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Case Study

Ensuring appropriate payment for transformative therapies to secure patient access to CAR Ts


CAR T therapies first entered the market in late 2018. These transformative treatments for certain
types of cancer involve modifying a patient’s own cells to fight the cancer—producing a long term,
potentially curative response. Initially, CAR T therapy was administered to patients in the inpatient
hospital, where Medicare payments are bundled so that the hospital gets a single payment for the
entire hospital stay. The cost of the CAR T therapy greatly exceeded the payment rate the hospital
would receive, leading to concerns that hospitals would be reluctant to provide CAR T.

Download and read the approach and results.

Brief & Report

HMA paper examines federal funding streams supporting crisis pregnancy centers


Crisis pregnancy centers (CPCs) are organizations that represent themselves as reproductive healthcare clinics offering services for pregnant people and appear similar to clinics offering a full range of reproductive health services. Federal funding to CPCs may constitute non-allowable uses of such support based on the legislative intent and grant requirements of these programs. In this paper, HMA provides a comprehensive analysis of federal funding streams and state allocations of that funding to CPCs and CPC networks. HMA found that more than 650 CPCs in 49 states and Washington, DC, received federal funding between 2017 and 2023, totaling more than $400 million.

Brief & Report

HMA report evaluates needs of Nevada’s Medical Assistance for the Aged, Blind, and Disabled program


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 Preparedness Services

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“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.

Contact our experts:

Brent Barkett

Brent Barkett


A purpose driven leader and recognized expert in healthcare value transformation, Brent Barkett has a unique combination of clinical application, … Read more
Lisa Harrison

Lisa Harrison

Associate Principal

Lisa Harrison is a physician associate with more than 20 years of direct experience in clinical practice as a primary … Read more
Zipatly Mendoza

Zipatly V. Mendoza

Senior Consultant

Zipatly V. Mendoza is a results-driven public health professional with over 15 years of program management experience and a demonstrated … Read more
Yamini Narayan

Yamini Narayan

Senior Consultant

A diversified professional who thrives on solving the most complex questions in health policy, Yamini Narayan is a skilled researcher … Read more
Hannah Savage

Hannah Savage


Hannah Savage is an experienced public health professional with skills in program evaluation, data analysis, survey development, survey analysis, and … Read more
Linda Vail

Linda Vail


Linda Vail is an accomplished public health leader, creative problem solver and strategic thinker. She has extensive experience in opioid … Read more
Helena Whitney

Helena Whitney

Associate Principal

Helena Whitney effectively bridges the policy and the politics of healthcare with her combination of public health, legislative affairs and … Read more
Emily Wilson

Emily Wilson

Associate Principal

A multi-disciplinary public health leader, Emily Wilson is passionate about bringing people together to solve the most pressing problems in … Read more

Webinar replay: supporting family caregivers: the changing policy and practice landscape

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This webinar was held on June 27, 2024.

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.

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Ohio releases next generation MyCare Ohio program RFA

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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.  


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. 


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. 


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.  


Webinar replay: D-SNP growth and integration: key implications of the 2025 CMS final rule

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This webinar was held on June 20, 2024.

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.

Summary of the CMS managed care final rule and its impact on states, managed care organizations and providers

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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].


Webinar replay: Medicare physician fee schedule reform – structural topics and recommendations

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This webinar was held on June 13, 2024.

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.