Insights

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

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

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Webinar

Webinar replay: Collaborating to improve children’s behavioral health – a comprehensive playbook to fostering wellbeing in children

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This webinar was held on December 12, 2023. 

Beyond the statistics lie the stories of countless children and families needing immediate and critical access to behavioral health services and community-based supports. Addressing these issues requires comprehensive cross-system reforms, including policies that promote integrated financing, enhanced care coordination, increased provider collaboration, and bolster upstream prevention efforts. HMA is working with these national partner organizations to prioritize and focus on cross system integrated and interoperable solutions to address the needs of children, youth, and families with complex behavioral health needs.

HMA hosted a webinar in partnership with the National Association of State Mental Health Program Directors (NASMHPD), National Association of Medicaid Directors (NAMD), Child Welfare League of America (CWLA), American Public Human Services Association (APHSA), and with support from the Annie E. Casey Foundation, Casey Family Programs and other funders. Together, these organizations have developed a multi-state policy lab to be held in February 2024. Applications for state agency participation opened the week of November 11th. State agency decision makers can click here to fill out and submit your state agency’s application. This webinar focused on the overall effort and for states to hear from this partnership on the importance of collaborating to strengthen the children’s behavioral health system.

If the link above (https://healthmanagement.qualtrics.com/jfe/form/SV_9YwdBb5xJzIVfIq) to the online form causes problems or does not work for you, please use this fillable PDF application and send it to [email protected] with all relevant attachments. Applicants must submit the full application no later than 5 pm on December 20, 2023.

Key highlights of this webinar include:

  • Explaining the need to develop a collaborative multi-system response to meet the behavioral health needs of children, youth and their families
  • The opportunity for 8 state child serving agency teams to participate in the children’s behavioral health policy lab

Featured Speakers:

Julie Collins, MSW, LCSW, VP, Practice Excellence, CWLA
David Miller, M.P.Aff., Senior Operations & Project Director, NASMHPD
Sheila Poole, Vice President, External Relations, APHSA
Joe Ribsam, JD, Child Welfare and Juvenile Justice Policy Director, AECF

 

Brief & Report

A Look at Swedish Maternity Care with Medicaid in Mind

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Health Management Associates (HMA) collaborates with state and federal agencies, health service providers, and community-based organizations to enhance access to comprehensive reproductive healthcare and address disparities in birth outcomes, particularly in the context of Medicaid. This involves evaluating and supporting the implementation of perinatal care models, addressing health determinants affecting birth outcomes, and overcoming barriers to reproductive health services. In an effort to inform these initiatives, Diana Rodin, an associate principal at HMA interviewed Swedish experts to understand the country’s universal, publicly funded maternity and reproductive healthcare system. The Swedish model emphasizes universal healthcare, generous socioeconomic supports, and collaborative team-based perinatal care led by midwives. Lessons from Sweden, such as the utilization of “kulturdoulas” for culturally aligned support, a consensus-driven decision-making approach, and a centralized perinatal data system, provide valuable insights for improving birth outcomes for Medicaid recipients in the United States. 

Blog

HMA Fall Conference: Highlights and Takeaways

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HMA Fall Conference October 2023

As we look back at our 2023 Fall Conference on publicly sponsored healthcare held in October, we wanted to highlight a few key takeaways from the event:

  • Behavioral Health Pre-Conference workshop: An impactful pre-conference session convened influential leaders in behavioral health to deliberate on the urgent need for a purposeful disruption of mental health accessibility across multiple sectors. Participants were actively challenged to reimagine strategies that could effectively disrupt the prevailing status quo in behavioral health, focusing on three key components essential for constructing a comprehensive system of care: population health and prevention, quality, and network.

The discourse highlighted pervasive issues such as silos that contribute to a lack of accountability within the system. There was a unanimous recognition of the imperative to eliminate barriers to access, accompanied by a resounding call for a pivotal transformation in payer models. Throughout the session, a prevailing theme underscored the critical need for fostering collaborative efforts across different sectors, emphasizing the creation of opportunities for cross-sector groups to work together.

Participants echoed a shared sentiment regarding the urgency of dismantling the current lacking system and replacing it with a more inclusive, patient-centered approach. The session served as a platform for thought-provoking discussions, inspiring innovative solutions to address the challenges in behavioral health, paving the way for a more effective and accessible system.

The three main conference themes – Equitable Access, Digital Innovation, and Value-based Care – were touched upon in many of the panels and plenary sessions.

