need to be developed and executed to ensure it does not. Expense allocation methodologies will need to be documented more extensively and evaluated for reasonability to ensure that they can withstand regulatory scrutiny when additional detail is provided to state Medicaid agencies.

Medicaid and CHIP Quality Rating System (MAC QRS)

In the proposed rule, CMS outlines 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 MCOs will be required to adopt and implement the MAC QRS framework developed by CMS or adopt and implement an alternative managed care quality rating system. CMS will update the mandatory measure set at least every other year. Measures will have public notice through a call letter (or similar guidance) on any planned modifications with measures being 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. Additionally, state Medicaid agencies must calculate each measure and issue ratings to each MCO for each measure. Finally, the mandatory state website 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.

For local and regional MCOs, the MAC QRS framework proposed by CMS will require assessing their capability to produce the mandated data upon request by state Medicaid agencies. It will also then require ensuring that all mandated data is available to be provided on an annual basis. To the extent possible, at the appropriate time, assessing baseline performance on measures and proactively developing and implementing strategies to improve performance will be prudent. Assessing the impact of the greater transparency around quality performance that the proposed MAC QRS will bring in order to understand the potential impact on competitive position will also be important.

Network Adequacy Requirements

In the proposed rule, CMS outlines important network adequacy requirements meant to further timely access to care for Medicaid and CHIP managed care enrollees. Two of these are focused upon here: (1) appointment wait time standards and (2) secret shopper surveys. Other policies to enhance access are also included in the proposed rule including, for example, a requirement that state Medicaid agencies conduct an annual enrollee experience for each MCO.

For appointment wait time standards, CMS proposes that state Medicaid agencies develop and enforce wait time standards for 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 the state Medicaid agencies in an evidence-based manner (in addition to the previous three noted). The maximum wait times must be no longer than 10 business days for routine outpatient mental health and SUD appointments and no longer 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 selected by state Medicaid agencies will be determined at the state level.

For secret shopper surveys, state Medicaid agencies will be required to utilize 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% of the time. State Medicaid agencies would be required to develop remedy plans when MCO compliance issues are identified which designate the party responsible for taking action, outline the appropriate steps to be taken to address the issue, and document the intended implementation timeline.

For local and regional MCOs, the wait time standards and secret shopper surveys present opportunities to prepare to ensure compliance and to collaborate with state Medicaid agencies. For preparation, undertaking secret shopper surveys ahead of implementation to determine the current performance relative to maximum wait times may be advisable. Additionally, there is an opportunity to collaborate with state Medicaid agencies regarding the selection of the fourth service type for which wait time standards will be established.

For More Information

If you have questions about how HMA can support your efforts related to the proposed rule’s implications for local and regional MCOs, please contact Michael Engelhard, managing director, Patrick Tigue, managing director, or Sarah Owens, principal.

Webinar

Webinar replay: Medicaid 1115 justice waiver opportunities- medication assisted treatment for substance use disorder in carceral settings

Watch Now

This webinar was held on July 13, 2023.

HMA’s webinar series, 1115 Medicaid Justice Demonstration Waivers: Bridging Healthcare, focuses on helping stakeholders optimize care for persons in carceral settings and during their transition back to the community.

Part 4 focused on access to medication assisted treatment (MAT) for substance use disorder (SUD) during and after transition from a carceral setting into the community, to ensure continuity of care for those leaving incarceration to reduce overdose and recidivism.

Learning Objectives:

  • MAT Trends: Understand benefits of MAT for incarcerated individuals and related risk management for correctional facilities, providers, counties, and health plans.
  • Building Connections to Community-Based SUD Care: Discover approaches to release planning for successful community re-entry for those on MAT to support recovery and reduce recidivism.
  • Integrated and Coordinated Care: Understand the role of community-based and health plan care managers and persons with lived experience in supporting access to MAT and successful community re-entry.

Other webinars in this series:

Watch a replay of Part 1: Medicaid Authority and Opportunity to Build New Programs for Justice-Involved Individuals

Watch a replay of Part 2: 1115 Justice Waivers to Improve Carceral Healthcare Delivery Information

Watch a replay of Part 3: 1115 Justice Waivers: Connecting Community Partners to Improve Transitions of Care

Save the Date – Thursday August 17, 2023, 2 p.m. ET: Part 5: 1115 Justice Waivers and Special Populations: Meeting the Needs of Justice-Impacted Youth

HMA News

New experts join HMA in May 2023

Read News

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

Elvia Delgado – Principal
HMA

Elvia Delgado has over 20 years of government programs experience and has served in various leadership roles throughout the healthcare industry.

