Kevin Kirby, managing director at Health Management Associates, gives a closer look at the evolution of Medicare’s drug coverage and the policies that have transformed patient access and affordability. From Clinton era ideas, to the launch of the Medicare Modernization Act and then the Affordable Care Act, Kevin has advised clients as these significant milestones have shaped and reshaped Medicare’s drug benefits. He discusses the implications of the Inflation Reduction Act, raising important questions about sustainability and cost control. The episode will explore how these pivotal policies will impact access to treatment and the sustainability of Medicare in a rapidly changing healthcare landscape.
242 Results found. Clear filters.
Health policy priorities on the table: Understanding the post-election landscape for Marketplace, Medicaid, and Medicare programs
This week’s In Focus section addresses post-election implications and initial considerations for understanding President-Elect Donald J. Trump’s possible federal healthcare policy agenda. Though healthcare was not the highest priority campaign issue, the president-elect and his team have signaled the policy agenda could include changes to the Affordable Care Act (ACA), Medicaid, and the nation’s public health programs.
Additionally, President Trump’s first term policy agenda and how these policies fared, provide critical insights into the policy direction for his second term, including policies on Medicare drug pricing, ACA marketplaces, and interoperability. Also vital to understanding and planning for a second term will be the appointees to key healthcare positions at the Department of Health and Human Services and in the White House.
Policy officials and specific policy agendas are still nascent, and Health Management Associates, Inc., federal and state experts are continuing to monitor these developments. The remainder of this article focuses on a few key considerations for the Marketplace, Medicaid, and Medicare healthcare insurance programs heading into 2025.
ACA Marketplace Issues to Watch
President-Elect Trump signaled he is uninterested in revisiting a legislative initiative to repeal and replace the ACA. However, one of the major defining issues facing the president-elect and the next Congress is the temporary policy providing enhanced tax credits that lower ACA premiums, which expires at the end of 2025. This and other tax policies are very likely to be on the table, particularly as budget reconciliation is an available tool in unified government.
Key considerations for healthcare stakeholders regarding the subsidy policy and federal funding for Marketplace outreach and education programs include:
- The Congressional Budget Office (CBO) estimates that extending the present enhanced subsidy policies would cost more than $300 billion over 10 years. The CBO also reports that ACA marketplace enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 if the subsidy policy is not renewed.
- The loss of subsidies would increase the number of uninsured individuals in the United States, but the size of the increase would depend on the state-specific landscape. For example, states that have not adopted the ACA’s Medicaid expansion for adults are expected to have a higher increase relative to states that have more expansive Medicaid eligibility. One potential approach is for lawmakers to modify the enhanced subsidy policy, rather than let it expire entirely.
- Marketplace plans should be prepared for a change in the acuity mix of enrollees while providers should expect a change in their payer mix, with more uninsured individuals in states that have not expanded Medicaid.
Federal and state policymakers may pursue a combination of alternatives to fill gaps in access to healthcare coverage and services. For example, the president-elect and incoming congressional leaders may focus on alternative coverage options and other state-driven reforms to Marketplace programs. Alternatives that could become part of the regulatory policy agenda include:
- Supporting association health plans (AHPs) and high-risk pools
- Reverting to a federal regulatory environment that supports short-term limited-duration healthcare insurance (STLDI) plans
- Approving Section 1332 waivers to allow state-designed programs
Medicaid Policy Outlook
During Mr. Trump’s first term, one of his administration’s signature Medicaid initiatives was approving Section 1115 demonstrations that allowed states to apply work requirements to certain populations, including adult expansion populations. The first Trump Administration also revised the demonstration parameters for Section 1115 Institutions for Mental Disease (IMD), allowed coverage lockout for beneficiary noncompliance with premium payments, and approved a pilot program to test interventions addressing health-related social needs (HRSNs).
Key considerations for healthcare stakeholders regarding Medicaid flexibilities and funding include:
- Officials in the first Trump Administration approved North Carolina’s Medicaid 1115 demonstration program to address HRSNs. President Biden’s Administration expanded these policies and approved demonstrations in more than 10 states, with additional state applications pending. Incoming officials may maintain the overall policy direction with regard to HRSNs. However, they could pivot to narrow the scope of future state HRSN proposals. Another approach could include directing states to use in lieu of services (ILOS) authority in managed care delivery systems to address HRSN.
- During President-Elect Trump’s first term, Centers for Medicare & Medicaid Services (CMS) officials prioritized work requirements and capped allotments for certain components of a state’s Medicaid program. Some states might consider revisiting these options, with modifications. If this policy direction is refreshed, federal and state officials would benefit from the foundational work conducted during the first term.