  • Equitable Access: Several panels and speakers talked about health equity as a moral imperative as well as an organizational priority. Payers and providers understand that the Centers for Medicare and Medicaid Services (CMS) is developing metrics and measures to incorporate equity into accreditation and reimbursement and are anxious to get down to the details of the specific items that will be included. There was also robust discussion about how to incorporate community-based organizations and social services into Medicaid managed care plans to ensure that health-related social needs are being addressed in a more holistic way. There are opportunities to ensure contracting parameters and quality metrics work as intended to enable payers and providers to improve outcomes and reduce inequities of all types.
  • Digital Innovation: In addition to a “shark tank” style presentation of innovative technology vendors, the HMA conference featured a panel of experts in data liquidity and interoperability. They discussed the opportunity to embrace application programming interfaces (APIs) and digital health as a strategic imperative instead of a compliance issue. The new electronic prior authorization requirements are already starting to produce big results by expediting approvals, which is good for patients, but also reducing workload to allow staff to be redeployed to other areas of need. The panel also discussed the real need to improve digital access for rural health clinics (RHCs) and federally qualified health centers (FQHCs) that serve rural communities, where fee-for-service payment creates barriers to greater data coordination. And finally, the panel discussed the need to improve Medicaid procurement, so it does not impose barriers to digital innovation for vulnerable populations.
  • Lessons of Value-Based Care: This session featured a lively conversation about how value-based care is more important than ever, and frankly, that it is the right thing to do for mission-driven organizations to improve the health of patients. The organizations represented discussed how it has not been easy to learn new approaches to care coordination and managing financial risk, but they can do what is best for the patient by investing in the right things up front. Value-based care approaches are proliferating, including FQHCs where the providers’ motivation to serve vulnerable families is now supported by the right financial incentives.

HMA is committed to bringing together experts from across the healthcare spectrum, and advancing the conversation about ways to improve access, equity, and innovation in healthcare. In early March 2024, we will be offering an HMA Spring Workshop on value-based care in Chicago. Registration will open soon; to receive the invitation, please be sure you are subscribed to the HMA News and Events list.

Brief & Report

Opportunities to Enhance HCBS for Older Adults and Individuals Providing Care

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Minnesota Department of Human Services partnered with HMA to study Minnesota’s home- and community-based services (HCBS) trends; changes in its demographics, including the experiences of diverse communities; and successful local and national HCBS models to inform future efforts to improve access to supports for older Minnesotans and their informal caregivers. The report outlines recommendations to help address several of the challenges outlined in the brief, and identified several areas for DHS to consider for future innovations.

HMA has extensive expertise in HCBS and long-term services and supports (LTSS). If you would like to learn more about what HMA can do for your organization, you can contact the report authors Susan McGeehan, Barry J. Jacobs, Chris Dickerson, Aaron Tripp, Erica Reaves, and Anya Yermishkin.

Blog

Proposed changes to opioid treatment: what they will mean for providers, payers, and regulators

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After more than two decades, SAMHSA and its Center for Substance Abuse Treatment (CSAT) is revisiting regulations governing opioid treatment programs (OTPs), as required by the 2023 Consolidated Appropriations Act passed by Congress. These new federal rules around treatment will change how medications are delivered to persons with opioid use disorder (OUD), offering opioid treatment centers a unique opportunity to advance person-centered care, and can build on the lessons learned from the flexibilities offered during the public health emergency.

This is a real opportunity to change how care is delivered. It will increase access to lifesaving medications, including:

  • A change in take-home schedules, which will allow for additional take-home medications sooner in the treatment process to reduce the burden of coming to the program daily, alleviating transportation challenges and the disruption of work and family routines.
  • Emphasizing and codifying the importance of harm reduction.
  • Clarifying diagnoses required for admission to be active moderate-to-severe OUD, OUD in remission, or at high risk for recurrence or overdose.
  • Removing access barriers for persons under 18; expanding use of telehealth; and finally, expanding interim maintenance dosing up to 180 days in a 12-month period. 

These new changes will help alleviate admission barriers caused by workforce shortages and allow patients better access to medication and treatment. The increase in use of telehealth combined with medications for opioid use disorder (MOUD) will remove time and travel barriers for treatment, allowing persons treated with methadone and buprenorphine, including new persons, to be treated remotely.

What does this mean for the field?

OTPs have historically been reimbursed based on volume, with daily attendance as a steady source of revenue and a “captive” audience for counseling services. For persons with OUD to feel the full benefits of the new rule, changes will need to be made at all levels:

  • OTPs will need to rethink their clinical models to develop a service mix driven by a person’s need as opposed to regulations. Engagement will drive attendance, outcomes and thus revenue. Additionally, there will be a need to:
    • Retrain staff.
    • Work with medical team to develop new clinical protocols.
    • Structure revenue cycle management processes and business models of service delivery.
  • Regulators will need to adapt state licensing rules and re-train licensing staff.
  • Payers have an opportunity to move Value-Based Payment (VBP) more steadily into the OUD treatment space and will need to realign payment structures to incentivize providers to provide care according to a person’s need.

