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Blog

Indiana releases MLTSS RFP

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This week, our In Focus section reviews the Indiana Medicaid managed long-term services and supports (MLTSS) request for proposals, released by the Indiana Department of Administration on behalf of the Family and Social Services Administration on June 30, 2022. Indiana is seeking three managed care organizations (MCOs) that will serve an estimated 106,000 enrollees, beginning January 1, 2024, for a period of four years, with two one-year renewal options.

MLTSS Program

Indiana began forming a plan to reform the state’s Medicaid LTSS services in 2019 by holding stakeholder meetings. The state estimated that from 2010 to 2030 the proportion of Hoosiers over age 65 will grow from 13 percent to 20 percent, and that the state’s system would need to be reformed to meet the growing demand. The state set an objective to shift the LTSS program to a managed care model and to move a higher percentage of new LTSS members into home and community-based settings.

The new statewide, risk-based MLTSS program will serve Medicaid beneficiaries who are aged 60 years and older and are classified as aged, blind, or disabled. These beneficiaries will include individuals who are dually eligible for Medicare and Medicaid, those in a nursing facility, and those who are receiving LTSS in a home or community-based setting.

Beneficiaries in this program will receive all traditional Medicaid services, delivered through a capitated managed care arrangement. Those who meet a specified level of care will be eligible to receive home and community-based services (HCBS) waiver services. The Medicaid Rehabilitation Option (MRO), Adult Mental Health Habilitation Services Program (AMHH), and Behavioral and Primary Care Coordination (BPHC) will be carved out of the capitated arrangement. For dually eligible beneficiaries, Medicare will be the first payer for all Medicare covered services, including services that are covered by both Medicare and Medicaid.

Indiana seeks to contract with MCOs that can address complex and chronic health conditions of the program population and integrate care along the continuum and settings of LTSS in the state. Program goals include simplifying access to HCBS and expanding the HCBS provider network, especially in rural areas; using a person-centered approach; improving quality outcomes and consistency of care across the delivery system; promoting caregiver support and skill development; in addition to others.

Timeline

The first part of the proposals is due September 19, with the second part due September 23. Awards are expected in February 2023.

Evaluation

After ensuring proposals meet the mandatory requirement, proposals will be scored out of a total possible 103 points, as shown in the table below.

Preliminary Capitation Rate Summary

Based on the preliminary calendar year 2024 capitation rate development, contracts are estimated to be worth $3.8 billion annually.

Link to RFP

Blog

CMS proposes regulation for Rural Emergency Hospitals

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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 assistant, 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) (zgaumer@healthmanagement.com), Amy Bassano (HMA Managing Director, lMedicare) (abassano@healthmanagement.com), or Andrea Maresca (HMA Principal) (amaresca@healthmanagement.com). To access CMS’s proposed Rural Emergency Hospital and Critical Access Hospital Conditions of Participation, visit: https://www.federalregister.gov/public-inspection/current.

Blog

CMS releases the Enhancing Oncology Model

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This week, our In Focus section reviews the new Center for Medicare and Medicaid Innovation (CMMI) model named the Enhancing Oncology Model (EOM), released on June 27, 2022, by the Centers for Medicare & Medicaid Services (CMS). This new physician specialty model builds off the previously implemented Oncology Care Model (OCM). The EOM incentivizes the coordination of care and the improvement of care quality for Medicare patients undergoing cancer treatment. The model also seeks to reduce Medicare fee-for-service spending for oncology services, because oncology services are an area of high spending within the Medicare program. As a part of the EOM model participating physician practices will be held accountable for financial and performance targets during six-month episodes of care for systemic chemotherapy administration to patients with common cancer types. The EOM will run for five years beginning on July 1, 2023. Applications to EOM are currently open and will close on September 30, 2022.

CMS indicated that EOM supports President Biden’s Cancer Moonshot initiative to improve the experience of people and their families living with and surviving cancer. EOM aligns with the Cancer Moonshot pillars and priorities of supporting patients, caregivers, and survivors, learning from all patients, targeting the right treatments for the right patients, and addressing inequities.

Consistent with CMS priorities, EOM also has a strong health equity focus and oncology practices who care for underserved beneficiaries are encouraged to apply.

