Caprice Knapp, a seasoned health economist with over 20 years of experience in Medicaid and healthcare policy, shares her journey through various roles in government, academia, and private insurance. In this episode, Caprice offers a unique perspective on the challenges of measuring quality in healthcare, the importance of data-driven decision-making, and how global healthcare models can inspire innovation in Medicaid. From pediatric palliative care to cost-effective policy solutions, Caprice sheds light on how improving quality of care can transform healthcare outcomes for vulnerable populations.
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Highlights from HMA survey on state approaches to managing the Medicaid pharmacy benefit
This week’s In Focus covers key takeaways and insights from a recently released HMA report, State Approaches to Managing the Medicaid Pharmacy Benefit: Insights from a National Survey for State Fiscal Years 2023 and 2024.
The report, released in August 2024 with support from Arnold Ventures, includes survey responses from 47 states (including DC) for state fiscal years (SFYs) 2023 and 2024. The survey instrument builds on questions posed in the 2019 Medicaid Pharmacy Study of all 50 states and the District of Columbia, which HMA and the Kaiser Family Foundation conducted.
The report discusses state trends for how Medicaid pharmacy benefits are administered across the country, including planned priorities and anticipated challenges in SFY 2025 and beyond. The findings are based on information provided by the nation’s state Medicaid Directors, Medicaid Pharmacy Directors, and other Medicaid agency experts.
Pharmacy Benefit Administration
In many states, managed care delivery systems play a pivotal role in administering Medicaid benefits, including prescription drugs. As of July 1, 2023, survey results found that:
- A total of 33 states carved pharmacy benefits into managed care organization (MCO) contracts, with one state, Kentucky, directing its MCOs to use a single state-selected pharmacy benefit manager (PBM).
- Eight states carve-out the pharmacy benefit—double the number in 2019.
MCO states were surveyed about their use of carve outs for certain drug products/classes, inclusive of physician-administered drugs covered under the medical benefit.
- In all, 19 states reported carving out one or more drug classes or select agents within a drug class—often high-cost specialty drugs.
- Of those states, 13 reported using the carve-out as part of a risk mitigation strategy.
Pharmacy Benefit Managers
The significant role and market power of PBMs have prompted many state legislatures to enact greater transparency practices and require health plans to accept more responsibility for monitoring the PBMs they contract with, which reflect notable changes since the 2019 survey. More specifically:
- A total of 33 states reported contracting with a PBM.
- The most frequently reported PBM functions included utilization management, drug utilization review, claims processing and/or payment, and rebate administration activities.
The 30 MCO states that carve in pharmacy benefits responded to survey questions about PBM transparency and spread pricing requirements. Of these states:
- 25 prohibit spread pricing in MCO PBM contracts—more than double the number of states reporting prohibitions on spread pricing in 2019.
- 17 reported having PBM transparency reporting requirements.
- 10 states reported having “any willing” pharmacy requirements.
The Role of PDLs, Prior Authorization, and Step Therapy in Controlling Drug Costs and Utilization
HMA’s experts also sought information on state payment strategies and utilization management protocols that are used to manage pharmacy expenditures. Nearly all responding states (44) have a preferred drug list (PDL) in place for fee-for-service prescriptions, which allow states to drive the use of lower cost drugs by encouraging providers to prescribe preferred drugs. Further, nearly two-thirds of responding MCO states (19 of 30 states) that do not carve out the pharmacy benefit reported having a uniform PDL for some or all drug classes, requiring all MCOs to cover the same drugs.
Many states have implemented step therapy and prior authorization (PA) guardrails in their Medicaid programs through legislation. However, 85.1 percent of responding states (40 of 47) report utilization controls like PA or step therapy applied to drugs that are reimbursed through the medical benefit to control utilization and costs. States also play an active role in managing MCO clinical protocols or medical necessity criteria, with 22 out of 30 MCO pharmacy carve-in states reporting that they require uniform clinical protocols for some or all drugs with clinical criteria. Approximately one-half of responding MCO carve-in states also require review and approval of MCOs’ PA criteria (15 of 30 states) and step therapy criteria (14 of 30 states).