If you want to learn more about the changes ahead, HMA hosted a 3-part webinar series on the effect of proposed regulations on delivery of opioid treatment services. The series New Rules in Treatment of Opioid Addiction was aimed at helping stakeholders prepare for and adapt to these changes to ensure a successful transition for the people they serve. Our series focuses on three areas where changes can help those managing OUD:

  1. How do OTPs deliver services to better support persons with OUD?
  2. How do payers create the right financial incentives to help providers deliver better behavioral health solutions for OUD?
  3. How do state regulators make changes to rules and laws to promote a treatment system that prioritizes a person’s health and recovery?

Watch here:

Part 1 Opioid Treatment Providers

Part 2 Opioid State Payers – Aligning Incentives for Treatment

Part 3 Opportunities for State Regulators to Shape Policy and Regulation of Treatment

If you are ready to explore these changes in your organization, HMA can help. We have experience in:

  • Developing clinical workflows
  • Aligning revenue cycle and clinical operations
  • Developing and implementing state OUD code
  • Supporting health plans and providers in moving into VBP
  • Supporting health plans in adapting to new clinical models

Blog

Advancing the Life Sciences with expertise from all aspects of healthcare

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Your organization’s success relies on understanding evolving market dynamics and navigating a complex statutory and regulatory environment. Drug, device, and diagnostic firms, from established to start-up, come to HMA when they want experienced partners who can help with regulatory strategy, coding, coverage, and payment solutions, investment strategy, navigating the complexities of federal and state law, or even creating new policy. HMA, working with our partner companies, provides consulting with depth and breadth throughout the life sciences sector and the broader healthcare industry.

We work with drug, device, and diagnostic companies and their trade associations, pharmacies, physician specialty societies, hospitals, health systems, and community health centers, as well as investment firms and their portfolio companies.

Before joining HMA, our team spent years as senior officials in Medicare and Medicaid; cabinet-level health secretaries; and policy advisors to governors and other elected officials. They also served as directors of large nonprofit and social services organizations, top-level advisors, and C-level executives. Our team is expert in federal and state policy, reimbursement, actuarial consulting, medical coding support, public affairs, and corporate development.

Our Life Sciences team, comprised of experts across our firm, can help with:

We help you navigate the complexities of FDA regulation to help with product development and marketing authorization strategies and regulation throughout the product lifecycle. 

Regulatory policy counseling

Product development and target product profile

FDA authorization strategy

Post-approval compliance  

Contact our FDA Experts:

Clay Alspach, Principal, Leavitt Partners
Ralph Hall, Principal, Leavitt Partners
Eric Marshall, Principal, Leavitt Partners
Amy Rick, Principal, Leavitt Partners
Vince Ventimiglia, CEO, Leavitt Partners Collaborative Advocates

We help your organization understand the commercial market for life sciences products and develop strategies to support patient access, product launches and growth, and value.

Market intelligence, including market, customer, and stakeholder analysis

Strategic planning, considering risk-based contracting, value-based care, and population health

Business development and strategy

Formulary and market access insights

Go-to-market and launch strategies

Contact our Commercial Experts:

Jeremy Bahr, VP, Client Relations, HMA
David Kulick, Managing Director, The Focus Group
Spencer Morrison, Associate Principal, Leavitt Partners
Rebecca Nielsen, Managing Director, Leavitt Partners
Alex Rich, Managing Director, The Focus Group

Experts in Medicare, Medicaid, and the commercial market, we help you understand and navigate the complexities of coding, coverage, and payment for approved products and develop and execute strategies to support product access and value.

Code assessment and recommendation

Coverage mapping and guidance

Payment strategy across settings

CMS engagement

Emerging technology strategies

Alternative payment model (APM) development

Payment change impact modeling

Contact our Reimbursement Experts:

Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, The Moran Company
Charlene Frizzera, Advisor, Leavitt Partners
Zach Gaumer, Principal, HMA
Kevin Kirby, Managing Director, The Moran Company
Rachel Kramer, Principal, The Moran Company
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, The Moran Company

We help you understand how evolving Federal policy impacts your business and develop strategies for creating and advancing Federal policy that advances value and your business.

Congressional and Administration intelligence and strategy

Policy development and strategy

Multi-sector alliances to create and advance new policy

Policy modeling and CBO scoring projections

Contact our Federal Experts:

Clay Alspach, Principal, Leavitt Partners
Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, The Moran Company
Zach Gaumer, Principal, HMA
Ralph Hall, Principal, Leavitt Partners
Kevin Kirby, Managing Director, The Moran Company
Rachel Kramer, Principal, The Moran Company
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, The Moran Company
Eric Marshall, Principal, Leavitt Partners
Sara Singleton, Principal, Leavitt Partners
Josh Trent, Managing Principal, Leavitt Partners
Vince Ventimiglia, CEO, Leavitt Partners Collaborative Advocates
Liz Wroe, Principal, Leavitt Partners

We help you understand how evolving State policy impacts your business and develop strategies to support product access and value in Medicaid programs.