Design of EOM

EOM is built off the foundation of OCM which ran from July 1, 2016, through June 30, 2022. CMS previously solicited feedback from the oncology community and other interested stakeholders on an OCM successor model. Those lessons plus an alignment with CMMI’s strategy refresh priorities of moving to total cost of care accountable models and making cancer care more affordable and accessible created the foundations for the design of the model.

Under EOM, participating Physician Group Practices (PGPs) will take on accountability for their patients’ health care quality and for total Medicare Parts A and B and certain Part D spending during six-month episodes of care.  Eligible Medicare patients are those with certain cancers (breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer) receiving chemotherapy treatment.

  • Participating practices may bill for a Monthly Enhanced Oncology Services (MEOS) ($70 per month) payment for Enhanced Services provided to eligible beneficiaries. The MEOS payment will be higher ($100 per month) for beneficiaries dually eligible for Medicare and Medicaid.
  • Enhanced services are
    • Provide EOM beneficiaries 24/7 access to an appropriate clinician who has real-time access to the EOM participant’s medical records.
    • Provide patient navigation, as appropriate, to EOM beneficiaries
    • Document a care plan for each EOM beneficiary that contains the 13 components in the Institute of Medicine (IOM) Care Management Plan applicable to the EOM beneficiary
    • Treat EOM beneficiaries with therapies in a manner consistent with nationally recognized guidelines
    • Identify EOM beneficiary social needs using a health-related social needs screening tool
    • Gradual implementation of electronic Patient Reported Outcomes (ePROs)
  • Participants will be required to take on downside financial risk from the start of the model (with the potential to owe CMS a performance-based recoupment). If participants successfully meet quality and savings targets, they will have the opportunity to earn a retrospective performance-based payment (PBP). These amounts will be based on actual practice performance.
  • CMS has not yet specified the quality measures for this model. Instead, the application says the EOM quality strategy will focus on the following domains: patient experience, avoidable acute care utilization, management of symptoms toxicity, management of psychosocial health, and management of end-of-life care. CMS will prioritize measures that; reflect national priorities for quality improvement and patient-centered care, are outcomes-based measures (including those collected from patients), minimize EOM participant burden where possible, and align with CMS and Innovation Center quality strategy.
  • Health equity provisions of the EOM include requiring oncology practices to screen for health-related social needs (HRSNs), CMS providing data reports on patient expenditures and utilization for to help health care professionals identify and address health disparities, and CMS increasing reimbursement for the provision of Enhanced Services to patients who are dually eligible for Medicare and Medicaid.
  • CMS also will issue payment waivers and benefit enhancements to provide additional flexibility to practices in the way they deliver care to patients. Expected enhancements include telehealth, post-discharge enhancements, and care management home visits.

CMS has designed EOM as a multi-payer model. Medicare Advantage plans, state Medicaid plans and other payers are invited to apply to enter into a Memorandum of Understanding with CMS to align on incentives for oncologists to improve care to their patients and increase participation in value-based care arrangements.

What’s Next

CMS intends to release additional information about EOM payment methodologies later this summer. CMS also will be hosting several upcoming webinars regarding the payment methodology, quality strategy and general application support office hours before the application due date of September 30, 2022. CMS intends to select participants later this year or early next year and will implement the EOM on July 1, 2023.

For more information about this new model and how providers and payers can apply to it, please contact our Medicare team who have knowledge in CMS and its value-based payment programs, Amy Bassano (HMA Managing Director, Medicare) (abassano@healthmanagement.com), Julie Faulhaber (HMA Managing Director, Medicare) ( jfaulhaber@healthmanagment.com) Andrea Maresca (HMA Principal) (amaresca@healthmanagement.com), or Zach Gaumer (HMA Principal) (zgaumer@healthmanagement.com). To access the EOM application and other model materials, you may visit https://innovation.cms.gov/innovation-models/enhancing-oncology-model.

Blog

Early bird registration discount expires July 11 for HMA conference on the future of publicly sponsored healthcare, October 10-11 in Chicago

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Be sure to register for HMA’s 2022 Conference by Monday, July 11, to get the special early bird rate of $1,695 per person. After July 11, the rate is $1,895.