- New CMS officials could prioritize work on transparency in Medicaid financing and reimbursement to providers. Federal officials, regardless of political affiliation, historically have sought to improve their understanding of the flow of Medicaid funding. Incoming officials could prioritize this issue again, which would have a varied effect on health plans and providers.
Medicare Priorities:
Relative to Marketplace and Medicaid, first term Trump Medicare policies were advanced with less conflict. Notable policy initiatives included a focus on healthcare-related challenges in rural communities, improving transparency, and reducing provider burden —all of which were also cross-cutting issues that encompassed policy work beyond Medicare and could continue to be central to the next Medicare policy agenda.
Key considerations for healthcare stakeholders regarding Medicare policy are as follows:
- The president-elect’s first term approach to Medicare Advantage (MA) plans sought to maximize enrollment in MA and encourage innovation and value-based design. It’s reasonable to expect second term CMS officials to maintain an overall favorable approach to MA too. Incoming officials could narrow their scrutiny of MA plans to bipartisan concerns, for example MA plans’ prior authorization policies.
- While improving outcomes for dually eligibles beneficiaries generally is a bipartisan issue, state agencies, MA and Medicaid managed care plans, and other interested stakeholders should monitor the incoming Administration’s policy agenda for dually enrolled beneficiaries in Medicare and Medicaid. During the Biden Administration, CMS issued final rules for Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) to improve integration for the Medicare-Medicaid dually eligible population., Incoming Trump officials could revisit the approach, including the breadth of requirements and compliance timelines.
- During his first term, President Trump was highly engaged in elevating concerns about prescription drug prices and HHS and CMS announced models and policies to lower drug prices for patients. In his second term, however, the President could seek to rein in certain aspects of the Inflation Reduction Act (IRA), while revisiting some of his prior proposals.
What to Watch
The incoming Administration and its transition team are moving expeditiously to nominate new Cabinet Secretaries and to identify key staffers. The individuals appointed to departmental, agency, and advisory leadership positions will have significant leeway in shaping the federal and state healthcare policy landscapes – determining which existing policies to review and potentially revise, new policies to develop, and the approach to working with state and local officials and stakeholders. This includes the Secretary of Health and Human Services, CMS Administrator, Director of the Centers for Disease Control and Prevention, Food and Drug Administration Commissioner, and Director of the National Institutes of Health, all of which require Senate confirmation. Additionally, healthcare stakeholders should continue to monitor the leadership races for the House and Senate and the primary congressional committees with jurisdiction over healthcare programs. These leaders will be key to a second term Trump legislative policy agenda.
Connect with Us
This article focuses in on a subset of issues within Marketplace, Medicaid, and Medicare and in the overall healthcare sector. Our 2024 Political Checkpoint webinar features our experts discussing these and other insights on the election results. They provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions.
Join us for our next two webinars in the series exploring the election results:
Webinar Replay: 2024 Political Checkpoint
This webinar was held on November 12, 2024.
In the 2024 Political Checkpoint hosted by Leavitt Partners, an HMA company, we explored up-to-the-minute insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Our expert panelists provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions, and shared their prediction for what to watch over the first 100 days:
2024 Wrap Up
Lame duck session in Congress, end of year regulatory action
A New President
Implementing campaign promises through appointments
2025 Policy Agendas
Where committees, agencies may set their sights
Key Issues
Healthcare priorities that could see the spotlight
How satisfaction impacts Medicare Advantage plans Star ratings
Medicare Advantage (MA) Star ratings are more than a quality score—they shape the financial and operational success of MA plans. These ratings hinge on factors that every plan can impact by developing continuous improvement processes. The Consumer Assessment of Healthcare and Provider Systems (CAHPS) survey, Healthcare Effectiveness Data and Information Sets (HEDIS) ratings, and the Member Retention rate are all significant levers affecting Star ratings.
The importance of member retention rate
Member retention rate is a measure of member satisfaction but also impacts plan scale. One Medicare Advantage (MA) plan typically reports 0% voluntary disenrollment each year. Another plan is reporting 60% voluntary disenrollment. The voluntary disenrollment threshold is currently set at 18% for a 4-star rating and 10% for a 5-star rating on the measure. The average MA plan is losing more than $60 million in Medicare premium annually due to voluntary disenrollments. The voluntary disenrollment measure excludes members moving out of the service area or sponsor-initiated contractions of the service area.
CAHPS survey impact on Star ratings
CAHPS metrics are an important factor in the Centers for Medicaid and Medicare Services (CMS) Star rating system. MA plans need to develop strong companywide focused member experience processes to help them navigate the healthcare delivery system and community resources available. Evaluating the entire member experience from enrollment through access to care, messaging, outreach, customer service, to disenrollment, involves mapping out every member touchpoint, from a population health approach, to ensure the plan has a caring, approachable, supportive, and balanced experience with the member. Opportunities to eliminate frustrative process steps include identifying health related social needs and disparities that provide easier and time-sensitive access to care and services that are essential to increasing member satisfaction and engagement.