State-related access issues

State policy impact modeling

State research support

Contact our State Experts:

Clay Alspach, Principal, Leavitt Partners
Anne Marie Lauterbach, Principal, Leavitt Partners
Stephen Palmer, Managing Principal, HMA
Matt Powers, Managing Director, HMA
Josh Trent, Managing Principal, Leavitt Partners

We work with investment firms and their portfolio companies to provide insight that helps you invest wisely in the rapidly evolving healthcare marketplace.

Comprehensive due diligence studies

In-depth research projects

Billing and compliance reviews

Identification, analysis, and outlook on federal, state, and local reimbursement/regulatory issues

Contact our Investment Strategy Experts:

David Kulick, Managing Director, The Focus Group
Greg Nersessian, Managing Director, HMA
Alex Rich, Managing Director, The Focus Group

Project Spotlight

Pipeline research and policy recommendations to address new innovative therapies

A large national pharmaceutical manufacturer hired HMA, The Moran Company, and Leavitt Partners, both HMA subsidiaries, to assess the current pipeline of innovative therapies, examine current reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process.

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Blog

CMS proposes significant changes to Medicare Advantage and Medicare prescription drug benefit programs for 2025

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This week, our In Focus section reviews a wide-ranging proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) on November 6, 2023. The rule would update various policies governing Medicare Advantage (MA, or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly. These proposed policy reforms would implement changes related to Star Ratings, marketing and communications, agent/broker compensation, health equity, dual eligible special needs plans (D-SNPs), utilization management, network adequacy, and other programmatic areas. The proposals reflect the agency’s continuing focus on increasing program transparency, improving health equity, reducing the cost of care for Medicare beneficiaries, and expanding access to behavioral health services.

MA and Part D stakeholders are encouraged to provide CMS with feedback and analysis regarding the potential impact of these changes. Comments on the proposed rule are due by January 5, 2024. The final rule would take effect in contract year 2025.

Improving Access to Behavioral Health Care Providers

CMS proposes regulatory changes intended to improve access to behavioral healthcare by adding certain provider specialties to the MA network adequacy standards as follows.

  • CMS proposes to add a new facility-specialty type to the existing list of facility-specialty types evaluated as part of its plan network adequacy reviews. The new facility-specialty type, outpatient behavioral health, would be included in network adequacy evaluations, including marriage and family therapists (MFTs), mental health counselors (MHCs), opioid treatment programs, community mental health centers, and/or other behavioral health and addiction medicine specialists and facilities.
  • MFTs and MHCs will be eligible to enroll in Medicare and start billing for services beginning January 1, 2024, because of the new statutory benefit category established in the Consolidated Appropriations Act (CAA) of 2023. CMS proposes to make corresponding changes to its network adequacy requirements for MA organizations.
  • For purposes of the network adequacy requirements, the new facility-specialty type would be evaluated using time and distance and minimum number standards in the proposed regulation.

Increased Transparency for Special Supplemental Benefits for the Chronically Ill

In 2018, Congress enacted new authorities pertaining to supplemental benefits for MA members with chronic health conditions. CMS refers to this category of benefits as Special Supplemental Benefits for the Chronically Ill (SSBCI). These services are available only to enrollees with ongoing conditions and who meet certain criteria established in the statute. In contrast to the general policy that MA benefits should be offered uniformly to all plan members, MA plans may offer SSBCI tailored to a qualifying individual’s specific medical diagnosis and needs.

Supplemental benefits, including SSBCI, are generally funded with MA plan rebate dollars. CMS notes that the number of MA plans that offer SSBCI—and the number and scope of SSBCI that individual plans provide—has increased since their introduction in 2019.

Under the proposed rule:

  • MA organizations would be required to demonstrate, through relevant and acceptable evidence, that an item or service offered as SSBCI has a reasonable likelihood of improving or maintaining the health or overall function of chronically ill beneficiaries. MA plans also must, by the date on which they submit a bid to CMS, include a bibliography of evidence supporting this position. According to CMS, this expectation would shift the burden of proof from the agency to MA organizations, requiring plans to demonstrate compliance with this standard and that SSBCI items and services are evidence-based.
  • MA plans must follow their written policies based on objective criteria for determining enrollee eligibility for SSBCI when making determinations.
  • Require that MA plans document denials of SSBCI eligibility rather than its approvals.
  • CMS would codify its authority to review and deny approval of an MA organization’s bid if the plan cannot demonstrate, through relevant and acceptable evidence, that its proposed SSBCI has a reasonable expectation of improving or maintaining the health or overall function of a chronically ill enrollee.
  • CMS also would codify its authority to review SSBCI offerings annually for compliance and in light of the available evidence.