Nearly 40 industry speakers, including health plan executives, state Medicaid directors, and providers, are confirmed for HMA’s The New Normal: How Medicaid, Medicare, and Other Publicly Sponsored Programs Are Shaping the Future of Healthcare in a Time of Crisis conference, October 10-11, at the Fairmont Chicago, Millennium Park.

In addition to keynote sessions featuring some of the nation’s top Medicaid and Medicaid executives, attendees can choose from multiple breakout and plenary sessions on behavioral health, dual eligibles, healthcare investing, technology-enabled integrated care, social determinants of health, eligibility redeterminations, staffing, senior care, and more.

There will also be a Pre-Conference Workshop on The Future of Payment Reform: Delivering Value, Managing Risk in Medicare and Medicaid, on Sunday, October 9.

Visit our website for complete details: https://conference.healthmanagement.com/ or contact Carl Mercurio at cmercurio@healthmanagement.com.  Group rates and sponsorships are available. The last HMA conference attracted 500 attendees.

State Medicaid Speakers to Date (In alphabetical order)

  • Cristen Bates, Interim Medicaid Director, CO Department of Healthcare Policy & Financing
  • Jacey Cooper, Medicaid Director, Chief Deputy Director, California Department of Health Care Services
  • Kody Kinsley, Secretary, North Carolina Department of Health and Human Services
  • Allison Matters Taylor, Medicaid Director, Indiana
  • Dave Richard, Deputy Secretary, North Carolina Medicaid
  • Debra Sanchez-Torres, Senior Advisor, Centers for Disease Control and Prevention
  • Jami Snyder, Director, Arizona Health Care Cost Containment System
  • Amanda Van Vleet, Associate Director, Innovation, NC Medicaid Strategy Office, North Carolina Department of Health & Human Services

Medicaid Managed Care Speakers to Date (In alphabetical order)

  • John Barger, National VP, Dual Eligible and Medicaid Programs, Humana, Inc.
  • Michael Brodsky, MD, Medical Director, Behavioral Health and Social Services, L.A. Care Health Plan
  • Aimee Dailey, President, Medicaid, Anthem, Inc.
  • Rebecca Engelman, EVP, Medicaid Markets, AmeriHealth Caritas
  • Brent Layton, President, COO, Centene Corporation
  • Andrew Martin, National Director of Business Development (Housing+Health), UnitedHealth Group
  • Kelly Munson, President, Aetna Medicaid
  • Thomas Rim, VP, Product Development, AmeriHealth Caritas
  • Timothy Spilker, CEO, UnitedHealthcare Community & State
  • Courtnay Thompson, Market President, Select Health of SC, an AmeriHealth Caritas Company
  • Ghita Worcester, SVP, Public Affairs & Chief Marketing Officer, UCare
  • Mary Zavala, Director, Enhanced Care Management, L.A. Care Health Plan

Provider Speakers to Date (In alphabetical order)

  • Daniel Elliott, MD, Medical Director, Christiana Care Quality Partners, eBrightHealth ACO, ChristianaCare Health System
  • Taylor Nichols, Director of Social Services, Los Angeles Christian Health Centers
  • Abby Riddle, President, Florida Complete Care; SVP, Medicare Operations, Independent Living Systems
  • David Rogers, President, Independent Living Systems
  • Mark Sasvary, Chief Clinical Officer, CBHS, IPA, LLC
  • Jim Sinkoff, Deputy Executive Officer, CFO, SunRiver Health
  • Tim Skeen, Senior Corporate VP, CIO, Sentara Healthcare
  • Efrain Talamantes, SVP & COO, Health Services, AltaMed Health Services Corporation

Featured Speakers to Date (In alphabetical order)

  • Drew Altman, President and CEO, Kaiser Family Foundation
  • Cindy Cota, Director of Managed Medicaid Growth and Innovation, Volunteers of America
  • Jesse Hunter, Operating Partner, Welsh, Carson, Anderson & Stowe
  • Bryant Hutson, VP, Business Development, MedArrive
  • Martin Lupinetti, President, CEO, HealthShare Exchange (HSX)
  • Todd Rogow, President, CEO, Healthix
  • Joshua Traylor, Senior Director, Health Care Transformation Task Force
  • James Whittenburg, CEO, TenderHeart Health Outcomes
  • Shannon Wilson, VP, Population Health & Health Equity, Priority Health; Executive Director, Total Health Care Foundation
Blog

Staying ahead of the star rating curve – a case study

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This week, our In Focus section highlights a presentation from HMA and Wakely, an HMA company, titled “Staying Ahead of the Star Rating Curve – A Case Study,which was given at the 12th Medicare Stars, HEDIS, Quality Assurance, & Risk Adjustment Summit on June 15, 2022.