State Adoption of VBAs: Improving Patient Access to Cell and Gene Therapies
A growing number of states are actively considering entering into value-based arrangements (VBAs) with manufacturers, as pressure to improve patient access to cell and gene therapies increases. Nine states have at least one VBA in place, and 23 states reported that VBAs are among their future solutions for addressing coverage of new high-cost therapies. States will need to address common barriers to VBA implementation, which involves more upfront costs and operational challenges to implement than traditional contracts.
Subsequent to the submission of survey responses, the Centers for Medicare & Medicaid Services (CMS) released a Cell and Gene Therapy (CGT) Access Model, which begins with a focus on sickle cell disease, anticipated to go live on January 1, 2025. Under the model, CMS will negotiate outcomes-based agreements with manufacturers on behalf of the state to ensure that treatment pricing is related to treatment effectiveness. In the coming years, experiences with this model will help determine whether a CMS-led approach to developing and administering VBAs for CGTs improves Medicaid member access to innovative treatment and their impact on expenditures, if any.
Looking Ahead
Managing the Medicaid pharmacy benefit has never been more challenging. In FY 2025 and beyond, most states will be focused on managing their Medicaid pharmacy budgets, especially the development of VBAs and other policies and strategies for managing new high-cost therapies. Other top priorities and challenges cited by multiple states include management of PBM arrangements and considering coverage of the new generation of GLP-1 anti-obesity medications. States also must react to changing drug marketplace conditions driven, in part, by federal policy changes to the Medicaid drug rebate formula and changes designed to lower Medicare drug costs. Drug manufacturer responses to these changes have implications for Medicaid state budgets, but also for state PDL management decisions and beneficiary access to needed medications.
Connect with Us
The upcoming event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, hosted by HMA, will offer more opportunities to engage with report author Kathy Gifford at the pre-conference workshop Paying for Innovative Pharmaceuticals: State and Federal Trends Shaping Public Programs. Leaders from various sectors will join Kathy to discuss trends in prescription drug policies in public and commercial insurance programs.
For details about the report, contact our featured experts below.
How states are shaping Medicaid managed care and marketplace participation
This week, our In Focus section reviews state policies designed to increase insurer participation in Medicaid managed care and Marketplace programs. As states seek to address healthcare costs, affordability, and consumer experiences, they are exploring a range of initiatives—from the rise of prescription drug affordability boards to cost containment commissions, cost growth benchmarks, transparency, and examination of mergers and acquisitions.
A notable trend is the use of state policy and purchasing power to encourage or mandate that Medicaid managed care organizations (MCOs) offer Marketplace plans. Dual-market participation can help smooth coverage transitions, ensure continuity of care, and expand consumer choice. The remainder of this article addresses original research and analysis of this trend by our Health Management Associates, Inc. (HMA), featured experts.
Current Landscape
In 2024, enrollment in the Marketplace program has surged to more than 21 million, approximately a 30 percent increase from 2023. This growth was largely attributed to the temporary enhanced subsidies that allowed more people to access affordable coverage. Over the past several regulatory cycles, federal policymakers also have taken steps to further align the Marketplace framework with Medicaid on key issues, such as essential community provider access, eligibility and enrollment processes, and plan design standards. In response, states are innovating to meet federal requirements while pursuing their own healthcare goals related to coverage, affordability, access, and healthcare outcomes.
Value Proposition
A compelling value proposition for Medicaid MCOs to participate in the Marketplace (and vice versa) includes the ability to market to and retain people moving from one program to another as life circumstances change. Dual-market participation also supports diversification and growth strategies. In fact, enrollment in the Marketplace has nearly doubled since 2020. For Medicaid MCOs in particular, expanding product offerings to include Marketplace plans presents a unique opportunity to leverage existing provider networks and reimbursement arrangements to deliver more competitive rates.
Consumers benefit when the same organization participates in both markets. Families with parents and children who obtain coverage under different programs have an opportunity to work with a single organization and choose providers from the same or overlapping networks. Income fluctuations may result in disenrollment from one program (e.g., Medicaid) and eligibility for a new program (e.g., Marketplace subsidies). Continuity of care policies can smooth these transitions in areas such as prior authorization, care management, and provider network.