According to CMS, these proposals, if implemented, would better ensure that the benefits offered as SSBCI are reasonably expected to positively affect the health and well-being of chronically ill beneficiaries and guard against the use of MA rebate dollars for SSBCI that unsubstantiated.

In addition, CMS is proposing new policies to improve transparency regarding SSBCI so that beneficiaries are aware that SSBCI are only available to enrollees who meet the eligibility criteria. More specifically, CMS proposes to:

  • Modify the current requirements for the SSBCI disclaimer that MA organizations must use whenever SSBCI are mentioned. The SSBCI disclaimer would have to list the relevant chronic condition(s) that qualify for the benefits that MA organizations offer.
  • Establish specific font and reading pace parameters for the SSBCI disclaimer in print, television, online, social media, radio, other voice-based ads, and outdoor advertising, including billboards. Finally, it would clarify that MA organizations must include the disclaimer in all marketing and communications materials that mention SSBCI.

Requiring Mid-Year Enrollee Notification of Available Supplemental Benefits

As noted previously, over the past several years, the number of MA plans offering supplemental benefits has increased. The benefits offered are broader in scope and variety, and an increasing amount of MA rebate dollars are being directed toward these benefits. At the same time, plans have reported that the number of enrollees who use many of these benefits is low.

  • CMS proposes requiring MA plans to notify enrollees mid-year of the unused supplemental benefits available to them. The notice would list any supplemental benefits that a beneficiary does not use during the first six months of the year (January 1−June 30).
  • At present, MA plans are not required to send any communication specific to an enrollee’s usage of supplemental benefits. This policy is intended to educate enrollees on their access to supplemental benefits and encourage greater use of these benefits.

Enhancing “Guardrails” for Agent and Broker Compensation

For many years, CMS has set upper limits on the compensation that agents and brokers can receive for enrolling Medicare beneficiaries in MA and Part D plans. CMS believes that many MA and prescription drug payment plans, as well as third-party entities with which they contract, make structured payments to agents and brokers that circumvent these compensation caps.

  • In this regulation, CMS proposes to generally prohibit contract terms between MA organizations and agents, brokers, or other third party marketing organizations (TPMOs) that may interfere with the agent’s or broker’s ability to objectively assess and recommend the plan that best-suited to a beneficiary’s healthcare needs; to set a single reimbursement rate for all plans; to revise the scope of items and services included within agent and broker compensation; and to eliminate the regulatory framework that currently allows for separate payment to agents and brokers for administrative services.
  • The agency would make conforming changes to the Part D agent broker compensation rules.

Requiring an Annual Health Equity Analysis of Utilization Management Policies and Procedures

CMS proposes several regulatory changes to the composition and responsibilities of an MA organization’s utilization management (UM) committee.

  • The new rules would require that a member of the UM committee have expertise in health equity and that the UM committee conduct an annual health equity analysis of the use of prior authorization.
  • The proposed analysis would examine the impact of prior authorization on enrollees with one or both of the following social risk factors (SRFs): receipt of the low-income subsidy, dual eligibility for Medicare and Medicaid (LIS/DE), or a disability.
  • The proposed analysis must compare metrics related to the use of prior authorization for enrollees with the specified SRFs with enrollees without the specified SRFs. The results of the analysis must be made publicly available on the MA organization’s website in an easily accessed manner.

Enhancing Enrollees’ Right to Appeal an MA Plan’s Decision to Terminate Coverage for Non-Hospital Provider Services

Beneficiaries enrolled in traditional Medicare and MA plans have the right to a fast-track appeal by an independent review entity (IRE) when their covered skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. At present, quality improvement organizations (QIOs) function as IREs and conduct these reviews.

Furthermore, MA enrollees do not have the same access to QIO review of a fast-track appeal as traditional Medicare beneficiaries.

CMS proposes to:

  • Require that QIOs, instead of MA plans, review untimely fast-track appeals of an MA plan’s decision to terminate HHA, CORF, or SNF services
  • Fully eliminate the provision requiring the forfeiture of an enrollee’s right to appeal a termination of services decision when they leave the facility

According to CMS, these proposals would align MA regulations with the parallel reviews available to beneficiaries in traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.