The presentation provided an overview of major changes in the Medicare stars program, which will result in both higher ratings and significantly higher revenues for many Medicare Advantage plans in 2023.  However, the presentation indicated the higher ratings reflect temporary changes and not necessarily improvements in quality, adding that Medicare Advantage plans should be cautious about enhancing future benefits based on additional 2023 revenues.

Click here to view the presentation.

For questions please contact Linda Lee, Managing Principal; Christina Byrne, ASA, Consulting Actuary; Ann Pogrebitskiy, ASA, Associate Actuary.

Blog

Quality standards in addiction care

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Across the healthcare landscape, quality standards are in place to ensure patients are receiving safe, appropriate, evidence-based, and standardized care that is tailored to their individual needs and symptomology.   

A significant gap has long existed in the treatment of substance use disorders (SUD), as there was no standardized method to provide treatment based on an individual’s needs at that moment, meaning people seeking treatment often received care that was either too intense or not intense enough, preventing them from attaining sustained recovery.

To create standardized treatment protocols and build additional credibility around programs, the American Society of Addiction Medicine (ASAM) developed criteria based on a holistic, multidimensional assessment[1] to determine what level of care (LOC) an individual needs. This development was revolutionary as it was the first time the field agreed on established criteria. After 35 years of improvement and refinement, the ASAM Criteria has become the national standard.

While many providers have adopted the ASAM criteria, and most regulators and payers require its use to determine the LOC a person may need, a significant gap still persists in ensuring services are delivered with fidelity to the criteria. As a result, those seeking treatment for themselves or a loved one continue to face challenges identifying a setting that provides evidence-based treatment focused on their specific needs. 

To close this gap, ASAM partnered with CARF International, the leading accreditor of behavioral health services, to develop criteria that demonstrates providers are, in fact, delivering the LOC for which they are admitting persons. Programs that are providing levels of residential care can be certified for three levels including: 3.7- Medically Monitored Intensive Inpatient Services, 3.5- Clinically Managed High  Intensity Residential Services, and 3.1- Clinically Managed Low Intensity Residential Services.

By achieving the ASAM LOC certification, residential treatment programs can establish themselves as high quality SUD providers and ensure future program licensing as well as future funding from states, and private and public payors. This certification demonstrates that facilities are delivering the appropriate care to the appropriate person at the appropriate time. 

Preparing for certification is different from preparing for licensure in that a program must take an in-depth look at their clinical practice to ensure alignment with the ASAM criteria.

Because of our long and proven track record of helping clients prepare for, and secure, NCQA, AAAHC and URAC accreditation as well as deep expertise in SUD programs and treatment, HMA was selected by ASAM as a preferred partner to provide technical assistance and usher programs through the certification process as well as help address shortfalls and gaps in programs and care.

Our team has the right mix of clinical and operational knowledge, training, and frontline experience to guide clients through the certification process and help build better systems of care and accountability from the ground up.

HMA has the depth and breadth of services across the healthcare spectrum, and we are uniquely positioned to help organizations address gaps identified in the certification process and improve care by ensuring services are delivered in fidelity to the LOC at which a person presents.

HMA’s Institute on Addiction is also able to provide a full complement of services and support to residential providers including ASAM LOC clinical expertise, developing policies and procedures, building and operationalizing clinical programs, and improving revenue cycle, operations, and as well as payor contracting strategies.

Certification is really step number one. Utilizing HMA’s “Survey Ready Model,” we will identify ways to build quality into everyday practice allowing programs to stay on top of – and ahead of – requirements. 


[1] https://www.asam.org/asam-criteria/about-the-asam-criteria

Blog

CMS breathes new life into Medicaid HCBS investment opportunities

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On June 3, 2022, the Centers for Medicare & Medicaid Services (CMS) notified states that they will have an additional year, until March 31, 2025, to use funding from the American Rescue Plan Act (ARPA) to strengthen their Medicaid home and community-based services (HCBS). CMS’ update extends important flexibility to ensure state Medicaid programs and stakeholders, including beneficiaries, realize maximum benefit from federal investments in expanding and enhancing HCBS services.