State Strategies to Increase Dual-Market Participation
The Affordable Care Act expanded access to affordable health insurance coverage for as many as 45 million individuals by giving states the option to expand Medicaid and provide federal subsidies to people who purchase Marketplace plans. States are now using various strategies to encourage or require insurer participation in both programs to ease transitions for individuals and families “churning” from one program to another, increase competition and choice of Marketplace plans, and reduce the risk of coverage gaps. For example:
- Nevada is requiring any bidder that plans to respond to its upcoming Medicaid MCO procurement to separately submit a “good faith” response to the Battle Born State Plans (BBSP) RFP. This state-contracted, public option will be available on the Silver State Health Insurance Exchange beginning in 2026. Failure to submit a good faith proposal will disqualify an organization from participating in the Medicaid MCO procurement later this fall. Nevada’s current Medicaid MCOs must participate in the Marketplace by offering at least one Silver and one Gold qualified health plan (QHP) that has overlapping provider networks, serves the same service area, and charges reasonable premiums.
- Rhode Island and New Mexico require or intend to require that their Medicaid MCOs participate in the Marketplace. As an awardee of Rhode Island’s recent Medicaid MCO procurement, UnitedHealthcare, must reenter the HealthSource Rhode Island market in 2027. These states also have designed their Medicaid MCO auto-assignment methodology to favor enrollment in a Medicaid MCO affiliated with an individual’s previous Marketplace plan or a family member’s Marketplace plan.
- In its last Medicaid MCO procurement (2018), North Carolina offered bonus points to any bidder that agrees to offer a Marketplace MCO. The resulting contract codified the market entry commitment and included implications for failure to follow through. Nonfulfillment could result in the highest level of contract noncompliance and associated penalties.
- Arkansas expanded its Medicaid program using federal matching funds to purchase QHP coverage through the Marketplace. Minnesota, one of the few states offering a basic health program, contracts with the same organizations to provide coverage under both programs.
- Iowa uses contract language to encourage, but not require, Medicaid MCOs to participate in the Marketplace to facilitate continuity of care during coverage transitions.
The Centers for Medicaid & Medicare Services (CMS) collaborated with states to promote continuity of coverage following the end of the Medicaid continuous enrollment requirement established in the Families First Coronavirus Response Act of 2020, also known as the Medicaid public health emergency (PHE) unwinding. This support includes the clarification of permissible outreach activities by Medicaid MCOs that also offer a Marketplace plan, information sharing, and other assistance. Many states have incorporated the CMS guidanceiii into Medicaid MCO contracts. North Carolina, Utah, and West Virginia include additional contract terms supporting their Medicaid MCOs’ ability to co-market Medicaid and Marketplace plans, including when an individual is losing Medicaid eligibility.
What to Watch For
Coverage transition challenges throughout the Medicaid PHE unwinding have highlighted the real-life impact of coverage gaps and the importance of policies and practices that promote uninterrupted access to healthcare coverage. Historic Marketplace enrollment levels and recent CMS guidance clarifying the allowability of outreach to people who are losing Medicaid coverage about Marketplace plan available make the prospect of dual-market participation increasingly attractive for Medicaid MCOs. A greater focus on improving continuity of care and Marketplace plan choice may lead to more states encouraging or requiring Medicaid MCOs to participate in the Marketplace.
Connect with Us
The upcoming HMA event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, will offer more opportunities to engage with leaders from various sectors who are advancing innovations in Medicaid managed care and Marketplace programs and the points at which these programs intersect. State Medicaid and insurance commissioners, health plan executives, and community leaders, among others, will share insights into their market success and initiatives designed to address healthcare costs and insurance affordability.
Experts from HMA and our family of companies have extensive experience in the policy, structure, and administration of healthcare markets and health plan contracting. For more information, contact our featured experts below.
Improving healthcare for justice-involved populations: key insights on Medicaid Section 1115 reentry demonstrations
This week, our In Focus section considers state and local initiatives centered on the intersection of carceral care and state Medicaid programs.
