Weekly Roundup

HMA Weekly Roundup

Trends in Health Policy

In Focus

New CMS Dementia Care Model Emphasizes Role of Caregivers

This week, our In Focus section reviews the new Guiding an Improved Dementia Experience (GUIDE) Model, announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) on July 31, 2023. 

In addition to announcing the Innovation Center’s GUIDE Model, CMS released five final fiscal year (FY) 2024 payment rules this past week. Of note, these regulations set higher than anticipated reimbursement rates for many providers:

CMS also released the 2024 projected Medicare Part D premium and bid information, which may provide early indications on the effects of the Inflation Reduction Act’s drug pricing policies.

GUIDE Model: Parameters and Opportunities

President Biden signed an Executive Order in April 2023 on Increasing Access to High-Quality Care and Supporting Caregivers. The order directed the Innovation Center to develop a payment and delivery system model for dementia care. The program is intended to improve the quality of life for people living with dementia, reduce strain on unpaid caregivers, and help people remain in their homes and communities through improved care coordination and management, caregiver education and support, and respite services.

The announcement this week outlines the basic parameters of the model, which track with CMS’s focus on reducing health disparities, supporting innovation, and addressing affordability. CMS expects that the model’s additional support for caregivers will reduce federal spending on hospitalizations and post-acute care. Notably, CMS projects savings will come from reduced long-term nursing facility placement through a decrease in Medicaid spending on the federal medical assistance percentage (FMAP). Helping Medicare enrollees stay in their homes may also lower state spending on long-term care.

Additional information, including the application to participate, will be available this fall. In the meantime, CMS is accepting letters of interest through September 15, 2023. The model will begin on July 1, 2024, and run for eight years.

HMA’s experts identified the below list of policies that will be important for provider organizations, caregivers, and other stakeholders considering participation in the model:

  • GUIDE Model participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, that are eligible to bill for Medicare physician fee schedule services and agree to meet the care delivery requirements.
  • The GUIDE Model comprises two tracks for participation—one for established programs and another for new programs.
    • Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record (EHR) platform that meets the standards for certified EHR technology, and meet other care delivery requirements as outlined in the request for applications.
  • If a participant cannot meet the GUIDE healthcare delivery requirements alone, CMS will allow the provider or supplier to partner with other Medicare organizations, to meet the mandates.
  • The model also includes policies designed to reduce disparities in dementia care. For example, CMS plans to conduct outreach with organizations that do not yet offer comprehensive dementia care or lack prior experience with alternative payment models such as safety net providers. Participants also will need to develop health equity plans, and a “health equity adjustment” will be made to payments for providers that serve disadvantaged beneficiaries.
    • CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for participation.
  • CMS will test an alternative payment methodology for participants that deliver key care management and coordination services to people with dementia and their family caregivers, including comprehensive, person-centered assessments and care plans; 24/7 access to a helpline; and caregiver support and education, such as training on how to best care for a relative with dementia. CMS clarifies that GUIDE is not a shared savings or total cost of care model and does not address coverage of novel Alzheimer’s drugs.
  • Participants will assign Medicare fee-for-service beneficiaries, including people who are dually eligible for Medicare and Medicaid, living with dementia and their caregivers to a care navigator. This individual will help people access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants will also help caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities. Evidence demonstrates that respite enables caregivers to care for individuals with dementia at home for a longer period, thereby forestalling institutional placement.

CMS will host a webinar with more details about the model on Thursday, August 10, from 2:00−3:00 pm.

The HMA team will continue to evaluate the GUIDE model and other Innovation Center opportunities. If you have any questions about the model, contact Amy Bassano ([email protected]), Barry Jacobs ([email protected]), or Maddy Shea ([email protected]).

We also can assist with questions about any of the new regulations. Contact Zach Gaumer ([email protected]), Andrea Maresca ([email protected]), or Amy Bassano ([email protected])

We also would like to remind our readers that the HMA team hosted a webinar last week on the Medicare Behavioral Health proposed changes. We previously discussed those changes in the July 19, 2023 In Focus. If you missed the webinar, you can find the recording and slides on the HMA website.