For over a decade, the Medicaid program has been leading transformations of state long-term services and supports systems (LTSS), including physical and behavioral health services and health-related social needs. These efforts primarily focus on broadening eligibility, making more significant Medicaid investments in HCBS, and improving beneficiaries’ access to HCBS programs. The COVID-19 pandemic heightened attention to beneficiaries’ disparate experiences with accessing HCBS and exacerbated pre-COVID challenges faced by the LTSS workforce.

Section 9817 of ARPA provides an increase for Medicaid-funded HCBS by offering states the option to claim an additional 10 percentage point increase in federal match (FMAP) for the one-year period from April 1, 2021, to March 31, 2022. To receive the higher federal funding, states cannot make changes to the amount, duration, and scope of covered HCBS; they cannot reduce HCBS provider payment rates; and they cannot make eligibility standards for HCBS programs or services stricter until all additional funds are expended. CMS also requires states to submit a spending plan and narrative that describes planned enhancement activities.

Notably, a state must reinvest the higher federal funding in Medicaid HCBS while maintaining the spending levels they had in place on April 1, 2021. According to CMS’s new guidance, states can now use the funds until March 31, 2025, rather than March 31, 2024, under the previous guidance.

Actions Stakeholders Can Take to Maximize the Extra Time

The updated spending deadline is grounded in a better understanding of the level of effort and time necessary for states to identify, build consensus, and implement specific actions to include in a state’s HCBS spending plan. HMA works with states, providers, health plans, and other stakeholders, including consumers, who will benefit from the additional time to make investments. Our work includes supporting states as they align the multitude of needs and priorities with the available funds and supporting robust stakeholder engagement efforts to inform the plans.

The following are some of the most impactful “next steps” that states and stakeholders can pursue to best utilize the additional time to reinvest in Medicaid HCBS programs:

  • States can communicate with stakeholders, including health plans, providers, community organizations, consumers, and others, to share how the extension impacts the state’s spending plan.
  • States and stakeholders can renew their engagement to consider potential changes to the spending plan activities, timelines, or both. Stakeholders may have additional opportunities to offer input to refine further and prioritize the design and delivery of augmented or new services, systems, and related initiatives.
  • State Medicaid, aging, and various other programs and providers have more time to strengthen their collaboration to meet the needs of individuals of all ages who are living with disabilities.
  • States, vendors, health plans, and providers can evaluate through evidence, analysis and stakeholder feedback, if the projects they are pursuing are effective and/or should be modified. For example, it may be beneficial to provide more flexibility in the deadlines for case management and referral systems builds and implementation of the training for workers on these new systems.
  • States and their stakeholder partners can refocus on workforce issues, including examining eligible provider types and scopes, evaluating provider network issues, considering the role of virtual services, conducting provider and managed care rate setting studies, and other changes to support the HCBS direct care workforce.
  • States can develop reasonable timeframes to strengthen existing efforts or pursue new initiatives to develop and implement managed long-term services and supports for certain groups of Medicaid beneficiaries.

Looking ahead, states and all stakeholders need to assess the impact of these investments. ARPA funds are a significant investment in strengthening Medicaid LTSS programs, but these transformative efforts require sustained commitment. There is continued uncertainty around additional federal Medicaid funding over the long term that are necessary to address ongoing needs and make further progress towards high-quality, accessible HCBS services. Understanding the extent to which the funds are achieving the desired structural transformations and the impact on Medicaid beneficiaries can guide future areas of federal and state focus and investments.

For more information please contact HMA consultants Kevin Hancock, Principal, Andrea Marescaa, Principal, and Aaron Tripp, Principal.

Related posts:

Blog

Low-cost carriers in ACA: insights from the 2018-2021 market experience

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This week, our In Focus highlights a white paper from Wakely, an HMA Company, exploring the potential design elements and expected effects of a public option or a low-cost plan being newly introduced in the Affordable Care Act (ACA) individual market.