Health plans need a process to identify members who are most likely to be dissatisfied due to events and contact these members to understand the needs and resolve issues quickly. A dissatisfying process issue will repeat if not addressed. Understanding what data the health plan should be continually monitoring and the steps to effectively address any issues is essential to increasing trust with members. It is imperative that members get the opportunity to express their concerns to the health plan with the opportunity to resolve issues satisfactorily before they receive a CAHPS survey.
HEDIS and Star ratings
MA plans need to develop focused processes to proactively monitor HEDIS metrics and drive improvement interventions to keep up with the competition. Having a holistic approach to monitoring, understanding the status and what gaps persist, and a year-round strategy for addressing these gaps is essential to being able to focus efforts on improvement.
As the National Committee for Quality Assurance (NCQA) is moving from a hybrid sampled process to an administrative whole population calculation system, it’s essential that MA plans are addressing each measure in its entirety throughout the year. Digital measurement and Electronic Clinical Data Sets (ECDS) measures are increasing with CMS having a goal of interoperability and implementation of digital quality measures by 2030. Changes with CMS Star metric weightings has increased the total percentage that HEDIS impacts the overall calculation.
Partnering with Pharmacy Benefit Manager to improve Stars
Medicare Part D measures are among the most highly weighted measures in the CMS Stars performance program. Having a strong Pharmacy Benefit Manager (PBM) p artner is a necessity for success. Measures include medication adherence for high blood pressure, cholesterol, and diabetes. Successful plans ensure that members have sufficient prescription fills and re-fills to cover 80% of the days during the year. Measures are scored based on the percentage of members in the denominator who are compliant by the end of the measurement year. Member satisfaction with the plan’s pharmacy program is a key determinant in plan rating by the member and plan retention, impacting other parts of the CMS Stars program, whether Part D is measured alone or as part of an MA-PD plan.
Accelerating Star Rating Performance
The HMA Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple “what-if” scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year.
The Accelerator approach includes “all-hands-on-deck” – care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.
HMA Accelerator plans experience a reduction in members choosing to leave, attributed more to prevailing cultural changes over time than to enhanced benefits or member rewards. This program is a cultural transformation designed to strengthen star performance. Click here to learn more about the HMA Stars Accelerator Solution’s capabilities, where you can request a copy of the HMA Stars Accelerator Playbook. Let’s have a conversation about how your plan can improve member retention for increased star rating and increased enrollment scale.
We are also holding two webinars that may be of interest:
Falling Stars: Who’s Who in the 2025 Star Ratings
November 7, 2024 – 3:30 PM ET
Register now
Colleagues from Wakely Consulting Group, an HMA Company, will discuss trends in Overall Star Ratings, the appeals and lawsuits filed in response, and future changes to the Star Rating program that are likely to depress Star Ratings even further over the next few years.
Mastering Star Performance: Strategies from the HMA Stars Accelerator Program
November 13, 2024 – 12:00 PM ET
Register now
Healthcare solutions unlocked: Key takeaways from the 2024 HMA Conference
The HMA Conference – Unlocking Solutions in Medicaid, Medicare, and Marketplace – was held in early October in Chicago, drawing a crowd of 350 participants hailing from all parts of the healthcare ecosystem. In the words of one attendee, what made the HMA conference unique was that “it was very rare to have providers, CBOs, health systems, insurers, and public sector organizations in one place…I gained significant value by viewing similar issues from different perspectives.”
Attendees participated in plenary sessions and breakouts that were grounded in Medicaid, Medicare, and Marketplace, with each session extending beyond the traditional topics for these public health insurance programs. Attendees were challenged and inspired to consider the cross-cutting work underway to address health equity, the integration of housing into healthcare, innovative strategies for behavioral health coverage for adults as well as children and families involved in the child welfare system, and the opportunities for federally qualified health clinics to engage in value-based care delivery to improve outcomes.
Signature HMA discussions with health plan leaders and Medicaid directors also provided valuable insights that will help guide the next phase of innovative programs and technologies designed and deployed to improve health. Breakout sessions offered in-depth exploration across Medicaid/Duals, Medicare/MA, and Marketplace/ACA tracks, alongside discussions on demand for innovation, advances in treating sickle cell disease, and creative workforce strategies. The conference concluded with a panel that prepared attendees for policymaking in the post-election, post-Chevron deference landscape.
The HMA event created opportunities to learn and network with potential partners against the background of the city of Chicago skyline, as one participant put it, “away from the daily craziness.” The discussions were robust and focused on new ideas that can be deployed by stakeholders all trying to improve the accessibility, quality, equity, and value of healthcare.