HMA Roundup


Alabama Seeks Medicaid Waiver to Cover Opioid, SUD Services for Individuals in IMDs. The Centers for Medicare & Medicaid Services announced on August 1, 2023, that Alabama is seeking a five-year Section 1115 Medicaid waiver to cover opioid and substance use disorder (SUD) treatment and recovery services for Medicaid beneficiaries in Institutions for Mental Diseases (IMDs). The waiver also proposes extending limited Medicaid coverage to eligible individuals who lack health insurance and meet the criteria for SUD. The federal public comment period runs from August 1, 2023 through August 31, 2023. Read More


Alaska Medicaid to Cover Assisted Living Services in At-home Settings. KINY Radio reported on July 29, 2023, that Alaska Governor Mike Dunleavy signed Senate Bill 57, which authorizes the state’s Medicaid program to pay for assisted living services in at-home settings for elderly adults and adult foster children. Under the bill, the Alaska Department of Health will also license individuals to run adult care homes and set rules for operating the homes.


California Receives Approval to Lift the Medicaid Asset Test in 2024. Beckers Payer Issues reported on July 28, 2023, that the Centers for Medicare & Medicaid Services has approved a state plan amendment to eliminate asset tests for Medicaid eligibility in California, effective January 1, 2024. Read More


Florida Seeks Waiver to Pilot Managed Care Program for Individuals with Intellectual and Developmental Disabilities. The Florida Agency for Health Care Administration announced on July 28, 2023, that it is seeking a federal waiver to pilot comprehensive managed care coverage for certain individuals with intellectual and developmental disabilities. The voluntary program would serve up to 600 individuals and provide managed medical assistance (traditional Medicaid), long-term care waiver services, and Florida Developmental Disabilities Individual Budgeting (iBudget) waiver services. A 30-day public comment period runs through August 27, 2023. Read More

Florida Deficient in Documentation of Medications Prescribed to Foster Children, Audit Finds. The Capitolist reported on July 28, 2023, that Florida has improperly documented psychotropic and opioid medications prescribed to children in foster care, according to a federal audit that analyzed Medicaid claim records, case files, and health care records. The audit found that 36 out of 85 of children prescribed psychotropic medications and 57 out of 60 children prescribed opioid medications were not recorded in Florida’s Safe Families Network. The audit recommended medication management training and coordination with the Florida Agency for Health Care Administration to broaden access to Medicaid data and improve medication oversight. Read More


Meridian Health Plan Names Cristal Gary as President, CEO. Meridian Health Plan of Illinois announced on July 31, 2023, that it has named Cristal Gary as president and chief executive, effective immediately. Cristal Gary has most recently served as the Chief Advocacy Officer for Ascension Illinois. Read More

Medica, OSF HealthCare to Introduce New Medicare Advantage Plan. OSF Healthcare announced on August 1, 2023, that it will introduce a new Medicare Advantage plan with MN-based health plan Medica this fall in central Illinois. The plans will be available during this fall’s Medicare annual enrollment period to residents in seven Illinois counties. Read More


Kentucky Republican Gubernatorial Nominee Supports Medicaid Work Requirements. The Associated Press reported on July 26, 2023, that Republican gubernatorial candidate Daniel Cameron would seek federal permission to institute Medicaid work requirements if elected. Under the plan, able-bodied adults would need to work, enroll in college, or be involved in job training or community service to receive Medicaid coverage. Read More


Louisiana Medicaid Enrollment Falls 3,000 in June. KTBS3 reported on July 26, 2023, that Louisiana Medicaid enrollment was 2.05 million in June, down 3,177 from a month earlier, marking the first month-over-month decline in the past year. Total enrollment in July 2022 was 1.98 million.