The Health Management Associates (HMA) team includes clinicians and leaders who bring extensive expertise in justice healthcare, Medicaid, managed care, administration and operations, quality and accreditation, and information technology. Drawing on this wealth of experience, we provide five key insights for states, industry professionals, and other stakeholders aiming to improve healthcare access and related services for justice-involved populations.
Community Reentry: A Pivotal Point to Impact Health Outcomes
The Centers for Medicare & Medicaid Services (CMS) designed the Medicaid Section 1115 Reentry Demonstration Opportunity to improve access to community resources that address the healthcare and health-related social needs of people who are preparing to reenter their communities after incarceration. Medicaid enrollment assistance and prerelease coverage for certain services can help ensure successful care transitions during reentry. This demonstration allows states to provide Medicaid-reimbursable services up to 90 days before release from carceral facilities. These services include care management, behavioral health consultations, and peer support designed aiming to smooth the transition back into the community.
States and their partners are using these Medicaid regulatory flexibilities to develop—and eventually implement—programs that focus on the critical point of transition and reduce emergency department visits and inpatient hospital admissions for both physical and behavioral health issues once individuals are released and return to the community.
Recent State Activity Interest in Medicaid Reentry Initiatives
In July 2024, CMS approved Medicaid Section 1115 reentry demonstration proposals from Illinois, Kentucky, Oregon, Utah, and Vermont. These states join California, Washington, Montana, and Massachusetts in their work to develop the operational details and implementation plans to cover some services prior to release, increasing access to and continuity of care for returning individuals. According to HMA’s monitoring and analysis, another 13 states and the District of Columbia have reentry proposals pending CMS review.
Roles for Medicaid Partners
With 41 states, including the District of Columbia, using managed care for specific Medicaid populations, local and regional managed care organizations (MCOs) are integral to this landscape. The Medicaid Reentry Section 1115 Demonstration highlights the importance of early engagement with state partners and MCOs in preparing to serve the justice-involved population effectively.
By understanding these demonstrations and strategically developing their policy and operational plans, states and MCOs can enhance their services and improve outcomes for individuals transitioning out of carceral facilities. The continued focus on integrating comprehensive care models reflects a commitment to advancing the quality of healthcare for justice-involved individuals and ensuring their successful reentry into the community.
Key Considerations for States and Partners
CMS approval of state reentry demonstration proposals is the first of several critical steps required to improve access to services and health outcomes. Based on their real-world strategy, policy, and operational experience in Medicaid and correctional systems, the HMA team identified the following key considerations for states and their partners pursuing reentry initiatives:
- Successful reentry programs require breaking down longstanding silos and challenges in policy, funding, contracting, systems/IT, bias, and other aspects integral to reentry.
- All stakeholders will benefit from operationalizing best practices that use data metrics and reporting to demonstrate compliance with federal and state oversight and monitoring across carceral, public health, and Medicaid programs.
- State and local carceral facilities may need to change their contracts with healthcare vendors to meet contractual and quality standards and best practices, including, in some cases, transitioning to provision of care to public health systems and university partners.
- Build a team that will support successful state reentry programs. For example, government and their partners need expertise in the intersection of healthcare and correctional systems, skills in delivery system transformation, and knowledge of the publicly funded healthcare industry. The team will benefit from comprehensive experience with state prison systems, county and municipal jails, drug courts, and probation and parole, including implementing and coordinating medications for addiction treatment along a continuum of care in response to the substance abuse and opioid use disorder crisis facing communities nationwide.
- Prepare to collaborate with new entities that have a range of experiences and perspectives.
Connect with Us
The July 2024 edition of HMA’s Podcast, Vital Viewpoints, features a discussion with HMA Managing Director for Justice-Involved Services Linda Follenweider about her insights on this pivotal moment in carceral healthcare. Linda, an advanced practice registered nurse and board-certified family nurse practitioner, discusses the critical gaps in continuity of care for incarcerated individuals. She emphasizes how many people receive necessary medical care while in jail or prison but struggle to maintain these services upon release. The episode showcases the opportunities presented by adopting routine screening questions about incarceration history to ensure better health outcomes and resource utilization.