Listed below are conference takeaways that will be of interest and relevant to the broader healthcare ecosystem:
Systemize the little things that improve outcomes.
Keynote speaker Dr. Darshak Sanghavi from ARPA-H challenged people to focus on systematizing the “little things” that drive measurable improvements in outcomes as a source of meaningful innovation. His presentation focused on how ARPA-H is investing differently in private sector innovation – not just big breakthroughs, but also in data-informed approaches that produce consistent quality.
Housing is a healthcare issue.
There is increasing overlap between initiatives to address housing support in Medicare and Medicaid. Bridging diverse sectors and stakeholders is essential to address critical gaps in service delivery. HMA’s new Housing Services & Supports practice group recognizes that housing is part of healthcare, but it does not have to be fully funded by healthcare entities.
Cross-payer collaboration would improve behavioral health.
Behavioral health coverage has historically relied on the Medicaid-based chassis of coverage, but the breadth of needs and federal parity requirements have created an urgent need for new approaches to coverage across all systems and all payers. Cross-payer innovation and collaboration are essential, and systems need to position themselves to scale effective solutions that allow individuals to access services when they need them. In particular, youth and family voices must be part of the transformation of children’s mental health systems to smooth their experience.
The ACA is stable, but 2025 brings uncertainty.
The stability and future success of the ACA marketplaces hinge on the decisions of the 119th Congress regarding the extension of subsidies. If these subsidies are reduced or cancelled it could disrupt what has become a robust and reliable segment of the health insurance market, potentially requiring another pivotal transformation.
Community collaboration can bridge Medicaid health gaps.
New norms are emerging in the Medicaid program. There is unprecedented policy and programmatic work underway to ensure member experiences are informing the design of Medicaid programs as well as the type and pathways for accessing health and health adjacent services. Federal and state government, managed care plans, and providers must work together to bridge the gap to ensure Medicaid programs are best able to serve their members.
Interoperability remains foundational to quality improvement.
We have many different information systems, but when data is pushed to providers to help them manage their patient panel — ED visits, medications, and other data – higher quality care is more likely to be provided to patients.
Provider networks can be structured to ensure success in value.
Medicare providers are embracing value-based care on different timelines and in varied ways. Policymakers, health plans, and other stakeholders need to think carefully about how to structure networks with those providers who are doing it well to get the best results.
Clinics need help with data and financing to drive value-based outcomes.
Poverty is the primary diagnosis for patients of federally qualified health centers (FQHCs), and payment can better recognize the connections FQHCs make to anti-poverty services and programs. As the healthcare industry moves providers along the trajectory of value-based payment, FQHCs will be positioned to deliver whole person care if their data and financing is aligned.
These – and other takeaways and partnerships – will inform strategic, policy, programmatic and operational decisions at the hundreds of organizations represented at the HMA conference. They are also key points as we shape the conversations for the 2025 event.
Webinar Replay: The Future of Medicare Advantage: How the Election Results Impact the Program
This webinar was held on November 19, 2024.
More than 50 percent of Medicare enrollees chose Medicare Advantage (MA) as their preferred coverage option. This growth brought increased scrutiny, with elected officials, regulators, think tanks, and news organizations raising questions about the program’s current makeup. With MA reform potentially on the table in 2025, attendees explored how the election results could impact policy changes in the coming year.
Learning objectives:
- Understand the political landscape for the Medicare Advantage program post-election
- Identify likely Medicare Advantage reforms
- Assess organizational strategies in response to Medicare Advantage reforms
Medicare Advantage Plans: It’s time for the Stars 4th quarter push
The Medicare Stars program is a year-round endeavor for Medicare Advantage (MA) plans. That being said, all MA plans intensify their Stars campaign during the fourth quarter of each year. The most important aspect of the fourth quarter push is to know where to focus. MA Star ratings are more than a quality score—they shape the financial and operational success of MA plans.
Some measures may no longer apply in the fourth quarter. Once the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey has been completed, the fourth quarter becomes a time to continue the effort to enhance and improve consumer experience for next year’s CAHPS survey. For example, post discharge follow-up is time limited and going back to earlier quarters is not possible. Adherence measures work similarly; if a member has already lost 80% of days covered, coverage cannot be made up during the fourth quarter. The message should be “focus only on measures where you can make a difference.”
Mammograms and colorectal exams can occur any time of year. These two measures should definitely be the focus of a fourth quarter push. A constraint may be provider capacity since all MA plans are focused on the same measures. Measures with low denominators like the osteoporosis management measure may be an important element in fourth quarter strategies.