Michigan Extends Deadline for Submitting Medicaid Renewal Paperwork by Month. The Michigan Department of Health and Human Services announced on July 26, 2023, that it has extended the deadline for Medicaid beneficiaries to submit eligibility renewal paperwork by a month through May 2024. The state had originally given beneficiaries with paperwork due in June until July 31. Now all beneficiaries will have an extra month past their original due date. Read More


Minnesota Disenrolls 6,867 Medicaid Beneficiaries During June Redeterminations. The Minnesota Department of Human Services announced on July 10, 2023, the disenrollment of 6,867 Medicaid beneficiaries during June redeterminations. The state renewed coverage for nearly 47,200 beneficiaries.


Missouri Disenrolls 32,000 Medicaid Beneficiaries During June Redeterminations. The Missouri Independent reported on July 27, 2023, that Missouri disenrolled more than 32,000 Medicaid beneficiaries during June redeterminations. Around half were children, with most losing coverage for procedural reasons. Out of the 116,000 beneficiaries up for review, the state renewed coverage for 43 percent. Reviews are pending for another 29 percent. Read More

New Hampshire

New Hampshire Disenrolls Approximately 39,500 Medicaid Enrollees, Launches Outreach Pilot. Seacoastonline reported on July 28, 2023, that New Hampshire has disenrolled approximately 39,500 Medicaid beneficiaries as of June out of 77,200 eligibility redeterminations conducted. Nearly 17,420 failed to apply for renewal, and the state has launched a pilot project in collaboration with the federal government to expand outreach to this population. Read More

North Carolina

North Carolina Reaches Agreement with CMS in Hopes of Launching Medicaid Expansion by October 1. The North Carolina Department of Health and Human Services announced on July 26, 2023, an agreement with federal regulators in hopes of implementing Medicaid expansion on October 1 once state lawmakers pass a budget. The agreement with the Centers for Medicare & Medicaid Services (CMS) will allow the state to proceed with required public notices. The state is also working to shorten the implementation timeline to 30 days from an originally expected 90 to 120 days. The state cannot implement expansion without a budget or unless legislators decouple expansion from the budget. Read More


Oregon Calls for Medicaid CCOs to Outline Plan for Investing Excess Profits in Community. The Portland Business Journal reported on July 26, 2023, that the Oregon Health Authority is calling on the state’s 16 Medicaid Care Coordination Organizations (CCOs) to detail plans for reinvesting higher than expected 2022 profits back into the community. Governor Tina Kotek has asked for a “significant” investment by CCOs, equivalent to between 1.5 percent and two percent of revenues, especially to support housing and behavioral health measures. Read More

Medicaid Needs to Improve Access to Mental Health, SUD Residential Treatment, Report Finds. The Oregon Capital Chronicle reported on July 31, 2023, that Oregon needs to improve access to residential treatment for mental health and substance use disorder, according to an annual ombuds report. The report found that individuals are turned away due to a lack of beds or a lack of providers accepting Medicaid patients. The Oregon Health Authority stated that they will address the gaps found in the report through a statewide assessment of residential mental health and addiction care options and a reevaluation of current rules and processes. Read More


Texas Receives CMS Approval to Continue State Directed Payment Programs. The Texas Health and Human Services Commission announced on July 31, 2023, that the Centers for Medicare & Medicaid Services (CMS) approved the continuation of the state directed payment programs for fiscal 2024. The five programs (Comprehensive Hospital Increase Reimbursement Program, Quality Incentive Payment Program, Texas Incentives for Physicians and Professional Services, Directed Payment Program for Behavioral Health Services, and Rural Access to Primary and Preventive Services Program) comprise around $8.5 billion in Medicaid payments for hospitals, nursing facilities, physician groups, behavioral health, and primary care. Read More


Virginia Medicaid Managed Care RFP Release Delayed to Mid to Late August. The Virginia Department of Medical Assistance Services announced that the state’s Medicaid managed care request for proposals (RFP) will be released mid to late August, with an estimated issue date of August 18. Read More

Senator Pushes for Prescription Drug Affordability Board. NBC 29 reported on August 1, 2023, that Virginia Senator Bill Stanley (R-Moneta) is advocating for the establishment of a Prescription Drug Affordability Board to set limits on how much individuals would pay for prescription drugs. Read More