Increasing the Percentage of Dually Eligible Managed Care Enrollees Who Receive Medicare and Medicaid Services from the Same Organization

In the proposed rule, CMS expresses concern that a significant number of dually eligible enrollees receive Medicare services through one managed care entity and Medicaid services through another (misaligned enrollment), rather than from one organization (aligned enrollment. The proposed rule states that in the long run, “for dually eligible individuals who are in Medicare and Medicaid managed care, we believe that we should continue to drive toward increasing aligned enrollment until it is the normative, if not only, managed care enrollment scenario…. For dually eligible individuals that elect MA plans, we are focused on increasing enrollment in integrated D-SNPs: fully integrated dual eligible special needs plans (FIDE SNPs), highly integrated dual eligible special needs plans (HIDE SNPs), and applicable integrated plans (AIPs) [pages 286-287].”

To move in this direction, CMS offers several interconnected proposals as follows:

  • Replace the current quarterly special enrollment period (SEP) with a monthly SEP for dually eligible individuals and others enrolled in the Part D low-income subsidy program to elect a standalone PDP
  • Create a new integrated care SEP to allow dually eligible individuals to elect an integrated D-SNP on a monthly basis
  • Limit enrollment in certain D-SNPs to individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO)
  • Limit the number of D-SNP plan benefit packages an MA organization, its parent organization, or an entity that shares a parent company with the MA organization, can offer in the same service area as an affiliated Medicaid MCO

According to CMS, these initiatives would increase the percentage of dually eligible MA enrollees who are in plans that are also contracted to cover Medicaid benefits, thereby expanding access to integrated materials, unified appeal processes across Medicare and Medicaid, and continued Medicare services during an appeal.

Impose New Contracting Standards for Dual Eligible Special Needs Plan (D-SNP) Look-Alikes

Under existing regulations, CMS does not contract with and will not renew the contract of a D-SNP look-alike; that is, an MA plan that is not a SNP but in which dually eligible enrollees account for 80 percent or more of total enrollment. CMS proposes to lower the D-SNP look-alike threshold from 80 percent to 70 percent in 2025 and to 60 percent in 2026. CMS states that this proposal is intended to help address the continued proliferation of MA plans that serve high percentages of dually eligible individuals without meeting D-SNP requirements.

Other Topics in the Proposed Rule

In addition, the proposed rule calls for:  

  • Providing greater flexibility for Part D plan sponsors to substitute biosimilar products during the plan year
  • Limiting out-of-network cost sharing for D-SNP PPOs
  • Standardizing the MA risk adjustment data validation appeals process
  • Expanding permissible data use and data disclosure for MA encounter data including for support for Medicaid and state Medicaid agencies to better coordinate care for dually eligible individuals

The Health Management Associates Medicare team will continue to analyze these proposed changes. We have the depth and breadth of expertise to assist with tailored analysis, to model policy impacts, and to support the drafting of comment letters to this rule. For more information or questions about the policies described, contact Amy Bassano ([email protected]), Julie Faulhaber ([email protected]), Andrea Maresca ([email protected]), or John Richardson ([email protected]).

Blog

November is National Adoption Month

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When Love is Not Enough to Preserve a Forever Family for a Child

National Adoption Month image

Families formed by adoption face unique challenges in their lifelong journey as adoptees, parents, and siblings. Adoption-competent mental health is a necessary resource for adoptive families. This November, we are honoring adoption as a vital permanency strategy and the importance of forever families in the lives of children and youth who need this sense of permanency, security, and wellbeing.

The Children’s Bureau, part of the U.S. Department of Health and Human Services Office of the Administration for Children and Families (ACF) created National Adoption month to increase national awareness of adoption issues, encourage the development of permanent relationships, and bring attention to the need for adoptive families to provide placement for teens in the U.S. foster care system. The theme for 2023, “Empowering Youth: Finding Points of Connection,” focuses on ways to provide opportunities and services that connect youth to their identity—including culture, background, interests, and ambitions – to support meaningful permanent relationships with adults.

Adoption Statistics

The following are key data from the fiscal year 2021 report for the Adoption and Foster Care Analysis and Reporting System.

In the U.S., as of September 30, 2021, there were 114,000 children and youth waiting to be adopted who were at risk of aging out of foster care without permanent family connections.

  • More than one in five children waiting for adoption were 13–17 years old.  
  • The average age of all children waiting to be adopted was 7.5 years old.  
  • The average time in care for all children waiting to be adopted was 33.7 months.  
  • The average time in care for children waiting to be adopted after termination of parental rights was 19 months.  

The National Council for Adoption reports an 18 percent decrease in adoptions from FY19-FY21, with over 19,000 children who aged out of foster care without a permanent family. There has been a 24 percent decrease in domestic adoptions from 2019-2020 and 93 percent decline in intercountry adoptions since peaking in 2004.[1] .  These data points reflect the urgency of revitalizing adoption as an important tool for the wellbeing of children who need permanent loving families.