Star Ratings and Operational Excellence
Operational excellence begins with robust, accurate, and actionable data, and even using lean six sigma principles to drive process improvement. Advanced analytics platforms are needed to aggregate and analyze vast amounts of healthcare data and operational data. Accurate risk adjustments, quality measurement, and operational metrics like appeals are essential. Data discrepancies or delays result in penalties, lower Star ratings, and incorrect payments. MA plans must develop processes to validate via quality assurance process and audit data regularly against CMS requirements.
Operational excellence also relies on a well-trained engaged workforce. Training should focus on fostering a culture of continuous improvement, where every team member is aligned with the organization’s goals of improving quality and operational performance.
Star ratings are a byproduct of strategic, data-driven approaches to care management, quality improvement, and operational efficiency. Success lies in the ability to optimize data integrity, streamline care coordination, and proactively resolve member concerns.
Accelerating Star Rating Performance
The HMA Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans and makes sure that your intensified 4th quarter effort is productive. The HMA Stars Accelerator Solution analytics provides information to plans about prioritizing measures during the fourth quarter push. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple “what-if” scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year. The Accelerator approach includes “all-hands-on-deck” – care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.
As the fourth quarter push occurs in the middle of the Annual Enrollment Period, lessons learned can be applied immediately. The HMA team can backstop your organization during this very busy time, avoiding missed opportunities. The fourth quarter push does not end until midnight January 31st of each year.
The HMA Stars Accelerator Solution will create a permanent change in your organization that is designed to yield a 4-star rating or higher each year. The Accelerator is a cultural transformation designed to strengthen star performance. Click here to learn more about the HMA Stars Accelerator Solution’s capabilities, where you can request a copy of the HMA Stars Accelerator Playbook. Let’s have a conversation about how your fourth quarter push is designed and unfolding.
We are also holding two webinars that may be of interest:
Falling Stars: Who’s Who in the 2025 Star Ratings
November 7, 2024 – 3:30 PM ET
Register now
Colleagues from Wakely Consulting Group, an HMA Company, will discuss trends in Overall Star Ratings, the appeals and lawsuits filed in response, and future changes to the Star Rating program that are likely to depress Star Ratings even further over the next few years.
Mastering Star Performance: Strategies from the HMA Stars Accelerator Program
November 13, 2024 – 12:00 PM ET
Register now
CMS releases draft benefit and payment parameters for 2026 Marketplace
Our second In Focus article reviews the recently proposed Notice of Benefit and Payment Parameters (NBPP) for 2026. The Centers for Medicare & Medicaid Services (CMS) proposed rule, released October 10, 2024, describes the policy and payment changes that will affect the Affordable Care Act (ACA) markets in 2026. Public comments must be submitted to CMS by November 12, 2024. Key highlights from the proposed rule follow.
Broker Oversight and Monitoring
CMS proposes to increase oversight and accountability for brokers and agents that write policies through HealthCare.gov. In response to the discovery earlier this year of fraudulent actors reassigning broker designations and switching consumer enrollments without their permission or knowledge, CMS has already implemented several corrective actions, including the suspension of 850 Healthcare.gov agents and brokers. CMS intends to build on these actions through the following interventions:
- Clarify that lead agents, typically an agency owner or executive, are subject to the same rules as individual brokers, agents, and web-brokers and that enforcement action can be taken against the lead agents if they explicitly or implicitly condone misconduct or fraud
- Broaden CMS’s authority to suspend broker and agent system access, inclusive of instances of suspected misconduct that affects eligibility determinations, operations, applicants, or systems
- Update the model consent form to include documentation of the broker reviewing and confirming the accuracy of submitted application information with the consumer.
Marketplace User Fees
CMS proposes to increase the user fee collected to pay for administration of HealthCare.gov as follows:
- Between 1.8 percent and 2.5 percent in 2026 for federally facilitated marketplaces (FFM) states, up from 1.5 percent of monthly premiums in 2025
- Between 1.4 percent and 2 percent in 2026 for state-based marketplaces on the federal platform (SBM-FPs), up from 1.2 percent in 2025
The proposed changes are due, in part, to uncertainty caused by the future of the enhanced premium tax credits that are set to expire at the end of 2025. The enhanced premium tax credits are the driving force behind the increase in nationwide marketplace enrollment to more than 21 million people in 2020 from 11.4 million in 2020. If not extended, or if it takes past March 2025 for Congress to act, CMS has indicated the user fees will increase in 2026 to 2.5 percent for FFM states and 2% for SBM-FPs to accommodate expected enrollment declines. Notably, after several years of significant decreases, CMS is proposing to increase the user fees above 2025 levels regardless of the outcome of the enhanced premium tax credits.