CMS Releases Final Medicare Inpatient, Long Term Care Prospective Payment System Rule. The Centers for Medicare & Medicaid Services (CMS) released on August 1, 2023, the final fiscal 2024 Medicare prospective payment system rule for inpatient and long-term care hospitals. The rule includes a 3.1 percent increase in Medicare inpatient payment rates for hospitals that participate in the inpatient quality reporting program. Under the long-term care hospital prospective payment system, CMS expects rates to increase by 0.2 percent. The rule also includes a health equity adjustment in the scoring methodology for the hospital value-based purchasing program that rewards hospitals that serve higher proportions of dual-eligible patients and includes a policy to recognize higher costs that hospitals incur when treating people experiencing homelessness when hospitals report social determinants of health codes on claims. Read More

CMS Increases Medicare Reimbursement Rates for Skilled Nursing Facilities by 4 Percent in Fiscal 2024. Modern Healthcare reported on July 31, 2023, that the Centers for Medicare & Medicaid Services (CMS) released a final rule to increase Medicare reimbursement rates by 4 percent for skilled nursing facilities (SNFs) in fiscal 2024. The final rule includes updates to the SNF Quality Reporting Program and the SNF Value-Based Purchasing Program and finalizes a constructive waiver process to relieve administrative burdens for CMS related to processing Civil Monetary Penalty appeals. Read More

CMS Projects 1.8 Percent Decrease in Medicare Part D Premiums in 2024. The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2023, the projected average total monthly premium for Medicare Part D coverage to be about $55.50 in 2024, a decrease of 1.8 percent from 2023. CMS anticipates releasing the premium and cost-sharing information for 2024 Medicare Advantage and Part D plans in September. Read More

U.S. Lawmakers Introduce Bill to Support Individuals with Severe Mental Illness. Spectrum News reported on August 1, 2023, that U.S. Senator Kirsten Gillibrand (D-NY) and Representative Dan Goldman (D-NY) introduced the Strengthening Medicaid for Serious Mental Illness (SMI) Act to support individuals with SMI. The bill would create a new package of Medicaid services for individuals with SMI, set a national standard for SMI care, and incentivize states to provide intensive community-based services to treat SMI. Read More

Nearly Half of Dual Eligibles Receive Medicare Services Through Medicare Advantage Plans. KFF reported on July 31, 2023, that 51 percent of dual eligibles received Medicare services through traditional Medicare in 2020, while the remaining 49 percent received care via Medicare Advantage (MA) plans. MA includes 24 percent in coordination-only dual eligible special needs plans (D-SNPs), 17 percent in individual MA plans, 3 percent in dual demonstration plans, 3 percent in fully integrated dual eligible SNPs, 2 percent in other SNPs, and 0.4 percent in Program of All-Inclusive Care for the Elderly. MA enrollment rates were higher among beneficiaries who were age 65 and older than those under age 65. Read More

CMS Announces Alternate Payment Model for Dementia Care Services, Resources for Caregivers. The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2023, the Guiding an Improved Dementia Experience (GUIDE) Model, a voluntary, nationwide program which will test an alternate payment model for key supportive services to individuals with dementia, including comprehensive, person-centered assessments and care plans and care coordination. Individuals with dementia and their caregivers will have access to a care navigator who will help them access services and supports. Applications for the eight-year model will be released in fall 2023. Letters of intent are due September 15, 2023, and implementation will begin July 1, 2024. Read More

Medicaid, CHIP Enrollment Is Nearly 94.2 Million in April 2023. The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2023, that enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) was nearly 94.2 million in April 2023, an increase of 274,934 from March 2023. Medicare enrollment was approximately 65.8 million, up 88,441 from March 2023, including 31.9 million in Medicare Advantage plans. More than 12 million Medicare-Medicaid dual eligibles are counted in both programs. Read More