1332 state innovation waivers have been in place for a number of years and allow states to implement programs that increase access to and the affordability of healthcare coverage, subject to approval by the Department of Health and Human Services (HHS) and Department of Treasury (Treasury). Nearly all waiver programs in effect in 2021 employ a reinsurance program aimed at reducing the overall claim costs and premiums for members by reimbursing issuers for a portion of claim costs over a specified threshold.

A number of states have been exploring other ways to structure a waiver program, including introducing a public option plan into ACA markets (individual and small group plans subject to the ACA market reforms). The definition of a “public option plan” has evolved over time and can vary, but more commonly refers to a privately funded health plan with some level of government oversight or additional requirements established to improve consumer value and facilitate cost containment.

A public option plan aims to further increase access to coverage and affordability by offering a new qualified health plan, typically with a lower premium relative to existing premiums in the market. A public option plan specifically aims to extend a more affordable coverage to individuals who are currently not eligible for ACA subsidies (e.g., family glitch, non-citizens, and those with higher incomes). The plan could be structured in a variety of ways such as a state-sponsored product, state employee health plan buy-in, Medicaid plan buy-in, or a private plan offered by existing issuers. Colorado and Washington will require health plans to offer public option plans with a target premium reduction relative to other plans in the market, with constrained rate increases over time, giving health plans the opportunity to arrive at the lower premiums through their own means, for the 2023 plan year. Lower premiums would likely be achieved through a combination of lower provider reimbursement and lower risk margins.

Given the nature of premium subsidization in the individual ACA market, where premium subsidies are tied to the second lowest cost silver (SLCS) plan in the market, the introduction of a lower cost public option plan has a mixed impact on market growth and the types of member segments that benefit. Since Washington State is the only Exchange that currently offers a public option plan, there is minimal experience available to understand the impact a public option plan may have on the market. As a result, our goal was to look at states where a new issuer has entered a market as a low-cost plan over the last four years, to better understand plan enrollment migration (how many members switch to the low-cost carrier), competitors’ reactions, and the reduction in premium needed to incentivize members to take up coverage. This market dynamic potentially closely mimics a public option plan that offers lower premiums being introduced in a market. Over the last four years (2018-2021), we identified 51 instances of new issuers entering an individual on-Exchange market. Of those 51 new entrances, 25 met our criteria of a low-cost plan.

The analysis showed mixed impacts of a low-cost plan introduction in ACA markets, with minimal impact on the uninsured, but with improved affordability, particularly for the unsubsidized. The detailed observations are discussed further in this paper.

Link to White Paper

Please contact Ksenia Whittal at ksenia.whittal@wakely.com with any questions.

Blog

Oklahoma to transition to Medicaid Managed Care

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This week, our In Focus section reviews a new Oklahoma law to implement Medicaid managed care by October 1, 2023. The law, signed by Governor Kevin Stitt on May 26, 2022, requires the state to issue a request for proposals and to award at least three Medicaid managed care contracts to health plans or provider-led entities like accountable care organizations.

Provider-led entities would receive preferential treatment, with at least one targeted to receive a contract. However, if no provider-led entity submits a response, the state will not be required to contract with one.

Goals of the legislation include:

  • Improve health outcomes for Medicaid members and the state as a whole;
  • Ensure budget predictability through shared risk and accountability;
  • Ensure access to care, quality measures, and member satisfaction;
  • Ensure efficient and cost-effective administrative systems and structures; and
  • Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.

Plans would provide physical health, behavioral health, and prescription drug services. Covered beneficiaries would include traditional Medicaid members and the state’s voter-approved expansion population, but not the aged, blind, and disabled population eligible for SoonerCare.

Plans will need to contract with at least one local Oklahoma provider organization for a model of care containing care coordination, care management, utilization management, disease management, network management, or another model of care as approved by OHCA.

Oklahoma will also issue separate RFPs for a Medicaid dental benefit manager plan and a Children’s Specialty plan.

Background

Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state’s more than 1.2 million Medicaid members are in SoonerCare Choice, a Primary Care Case Management (PCCM) program in which each member has a medical home. Other programs include SoonerCare Traditional (Medicaid fee-for-service), SoonerPlan (a limited benefit family planning program), and Insure Oklahoma (a premium assistance program for low-income people whose employers offer health insurance). Prior efforts to transition to Medicaid managed care have encountered roadblocks, starting in 2017 with a failed attempt to move aged, blind, and disabled members to managed care.