The upcoming conference, Unlocking Solutions in Medicaid, Medicare, and Marketplace, hosted by HMA, will offer more opportunities to engage with fellow executives, policymakers, and thought leaders across multiple sectors and industries advancing policy and programmatic innovations in carceral care and reentry. Notably, HMA experts Tonya Moore and Stuart Venske offer invaluable insights from their involvement in the development and execution of the CMS Section 1115 demonstration policies, including the reentry opportunity.
For more information about HMA’s work at the intersection of carceral care and Medicaid, contact our featured experts below.
State Approaches to Managing the Medicaid Pharmacy Benefit
Millions of Americans rely on Medicaid drug coverage to treat acute illnesses and manage chronic and disabling conditions. Though optional, all states provide pharmacy benefits under Medicaid but administer the benefit in different ways in accordance with federal guidelines. To better understand how states across the country administer the Medicaid pharmacy benefit, as well as states’ planned priorities and anticipated future challenges, HMA surveyed all 50 states and the District of Columbia in early 2024. A total of 46 states and the District of Columbia participated.
The report includes survey findings addressing a variety of topics including how states administer the pharmacy benefit and use of pharmacy benefit managers, state containment and utilization management strategies, payment and rebate approaches, value-based arrangements, planned policy changes, priorities and challenges in managing the pharmacy benefit in FY 2025 and beyond, and more. The HMA authors are Kathy Gifford, Aimee Lashbrook, and Constance Payne.
The report authors will also be discussing this paper and presenting their findings at a pre-conference workshop “Paying for Innovative Pharmaceuticals: State and Federal Trends Shaping Public Programs” at HMA’s Unlocking Solutions in Medicaid, Medicare, and Marketplace conference, October 7-9. Register today!
HMA conference keynote speaker discusses innovation in Medicaid, Medicare, and Marketplaces
Given that 50 percent of Americans have publicly funded health insurance—including Medicare, Medicaid, or Affordable Care Act Marketplace plans in which many premiums are subsidized—the need is growing for innovations that will yield better quality at lower total cost. The Health Management Associates (HMA) Fall Conference, Unlocking Solutions in Medicaid, Medicare, and Marketplace, offers an agenda that dives deeply into the latest innovations and opportunities in these critical programs. Focused on improving collaboration and information sharing, the event will explore strategies and practical solutions to reduce health disparities and enhance outcomes for aging, disabled, and chronically ill people.
The federal government recently created the Advanced Research Projects Agency for Health (ARPA-Health), which is charged with supporting the development of high-impact solutions to improve health outcomes. We are fortunate to have as our keynote speaker Dr. Darshak Sanghavi from ARPA-H. We have asked him to share his thoughts on why innovation in the public healthcare space is critical.
Dr. Sanghavi will kick off the HMA conference with a discussion on how ARPA-H initiatives are intended to support new solutions to modernize today’s healthcare landscape—not only with technology, but also through changes in our approaches to healthcare delivery and payment.
Only a month before the November elections, the HMA conference presents a valuable opportunity to engage with healthcare leaders across the public and private sectors to hear how they are thinking about potential policy and regulatory changes that could affect publicly funded programs and supplemental coverage. Attendees will take home insights and actionable ideas to drive improvements in health and well-being. Join us to shape the solutions that will impact the future of healthcare!
Webinar Replay: The New Administrative State: Implications of Recent Landmark Supreme Court Rulings for Federal Regulations, Agency Deference, and State Implementation
This webinar was held on August 14, 2024.
While legal experts assess the recent U.S. Supreme Court rulings, federal and state agency leaders face significant questions about how their agencies and their responsibilities will be impacted. This webinar featured insightful discussions with former federal and state agency leaders exploring the known and yet-to-be determined impacts of recent rulings on federal regulations, rulemaking and actions, and agency deference, and also explored the impact on state agencies implementing federal rules. The webinar addressed the impact of the pivotal Loper Bright Enterprises v. Raimondo and West Virginia v. EPA decisions. Together these decisions overturned the longstanding Chevron deference doctrine, are pushing Congress to craft more specific legislation, and are directing courts to interpret ambiguous statutes. The discussion also explored the most appropriate responses of agency leaders, anticipated the ways that these decisions impact federal and state agency decision-making, and identified areas of growing uncertainty.