Plan Limits for Non-Standard Plans
CMS proposes to clarify rules limiting the number of non-standardized plans an issuer can offer through HealthCare.gov (two or less in 2025). The limit is applied per product network type (e.g., HMO, PPO), per metal level, per service area, per inclusion of adult/pediatric dental and/or vision benefits (with additional exceptions, starting in payment year (PY) 2025, for plans with specific design features that would substantially benefit consumers and meet other requirements). To maximize the number of non-standardized plans offered on HealthCare.gov, an issuer could offer up to 16 plans per metal level and network type in a given service area by creating every combination of adult dental, pediatric dental, and adult vision (or even more, if plans meet the exception requirements).
Though CMS does not limit the number of standardized plan options an issuer offers on HealthCare.gov, they propose reinstating a meaningful difference standard to prevent consumer confusion and unnecessary plan proliferation. The proposed standard is similar to the removed standard from 2019; for plans in the same metal level, product type, and service area, a reasonable consumer needs to be able to identify at least one material difference in benefit coverage, provider networks, and/or formulary.
New Premium Payment Threshold Options for Issuers
CMS proposes new options for issuers to avoid triggering late payment grace periods for consumers who make most but not all of their premium payment to minimize termination of coverage for consumers who owe a small amount. The options include:
- The current option of a “reasonable” percentage of net premium. CMS proposes codifying 95 percent as the minimum threshold.
- New proposals of as low as 99 percent of gross premium and a fixed-dollar threshold of $5 or less.
CMS is also considering limiting issuers to offering just one payment threshold option—either fixed-dollar or percent of premium—to avoid consumer confusion.
Increased Transparency for State-Based Marketplaces
CMS proposes new initiatives to promote transparency into state-based marketplace (SBM) program operations. These initiatives include:
- Publishing State Marketplace Annual Report Tool (SMART) submissions, which are used to monitor SBM compliance with select eligibility and enrollment, program integrity, and financial reporting requirements. SBMs must annually participate in independent programmatic and financial audits as part of SMART. CMS proposes to make the 2023 SMART submissions public in spring 2025.
- Expanding the disclosure of SBM information to include data collected but not currently published, including details on SBM eligibility, enrollment, and plan certification policies as well as Navigator program spending, call center metrics, and website traffic data.
SBMs already are required to publish programmatic and financial audit summaries and generally publish robust data and information on their program operations through public reports and meetings; however, this information is neither centrally located nor consistently published across all SBMs.
Key Considerations
The proposed 2026 NBPP would build on previous actions that CMS has taken to address fraudulent broker and agent activity and to shore up financial sustainability of Healthcare.gov operations in light of uncertainty about the enhanced premium tax credits. It also seeks to make clear how plan variations adding dental or vision benefits factor into HealthCare.gov plan limits and gives issuers new premium payment threshold options. Lastly, it proposes new transparency requirements for SBMs. Interested stakeholders, including SBMs and issuers, should monitor how these proposed changes will affect consumers, operational processes, product strategy, and financial sustainability.
Connect With Us
The Health Management Associates, Inc., team has the depth, experience, and subject matter expertise to assist with tailored analysis and the modeling capabilities to assess the policy impacts to consumers, marketplaces, and issuers. If you have questions or want to discuss the proposed rule, contact our featured experts below.
For additional information on elements of the proposed NBPP not discussed here, Wakely Consulting’s white paper, Summary of Provisions of HHS’ Proposed 2026 Notice of Benefit and Payment Parameters and Other Key Regulations, highlights the proposed changes to the Risk Adjustment program, Medical Loss Ratio, and the Actuarial Value Calculator, among other changes.
Webinar Replay: Mastering Star Performance: Strategies from the HMA Stars Accelerator Program
This webinar was held on November 13, 2024.
In this webinar, attendees learned the essential methods and practices to enhance Star ratings through the HMA Stars Accelerator program. The session explored how to leverage data analytics to effectively track current star performance and identify areas for improvement. Additionally, it covered stratification techniques that allow for targeted focus on key measure opportunities throughout the year to ensure optimal results.
Learning objectives:
- Learn how to implement proven strategies and best practices
- Understand how to leverage data analytics to monitor and assess trends
- Provide focus areas to measure opportunities and enhance performance
2025 Star rating cut point changes: key updates and their impact
This week’s In Focus highlights a white paper that Wakely, a Health Management Associates, Inc. (HMA), company published in September 2024, titled “A Cut Above the Rest: Summary of 2025 Star Rating Cut Point Changes.” The paper provides an in-depth analysis of the latest cut point changes from the Centers for Medicare & Medicaid Services (CMS) to demonstrate how policies like the Tukey Outer Fence Outlier removal logic (Tukey), guardrails, and changes in overall quality performance have led to the highest Medicare Advantage (MA) Star Rating cut points in the program’s history.