Recognizing that adoption is just the beginning of the family’s journey and the fact that adoptive families need special attention, especially when the children who have been adopted have suffered the trauma of entering the child welfare system, mental health treatment and resources are critical to the wellbeing of these families and the children in them.

Importance of Identity

Research has shown that strong cultural identity can contribute to mental health resilience, higher levels of social well-being, and improved coping skills, greater self-esteem, higher education levels, better psychological adjustment, and improved coping abilities.[2]  But many youth in foster care often have lower cultural identity strength than those who did not experience foster care. This can lead to higher levels of loneliness and depression, lower self-esteem, and difficult psychological adjustments that in turn affect coping skills and learning.[3]

In her book You Should be Grateful, Angela Tucker offers many practical insights and tools aimed at nurturing identity and helping transracial families and adoptees to center around the cultural norms and experiences of the adoptees themselves.[4] 

A Changing Landscape

Many states now have safe-haven laws where parents can drop off their babies without penalty at hospitals, fire stations or police department if they are not able to care for them knowing their babies will be cared for and placed in families through the child welfare system. At the same time there are many children and youth who languish in foster care waiting for a ‘forever family’ to adopt them. Thousands of teens in foster care are looking for the love, support, and encouragement that families provide throughout their lives—not just until they turn 18. Youth who were adopted from the foster care system when they are 16 or older may be able to access Education and Training Vouchers (ETV) of up to $5,000 per year. Those who were adopted from foster care when they are 13 or older are more likely to qualify for federal financial student aid because they do not have to count family income when applying.[5]

When it comes to medical and mental health benefits, qualifying families may receive federally funded monthly maintenance payments, and other support, often until a child turns 18 or 21, depending on the state where they live, and medical assistance until age 26 if they were in foster care at a certain age depending on the state. Recognizing the need for adoption competent mental health, the Federal Administration for Children and Families has awarded the Center for Adoption Support and Education the grant to build a national Center to Support Mental Health Services in the Child Welfare System.[6]

The recent Biden-Harris regulations strengthen services and supports for children and families in the child welfare system. These regulations require additional support for kinship families, and protections for LGBTQI+ youth and expansion of access to legal services for children and families entering the child welfare system. Congress could use the momentum from these regulations to make the Adoption Tax Credit fully refundable and extend it to legal guardians to assist with the financial resources of raising children.

The recent Supreme Court Dobbs decision will likely impact adoption trends, but that trend is still evolving and will need to be monitored before conclusions can be drawn.

How HMA Can Help

HMA assists organizations working in child welfare and adoption, and grounds our work in human-centered design, lived expertise, and change management and leadership principles in state and county program development. We can help support organizations working with children and youth in foster care or with adoption agencies by:

  • Providing technical assistance to state and local government, and community-based organizations
  • Developing system redesign and strategic planning
  • Facilitating stakeholder engagement
  • Implementing workforce and leadership development strategies

Visit the ACF website to learn more about National Adoption Month and find tools and resources to educate yourself and your community about how we can achieve better outcomes for youth in foster care. 

If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact:

Uma Ahluwalia, MSW, MHA, Managing Principal,

Jon Rubin, Principal, or

Caitlin Thomas-Henkel, Principal.


[1] Adoption by the Numbers – National Council for Adoption (adoptioncouncil.org)

[2] Anderson, M., & L.O. Linares. “The Role of Cultural Dissimilarity Factors on Child Adjustment Following Foster Placement.” Children and Youth Services Review 34(4), 2012, 597-601.

[3] Children on AdoptUSKids – AdoptUSKids

[4] “You Should Be Grateful” Stories of Race, Identity and Transracial Adoption — Angela Tucker

[5] Teens need families – AdoptUSKids

[6] Adoption Support Center & Services | C.A.S.E

Brief & Report

23rd annual Kaiser Family Foundation state Medicaid budget survey released

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The 23rd annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA) was released on November 14, 2023 in the report: Amid Unwinding of Pandemic-Era Policies, Medicaid Programs Continue to Focus on Delivery Systems, Benefits, and Reimbursement Rates”.

Survey results show that states expect a sharp increase in Medicaid spending that is a direct result of lower federal spending as Covid relief and enhanced matching declines. This budget pressure is compounded by increasing provider rates, workforce recruitment and compensation challenges, increased spending on behavioral health and maternity care, and spending on programs that improve health related social needs. These budget pressures will create a very challenging environment for state policy makers in the coming years.

The report was prepared by Kathleen Gifford, Aimee Lashbrook, Caprice Knapp, Beth Kidder from HMA and Leavitt Partner’s Bill Snyder; and by Elizabeth HintonElizabeth WilliamsJada RaphaelAnna MudumalaRobin Rudowitz from the Kaiser Family Foundation. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD).