Learning Objectives:
- Understand what we know about the impact of these decisions on agency rulemaking and decision making, consider the impact on federal agency discretion, and understand the shift in power towards Congress and judicial interpretation
- Analyze the likely impact on agency rulemaking processes
- Explore state governance issues, both as a partner to federal agencies and as an implementer of federal policy and funds
- Identify the most important questions yet to be answered
HMA celebrates 59th anniversary of Medicaid and Medicare
This week, Health Management Associates (HMA) shifts In Focus from a newsworthy development to commemorate a seminal event in the expansion and strengthening of healthcare access in the United States. On July 30, 1965, Medicaid and Medicare were signed into law under Title XVIII and Title XIX of the Social Security Act. Today we celebrate the 59th anniversary of this pivotal moment in America’s healthcare journey.
Medicaid: A Critical Safety Net that Remains Strong
All states, the District of Columbia, and the U.S. territories have Medicaid programs designed to provide health insurance coverage for low-income individuals. As of March 20241, 82,751,338 people, including eligible low-income adults, children, pregnant women, older adults, and people with disabilities are covered under their state’s Medicaid program in accordance with federal requirements. The COVID-19 pandemic underscored just how important this safety net program is for American families, as it continued to deliver vital services during unprecedented times.
Beyond its traditional role, Medicaid also drives significant innovations in care for people with complex conditions and challenges. States have implemented various programs and initiatives to improve healthcare quality and outcomes. These include:
- Managed Care Expansion: Many states have expanded Medicaid managed care programs to enhance care coordination and improve health outcomes.
- Value-Based Care Models: Innovations in value-based care are being tested, aiming to link reimbursement to quality of care and patient outcomes rather than volume of services.
- Integration of Behavioral Health: Several states are integrating behavioral health services into Medicaid to address mental health and substance use disorders more effectively.
- Telehealth: The pandemic accelerated the adoption of telehealth services in Medicaid, expanding access to care and reducing barriers for patients.
Medicare: Leading in Innovation and Coverage
Medicare provides coverage to more than 60 million seniors and people with disabilities. In addition to being a lifeline for so many Americans, Medicare is a force for innovation in health policy, piloting changes to payment and care delivery through the Innovation Center and through Medicare Advantage plan design. Key innovations include:
- Alternative Payment Models: The Innovation Center has been at the center of piloting various alternative payment models to improve quality and reduce costs.
- Medicare Advantage Enhancements: Medicare Advantage plans continue to evolve, offering more comprehensive benefits that include mental health and substance use disorder services and integrating additional services such as dental, vision, and wellness programs.
- Chronic Care Management: Medicare is expanding its focus on chronic care management, providing additional resources and support for individuals with chronic conditions.
HMA’s Commitment to Medicaid and Medicare
Since HMA’s founding, our experts have helped states, plans, providers, and other stakeholders deliver the full spectrum of Medicaid and Children’s Health Insurance Program (CHIP) services. As HMA has evolved, we have built a leading-edge Medicare team that includes former agency officials, plan leaders, policy and data analysts, and actuaries. Healthcare plans, providers, and innovators call upon our colleagues to anticipate policy and regulatory change, develop and support Medicare Advantage business, transform fee-for-service programs, and support access to new technologies and treatments that can both improve quality patient outcomes and reduce costs of care.
Our growing team of includes 10 former state Medicaid directors and many more former state agency leaders, hospital and health plan executives, senior officials from the Centers for Medicare & Medicaid Services (CMS), and public health leaders.
HMA Colleagues Who Are Former Medicaid Directors Looking Ahead
HMA’s Top Medicare Experts
Looking Ahead
As Medicaid and Medicare near their seventh decade, the programs will continue to evolve and change to better support covered individuals and meet the demands of policymakers and taxpayers. HMA experts are committed in service of this important mission, and we are excited about building their future together with our clients to create more innovative, high-quality care that improves health outcomes for all.