Why Cut Points Matter
MA Star Ratings are a critical measure of the quality and performance of MA plans. The MA Star Ratings cut points are the thresholds CMS has set to evaluate the performance of MA plans. These ratings, ranging from 1 to 5 stars, are based on various quality measures, including clinical outcomes, patient experience, and plan administration. CMS applies methodologies such as Tukey to set the cut points and guardrails to stabilize them over time. MA plans are evaluated and earn a rating that is based on their performance against the cut points. Higher Star Ratings can lead to increased enrollment and higher payments from CMS, making them a key focus for MA organizations.
Key Findings
Wakely used the 2025 Star Rating Technical Notes to analyze measure-level cut point changes. The data summarize how Medicare Advantage organizations (MAOs) performed on various quality measures during the 2023 measurement year. Notably, the Tukey methodology was applied for the first time within the 2024 Star Ratings cut points. Initially, the full impact of this methodology was evident in the initial 2024 Star Ratings, but the updated 2024 Star Ratings restricted use of guardrails and spread the impact of Tukey over a few years.
The analysis reinforces expectations for changes in MA spending in 2026, in part because of changes in Medicare Advantage Prescription Drug Overall Star Ratings.
Key Considerations
The Star Ratings have been on a steady decline over the last two years while CMS continues to refine and evolve its Star Ratings methodology and areas of focus. Key issues to consider in this climate include:
- MAOs are experiencing significant reductions in quality bonus and rebate payments, which potentially affects opportunities to improve member health outcomes.
- Strategies to enhance Star Ratings and elevate program quality are crucial for performance and meeting the unique needs of MA enrollees.
- MA plans and other stakeholders also should consider that as plans optimize performance on certain traditional quality measures, CMS is placing increased emphasis on member experience with their health plan and providers during care.
- The Star Ratings is an important tool CMS uses to redirect plan focus and resources.
CMS is scheduled to release the final scores and Star Ratings for Star Year 2025 in early October 2024. These ratings will be based on the performance data from the 2023 dates of service. This release will provide MAOs with updated quality and performance metrics, which are used to determine CMS Star Ratings and subsequent quality-based payments.
Connect with Us
For further insights into the Star Ratings and more information on the report, contact our featured experts below.
Strategies and actions MAOs implement in 2024 and 2025 will affect their 2026 Star Ratings. For further insights into programmatic strategies, best practices for design of meaningful solutions to implement, and approaches to measure the effectiveness of these solutions, explore The HMA Stars Accelerator Solution.
Illinois D-SNP RFP: Highlights and signals of forthcoming trends
This week, our In Focus section from the HMA Weekly Roundup highlights the Illinois Department of Healthcare and Family Services request for proposals (RFP) for a dual-eligible special needs plan (D-SNP) to replace its current Medicare-Medicaid Alignment Initiative (MMAI) demonstration.
Overview
Illinois is one of the states affected by the Centers for Medicare & Medicaid Services (CMS) decision to end the capitated model in the federal Financial Alignment Initiative (FAI) demonstration. Illinois is among the last states to issue an RFP that will support the transition from the demonstration program. Two states, Texas and South Carolina, have yet to issue RFPs. On September 10, 2024, CMS issued a memo discussing end-of-demonstration enrollment and operational considerations and deadlines by which states should make operational decisions.
The Health Management Associates, Inc., (HMA) In Focus article June 26, 2024, discussed related changes that CMS finalized to the federal policy framework for D-SNPs to enhance care coordination, improve health outcomes, and ensure that dual-eligible beneficiaries receive accurate information about their healthcare while integrating successful features of the FAI demonstration and the Medicare-Medicaid Plan (MMP) program. These decisions are prompting more states to develop new models for integrating Medicare and Medicaid services.
Illinois D-SNP RFP Highlights
This Illinois procurement will transition the state to a fully integrated dual-eligible special needs plan (FIDE-SNP) model, which will include a requirement that plans provide managed long-term services and supports (MLTSS) for both people who are dually eligible and Medicaid-only beneficiaries beginning in 2027.
The RFP is largely focused on quality care provisions and improved care coordination across all services lines, including overall expectations to achieve the following:
- Improved access and quality of community-based behavioral health services
- Better quality of care in facilities
- Fewer program opt-outs
- A strategy for increasing the use of alternative payment models (APMs) in Medicaid managed care in Illinois, particularly for behavioral health providers
Emerging National Trends
Overall, the Illinois D-SNP procurement reflects broader national trends toward more coordinated, equitable, and outcome-focused healthcare.