 

Blog

Preventing Type 2 Diabetes in correctional settings

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Today is World Diabetes Day, a day created to keep the importance of diabetes prevention and management in the public and political spotlight. One in every four U.S. healthcare dollars is spent on individuals diagnosed with diabetes, and more than half of that expenditure is directly attributable to diabetes. An estimated 37 million people in the U.S. have type 2 diabetes, and another 96 million (more than one out of every three people) have prediabetes, meaning they are at risk of developing type 2 diabetes.[i]

The urgency of preventing and managing type 2 diabetes is as applicable in correctional facilities as it is in populations in the community. Especially as there is an overrepresentation of populations that have a higher burden of prediabetes and type 2 diabetes in correctional facilities including individuals who:

  • are older,
  • have serious mental illness,
  • have poorer physical and mental health than counterparts in the community,
  • are above recommended body weight,
  • have reduced access to health insurance, and
  • are from racial and ethnic minority groups. 

Administrators of correctional facilities are responsible for the healthcare costs for individuals in their custody who have type 2 diabetes, and the cost of managing this condition in these settings is particularly high.

Fortunately, type 2 diabetes is preventable. One evidence-based and effective strategy for preventing type 2 diabetes is the National Diabetes Prevention Program (National DPP) lifestyle change program. This program is a year-long evidence-based program delivered over 22 sessions using a CDC-approved curriculum. Program participants are expected to lose 5−7 percent of their weight and engage in physical activity for 150 minutes each week.[ii] The National DPP lifestyle change program can be offered in person, online, through distance learning, or a combined approach and is led by a trained lifestyle coach.[iii] The program has been proven to reduce the risk of individuals with prediabetes developing type 2 diabetes by 58 percent (71 percent for people older than age 60).[iv] Projections in other settings that compare the cost of the National DPP lifestyle change program to the costs of treating type 2 diabetes show that the program is cost-effective.[v]

HMA recently published a white paper, “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings,describing how the National DPP lifestyle change program can be used to achieve cost savings and better health for people at risk of developing type 2 diabetes in correctional settings. There have been two successful implementations of the National DPP lifestyle change program to date. The first is described in the study “Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting,” where 47 people from a federal correctional facility participated in a modified version of the National DPP lifestyle change program. Participants who completed the program demonstrated significant reductions in their body mass index and A1C levels. Weight loss in the study was similar to what participants of the National DPP lifestyle change program in the community typically achieve.[vi]

The second successful implementation is with the Wisconsin Department of Corrections (DOC), which has successfully offered the National DPP lifestyle change program in three correctional facilities. To date, 19 Wisconsin DOC staff have trained as lifestyle coaches and 131 individuals across the three facilities have participated in the program. The Wisconsin National DPP state quality specialist shared the following cohort data in 2018−2019:

  • 16 percent of the participants were Black and 84 percent were White
  • 100 percent of participants were male, with an average age of 45.6 years
  • 58 percent of participants were eligible for the program based on a blood test
  • 100 percent of participants attended 14 or more sessions in months one through six (typically, 16 sessions take place in the first six months)
  • 71 percent of participants attended six or more sessions in months 7−12 (typically, six sessions take place in the second six months)

Overall average weight loss was 8.3 percent during the year-long cohort, well above the National DPP lifestyle change program goal of 5−7 percent weight loss. The response from program participants was positive. Wisconsin DOC plans to scale the National DPP lifestyle change program to all appropriate facilities in the future.

For additional information, consult the white paper “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings.

If you would like to learn more about how HMA can help your organization implement a DPP program, contact:

Angela Bowen, Consultant

Chris Wilks, PhD, Senior Consultant


[i] Centers for Disease Control and Prevention. The Facts, Stats, and Impacts of Diabetes. Available at: https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed April 18, 2023.

[ii] Centers for Disease Control and Prevention. Research Behind the National DPP. Available at: https://www.cdc.gov/diabetes/prevention/research-behind-ndpp.htm. Accessed on June 15, 2023. 

[iii] National DPP Coverage Toolkit. National DPP Coverage Toolkit: Delivery Options. Available at: https://coveragetoolkit.org/medicaid-agencies/medicaid-agencies-delivery/program-delivery-options/.  Accessed January 18, 2023.

[iv]Centers for Disease Control and Prevention. National Diabetes Prevention Program. Available at: https://www.cdc.gov/diabetes/prevention/index.html.  Accessed December 19, 2022.

[v]National DPP Coverage Toolkit. Cost & Value. Available at: https://coveragetoolkit.org/cost-value-elements/. Accessed June 15, 2023.

[vi]Fine A, Gallaway SM, Dukate A. Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting. Diabetes Spectrum. 2019;32(4):331-337.