CMS invites states to apply for transforming maternal health model
This week, our In Focus section reviews the notice of funding opportunity (NOFO) for the Transforming Maternal Health (TMaH) Model, which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on December 15, 2023. States interested in participating in this model must submit an application to CMS during the competitive application process.
As described in a December 2023 In Focus, pregnancy-related deaths have more than doubled since 1987 to 17.6 deaths per 100,000 live births, with health disparities only worsening outcomes for different racial and ethnic groups. For example, the pregnancy-related mortality rates for Black and Native American and Alaska Native people are approximately two to three times higher than the rate for White people. In recent years, 38 states have extended postpartum coverage, and 11 states now offer doula coverage for Medicaid enrollees. This initiative accelerates the focus on maternal outcomes and, with Medicaid paying for nearly 43 percent of births, has the potential to affect health across generations.
This model is designed exclusively to improve maternal healthcare for people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The TMaH model takes a whole-person approach to pregnancy, childbirth, and postpartum care, addressing the physical, mental health, and social needs people experience during pregnancy.
Model Overview
Up to 15 participating state Medicaid agencies (SMAs) will receive as much as $17 million over the 10-year period to develop a value-based alternative payment model for maternity care services, with the intention of improving quality and health outcomes and promoting the long-term sustainability of services. TMaH will focus on three pillars:
- Access to care, infrastructure, and workforce capacity
- Quality improvement and safety
- Whole-person care delivery
The TMaH model is designed to support birthing persons along their care journey, expanding continuity, and improving outcomes.
During the model’s first three years, states will receive targeted technical assistance to achieve pre-implementation milestones. The table below highlights the key activities in the pre-implementation phase.
Following pre-implementation, participants will enter a seven-year implementation period during which the SMAs will implement the program with partners, such as managed care organizations (MCOs), perinatal quality collaboratives, hospitals, birth centers, health centers and rural health clinics, maternity care providers, and community-based organizations.
In year four, states will offer partnering providers and care delivery sites upside-only performance payments from state funds (no cooperative funds may be used). In year five, states will transition partner provider and partner care delivery locations to a new value-based payment model. CMS will lead the development of the value-based model, and it will be finalized during the pre-implementation period.
The model also requires a health equity plan, which has been a consistent requirement across models from the Innovation Center. Awardees must develop a plan that addresses disparities among underserved populations, such as racial and ethnic groups and people living in rural areas, who are at higher risk for poor maternal outcomes.
State Medicaid Agency Requirements
For states considering TMaH, the NOFO outlines the requirements for participating SMAs, which include:
- States must include CHIP if pregnant people receive services through CHIP
- States that have managed care plans must contract with at least MCO for implementation
- Collaborate with partner providers (e.g., OBs, midwives, doulas), care delivery location (e.g., hospitals, birth centers, federally qualified health centers), and partner organizations
- Collaborate in the process to create cost and quality benchmarks with CMS
- Be actively involved in technical assistance activities, including attending regularly scheduled calls, providing input and working on portions of documents as appropriate
- Execute the data-sharing agreements necessary to support the exchange of data and information related to the TA activities and completion of milestones
- Provide CMS and contractors the necessary information and data to support the development of documents to help reach milestones
- States must demonstrate their ability to meet these requirements as part of the NOFO process, and CMS will evaluate their responses as part of the selection process
TMaH Opportunities and Considerations
The model offers states resources and technical assistance to develop value-based alternative payment models to support whole-person pregnancy, birth, and postpartum care and improved outcomes. Many SMAs already are working on programs to innovate care and payment, and the TMaH is an opportunity to expand and accelerate those programs.
The model offers an opportunity for states that have yet to expand postpartum coverage or added doula benefits to adopt these policies with the funding and technical assistance they may need to support their efforts.
SMAs interested in this opportunity should evaluate their application readiness and pre-plan for the application.
What’s Next?
States interested in TMaH should submit a letter of intent by August 8, 2024. Applications are due by September 20, 2024, and the model is expected to start January 2025.
The Health Management Associates team will continue to evaluate the TMaH model as more information becomes available. For more information, contact our featured experts below.