Focus on Health Equity. The procurement emphasizes health equity and reducing disparities, including information on innovations that are responsive to health-related social needs (HRSNs) and social determinants of health (SDOH). The state is weighing payers’ experience partnering with non-traditional providers to meet Medicaid customers’ needs, their innovative programs to address customers who are difficult to locate, and their strategies for improving care for adults with complex needs in facility or community-based settings.
In addition, the state will require plans to report outcomes by race, ethnicity, and geography. Given the demographic and health equity reporting requirements, payers should be prepared to speak to their data collection, member engagement strategies, and relationships with community-based organizations. This capability will be an essential component of addressing both population health and health equity activities.
Alternative Payment Models. The RFP also requests detailed information on the payer’s strategy for increasing the use of APMs in Illinois Medicaid managed care, including the models the payer intends to implement. Experience supported by data-driven outcomes and explanations of work with providers or clinics to adopt, manage, and support reporting and analytics for APMs is a key area of interest for the state. Notably, the state seeks information on plans to include behavioral health providers in APMs.
Long-Term Services Related Transitions. The RFP questions also reflect the long-term services and supports that dually eligible beneficiaries need, as well as those of Medicaid-only beneficiaries who are eligible for these services. More specifically, the RFP raises questions to determine how payers will effectively implement nursing home diversion plans, incentivize hospitals to discharge patients to community settings, and approaches to transition members from institutional settings to the home and community, including by connecting members with supports for HRSNs. Payers will be expected to provide specific examples of their experience and outcomes in other states.
Emerging National Trends
The emphasis on health equity in the Illinois RFP reflects a broader national trend. States are increasingly interested in—and in some situations required—addressing SDOH and reduce disparities, especially for the Medicare and Medicaid dual-eligible population. As a result, payers and other healthcare organizations must develop capacity internally and through external collaborations to build their expertise and evidence base for advancing improvements.
The push for APMs in the Illinois procurement aligns with national efforts to move away from fee-for-service models. Illinois’s inclusion of behavioral health providers in APMs and requiring integrated care models highlights the growing recognition of the importance of mental health in overall health outcomes.
Illinois’s RFP also reflects heightened interest in improving care transitions and coordination. The potential for incentive programs related to community placement and increased focus on nursing home diversion will require innovative plans and a long-term commitment to working with all stakeholders to build on the federal FAI experiences.
What We’re Watching
Responses to the Illinois RFP are due October 18, 2024, and awards are expected to be announced in December. The state anticipates making awards to the top four bidders. Contract execution is estimated July 2025, with implementation January 1, 2026.
As the FAI demonstration ends and CMS’s integration requirements take effect over the next several years, there will be a steep learning curve for states, payers, and other key stakeholders adapting to this evolving environment. Compliance with new CMS rules will be crucial, and experiences in Illinois and other FAI demonstration states can provide valuable insights for other states and stakeholders.
Additional growth and program refinements in the federal Medicare Advantage (MA) landscape are expected in the coming years, especially among MA D-SNPs. Those MA D-SNPs that have yet to participate in Medicaid will need to continue make significant business decisions on participation and actively compete to secure state Medicaid contracts, which will have downstream implications for their state and local partners.
Connect with Us
Health Management Associates (HMA) experts continue to review the evolving landscape and federal changes that will affect D-SNPs in 2025 and beyond. Contact our featured experts below for details about the nationwide D-SNP rules and landscape.
Countdown to HMA’s fall 2024 conference: Spotlight on Medicare-Medicaid integration
The upcoming HMA event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, offers extensive opportunities to engage with leaders from various sectors who are designing and implementing Medicare-Medicaid integration initiatives. Join us for main stage panel discussions with distinguished health plan executives from national and local plans and Medicaid directors from Iowa, New Mexico, New York, and Rhode Island.
HMA Principal Holly Michaels Fisher will lead a deeper dive into integration issues during the breakout session, Innovations to Improve Outcomes for Medicare-Medicaid Dually Eligible Individuals, with speakers Michael Carson, President and CEO of WellCare; Dr. Steven R. Counsell, Medical Director for the Division of Aging at Indiana Family and Social Services Administration; Dr. Linda Kurian, Executive Medical Director for the Center of Excellence of Medicare Duals/D-SNP at Aetna; and Juliet Marsala, Deputy Secretary for the Office of Long-term Living in the Pennsylvania Department of Human Services.
During the breakout, Meeting New Expectations for Health Equity and Improved Beneficiary Outcomes in Medicare Advantage, HMA Principal Greg Gierer will facilitate a conversation on the evolving landscape of MA rates and supplemental benefits, with experts Melinda Buntin, Health Economist and Bloomberg Distinguished Professor at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Carey Business School; Mark Fendrick, Director of the University of Michigan’s Center for Value-Based Insurance Design, and Matt Kazan, Vice President of Policy and Government Affairs at the SCAN Group.
Online registration ends October 1st.