More recently, in June 2021, the Oklahoma Supreme Court struck down a planned transition of the state’s traditional Medicaid program to managed care, ruling that the Oklahoma Health Care Authority does not have the authority to implement the program without legislative approval.

Contracts had been awarded to Blue Cross Blue Shield of Oklahoma, Humana, Centene/Oklahoma Complete Health, and UnitedHealthcare. Centene/Oklahoma Complete Health also won an award for the SoonerSelect Specialty Children’s Health Plan program, covering foster children, juvenile justice-involved individuals, and children either in foster care or receiving adoption assistance.

Link to Senate Bill 1337

Blog

Behavioral health crises drive bipartisan action in Congress

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Agreement about the severity of the nation’s mental health and substance use disorder crises is rising above the partisan politics in Congress. In fact, these are among a handful of issues driving work on bipartisan legislation across all the key House and Senate committees with jurisdiction over behavioral health programs and policies this year.

On May 18, the U.S. House of Representatives Energy and Commerce Committee unanimously approved the “Restoring Hope for Mental Health and Well-Being Act of 2022” (H.R. 7666). This legislation incorporates a collection of bipartisan bills to update and reauthorize over 30 Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA) programs addressing the mental health and substance use disorder (SUD) crisis. The bill also advances initiatives to strengthen the 9-8-8 National Suicide Prevention Lifeline implementation efforts, invest in the crisis response continuum of care, and support strategic opioid crisis response plans among numerous other policies. Energy and Commerce is one of several House committees planning to advance behavioral health bills this year.

U.S. Senate committee leaders have been similarly engaged in developing bipartisan proposals to address mental health and substance use disorders. Senate Health, Education, Labor and Pensions (HELP) and Finance committee leaders are expected to reveal their proposals as soon as this summer. The Finance Committee’s proposal will focus on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) policies and could reflect findings from the committee’s report, “Mental Health Care in the United States: The Case for Federal Action.” Similarly, HELP members Sens. Chris Murphy (D-CT) and Bill Cassidy (R-LA) introduced the Mental Health Reform Reauthorization Act to extend several expiring mental health programs, which could be incorporated in that Committee’s comprehensive proposal. Across committees, there has been an interest in strengthening parity, supporting integration of primary and behavioral health care, increasing access to youth mental health screenings, scheduling fentanyl analogues, and easing requirements for prescribing Medication Assisted Treatment.

What To Expect

Congressional leaders have consistently expressed their desire to advance bipartisan legislation to address the urgent needs and gaps in the mental health and SUD care delivery systems, as well as support education and research.  While these are key areas to watch, the diminishing number of legislative days on the congressional calendar and climate surrounding November’s mid-term elections create uncertainty for the timing and scope of Congress’ work. It remains to be seen whether a package of health care proposals, such as reauthorization of the U.S. Food and Drug Administration’s user fee programs, the Cures 2.0 legislation to advance biomedical research, mental health and substance use disorder legislation, and the PREVENT Act could be sent to President Biden’s desk before the end of September.

HMA companies are supporting clients impacted by the policy changes being discussed and the program funding addressed in these legislative proposals. Understanding the landscape for federal change allows state and local governments and stakeholders to plan for and shape these opportunities. For more information, please contact Andrea Maresca, Principal, Federal Policy, HMA; Matt Gallivan, Director, Leavitt Partners; and Laura Pence, Director, Leavitt Partners.

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New paper highlights seven ways stakeholders can help alleviate medical debt without unintended consequences

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As efforts continued at the beginning of 2022 to implement the No Surprises Act aimed at preventing surprise medical bills that patients are often unable to pay, the Kaiser Family Foundation published a report that estimates nearly one in 10 adults have medical debt, and that Americans’ total medical debt could be as high as $195 billion. About a week later the nation’s top three debt collection firms announced planned changes to medical debt practices designed to reduce the strain of medical debt on patients, and appease a Consumer Financial Protection Bureau that has made credit reporting and medical debt a priority. Less than a month later, the Biden Administration announced several initiatives aimed at alleviating issues related to medical debt for Americans.

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