Unlocking Solutions in the Medicaid, Medicare, and Marketplace programs
HMA is hosting its 2024 Fall Conference October 7−9 in Chicago, IL. Unlocking Solutions in Medicaid, Medicare, and Marketplace Programs promises to enhance your ability to navigate and shape healthcare programs and systems, focusing on improving health and well-being.
In a landscape dominated by endless video meetings, the HMA Fall Conference offers a refreshing change. Join us for an enriching experience featuring:
- Engagement with healthcare experts and thought leaders who are actively collaborating with stakeholders
- Participation in face-to-face discussions to exchange ideas and receive valuable feedback
- Opportunities to connect with peers who are committed to strengthening public programs and enhancing health outcomes
Keynote Address and Sessions
Darshak Sanghavi, MD, from the Advanced Research Projects Agency for Health (ARPA-H), will deliver the Keynote Address. He and other speakers will inspire attendees to explore innovative healthcare programs and their potential impacts on healthcare delivery, reimbursement, and health outcomes.
The conference will feature a diverse array of speakers and participants, including C-suite executives from national, regional, and local health plans. Federal and state leaders joining panels will include:
- State Medicaid directors from New York, Iowa, New Mexico and Alabama
- State insurance commissioners
- Behavioral health agency officials
- State housing agencies
- Leaders from the US Interagency Council on Homelessness
The conference will include a revamped pre-conference workshop on October 7, featuring hands-on exercises and interactive sessions led by HMA leaders. Sessions will include a value-based care contracting exercise, a value-based purchasing assessment discussion for providers, tips and tricks on navigating Medicaid section 1115 demonstrations, AI applications in healthcare, and more.
View the agenda and event details, including speakers confirmed to date.
Registration
Early bird registration is open until July 31. Don’t miss this opportunity to gain actionable knowledge, forge valuable connections, and discover fresh insights and best practices. Register now to secure your spot at the forefront of healthcare innovation.
The Health Equity & Access for Rural Dually Eligible Individuals Toolkit: Raising Rural Voices
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the “dually eligible”). Dually eligible individuals residing in rural areas represent about 5 percent of all rural residents. They reside at the intersection of a public health crisis and a fragmented Medicaid and Medicare care delivery system. As HMA wrote in Health Affairs, this small population is at risk of falling through the cracks of this crisis and suffering a steep rural mortality penalty.
With support from Arnold Ventures, HMA prepared “The Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit: Raising Rural Voices from New Mexico, North Dakota, and Tennessee to Create Action. The toolkit contains eight actionable solutions for federal and state policymakers to use and tailor to states’ needs. Ellen Breslin, Samantha Di Paola, and Susan McGeehan authored the toolkit, with research contributions from Rebecca Kellenberg and Andrea Maresca.
HMA toolkit and webinar to advance health equity & access for rural dually eligible individuals
In 2022, HMA convened stakeholder roundtables in three states – including New Mexico, North Dakota, and Tennessee to identify the challenges facing dually eligible individuals living in rural areas and to propose solutions to these challenges. Informed by this process, HMA developed the Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit.
The toolkit is structured around three domains used to organize eight solutions. For each solution, HMA provides a description of the rural access challenge, the proposed solution, and the proposed tool. Each tool is powered by some type of lever available to the federal and state government. We anticipate that policymakers will build upon this toolkit through continued dialogue with rural communities. The toolkit’s framework, goals, and actionable solutions are summarized in the figure below.
HMA Principal Ellen Breslin, Consultant Samantha Di Paola, and Senior Consultant Susan McGeehan authored the toolkit, with research contributions from HMA Principals Rebecca Kellenberg and Andrea Maresca. Download the toolkit.
On February 2, 2023, HMA will hosted a webinar on the HEARD toolkit. During this webinar, HMA experts and panelists including Dr. Kevin Bennett (USC-SOM Columbia, SC CRPH), Dennis Heaphy (DPC), Pam Parker (SNP Alliance), and Tallie Tolen (New Mexico Medicaid) will summarized and discussed the toolkit’s actionable solutions for improving rural dually eligible individuals’ health and social outcomes.