James Schroeder – Managing Principal
HMA

James Schroeder is an experienced clinical, strategic, and operational leader with over 20 years of experience in healthcare and a passion for improving communities and the lives of individuals, particularly the most vulnerable.

Leah Montgomery – Senior Consultant
HMA

Leah Montgomery is an expert in Medicaid and other federal needs-based programs such as Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Supplemental Security Income (SSI). 

Kelly O’Brien – Associate Principal
HMA

Kelly O’Brien is a highly accomplished healthcare executive with over 25 years of experience in executive leadership and C-Suite roles specializing in clinical and practice operations, revenue integrity, and transformation.

Zee Cui – Senior Consulting Actuary
Wakely

Zee specializes in reserving, forecasting, regulatory reporting, rate advocacy, risk adjustments, trend analysis, modeling and pricing actuarial work in both commercial and Medicaid sectors. Read more about Zee

Read more about our new HMA colleagues

Elvia Delgado

Elvia Delgado

Principal

HMA News

More than 20 Medicaid, Medicare, marketplace plan executives are confirmed speakers at 2023 HMA conference

Read News

C-suite executives from AmeriHealth Caritas, Centene, Community Health Choice of California, Health Care Service Corp., Humana, UnitedHealthcare, and UMPC Health Plan are scheduled to speak on trends in publicly sponsored healthcare at HMA’s Sixth Annual Conference, October 30-31 in Chicago.

They join keynote speaker Alan Weil, editor-in-chief of Health Affairs, and other experts in addressing innovation, value, equity, and growth opportunities and challenges facing Medicaid, Medicare, and Marketplaces across multiple and varied plenary, breakout, and panel sessions. See below for a list of confirmed speakers to date.

The conference also will feature a preconference workshop on October 29, during which HMA behavioral health leaders will address national trends and challenges for system redesign and serving complex populations. Participants will work on solving provider and population challenges during group activities.

We’re excited to welcome hundreds of attendees from health plans, providers, state and federal government, investment firms, and community-based organizations to enjoy top-notch content, interface with leading experts, make new connections, and garner fresh ideas and best practices. Last year’s event drew more than 500 healthcare professionals.

Early bird registration ends July 31.

Confirmed Speakers to Date

Keynote Speaker

Alan Weil, Editor-in-Chief, Health Affairs

Managed Care Speakers to Date (in alphabetical order)

Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas

Mitchell Evans, Market Vice President, Policy & Strategy, Medicaid & Dual Eligibles, Humana

John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan

Eric Mattelson, Chief Actuary, Zing Health

Anne Rote, Medicaid President, Health Care Service Corp.

Tim Spilker, CEO, UnitedHealthcare Community & State

David Thomas, CEO, Markets & Medicaid, Centene

Jaimie White, SVP, Medicaid Operations, Humana

Lisa Wright, President and CEO, Community Health Choice

State Medicaid Directors to Date (in alphabetical order)

Jacey Cooper, State Medicaid Director, Chief Deputy Director for Health Care Programs, California Department of Health Care Services

Kelly Cunningham, Medicaid Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services

Drew Snyder, Executive Director, Mississippi Division of Medicaid

Stacie Weeks, Administrator/Medicaid Director, Nevada Department of Health and Human Services Division of Health Care Financing and Policy

Healthcare, Provider, Policy Leaders to Date (in alphabetical order)

Richard Ayoub, CEO, Project Angel Food

Lynn Carr, Chief, Agency Operations, Medical Care Services, County of San Diego Health and Human Services Agency

Liz Goodman, Chief Legal and Public Affairs Officer, Commonwealth Care Alliance

Jesse Hunter, Operating Partner, Welsh, Carson, Anderson & Stowe

Monica Johnson, Director of the 988 & Behavioral Health Crisis Coordinating Office, SAMHSA

Peter Lee, Health Care Policy Catalyst; former Executive Director, Covered California

Kate Massey, Executive Director, MACPAC (Medicaid and CHIP Payment and Access Commission)

Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation

Bryan Buckley, Director for Health Equity Initiatives, National Committee for Quality Assurance

James R. Stringham, VP/CEO. Banner Government Health Plans, Banner Health

HMA offers attractive group rates and government discounts as well as sponsorship opportunities that help strengthen brand awareness and provide invaluable exposure and access to healthcare sector leaders. Visit the conference website for a complete list of sponsorship opportunities.

Contact Carl Mercurio for details.