CMS Increases Medicare Hospice Rates by 3.1 Percent in Fiscal 2024. Modern Healthcare reported on July 28, 2023, that Medicare hospice rates will increase 3.1 percent in fiscal year 2024, under a final rule issued by the Centers for Medicare & Medicaid Services. A draft rule proposed in March previously stated the increase would be 2.8 percent. Additionally, hospice providers that fail to meet quality reporting requirements will be subject to a four-percentage-point penalty, beginning in 2024. Read More

Medicaid Disenrollments Near 4 Million Following Redeterminations. The Associated Press reported on July 28, 2023, that nearly 4 million people have been disenrolled from Medicaid following eligibility redeterminations. A federal report found that of the 715,000 beneficiaries that lost coverage during April Medicaid eligibility redeterminations, four in five were for procedural reasons. Health and Human Services Secretary Xavier Becerra sent a letter to all governors calling for implementation of strategies to avoid Medicaid disenrollment due to procedural reasons. Read More

CMS Is Urged to Settle Discrepancy Between Proposed Prior Authorization Data Rules. Modern Healthcare reported on July 27, 2023, that hospitals, physicians, and insurers are urging federal regulators to reconcile two sets of proposed standards concerning the use of electronic data exchange when processing prior authorizations. The proposals would have health insurers and providers complying with one set of standards, while government-sponsored insurers would comply with another. The American Hospital Association, American Medical Association, health insurance group AHIP, and Blue Cross Blue Shield Association communicated their concerns to the Centers for Medicare & Medicaid Services (CMS). Read More

Justice Reportedly Begins Antitrust Investigation Into Managed Care Industry. Health Payer Specialist reported on July 26, 2023, that U.S. Department of Justice has reportedly opened an antitrust investigation into the managed care industry. Capitol Forum, which first broke the story, did not name specific health plans under investigation. Read More

House, Senate Committees Advance PBM Oversight Bills. Modern Healthcare reported on July 26, 2023, that the Senate Finance Committee and the House Ways and Means Committee have both advanced bills aimed at increasing oversight of pharmacy benefit managers (PBMs). The Senate bill bans spread pricing in Medicaid and prohibits PBMs from including outside fees and rebates into Medicare drug pricing. The House bill requires PBMs to calculate Medicare drug cost sharing for beneficiaries using negotiated rates or discounted cash price (whichever is cheaper), rather than manufacturers’ sticker prices. Read More

Seven Million Women Lack Maternal Care Access, Report Finds. USA Today reported on August 2, 2023, that nearly seven million women live in maternity care deserts, or U.S. counties without obstetric facilities or providers, according to a 2022 report released Tuesday by nonprofit organization March of Dimes. The number of maternity care deserts has increased by two percent since their 2020 report. In the 2022 report, approximately 36 percent of U.S. counties were designated as maternity care deserts, of which 61 percent were in rural communities. Read More

Industry News

The Ensign Group Acquires Skilled Nursing Facilities in Colorado, Washington. The Ensign Group announced on August 2, 2023, that it has acquired a 96-bed skilled nursing facility in Colorado and acquired three healthcare facilities in Washington: a 95-bed skilled nursing facility, a 125-bed skilled nursing facility, and a post-acute care retirement campus with 96 licensed skilled nursing beds and 46 independent living units. All acquisitions are effective August 1, 2023.

Help at Home Acquires IN-based My Care at Home, OH-based Berkshire Homecare. Help at Home announced on August 1, 2023, that it has acquired Indiana-based My Care at Home and Ohio-based Berkshire Homecare. The Indiana acquisition coincides with the state’s planned transition to managed long-term services and supports in 2024. Read More

Addus Homecare Considers Exiting States Over CMS Proposed Rule. Modern Healthcare reported on August 1, 2023, that Texas-based Addus Homecare is threatening to pull out of states with low Medicaid reimbursements over the Centers for Medicare & Medicaid Services’ (CMS) Ensuring Access to Medicaid Services proposed rule, requiring states to spend 80 percent of home and community-based services funding on caregiver wages. Addus, currently serving in 22 states, would instead look to grow in markets where the rule would be advantageous. Read More

UnitedHealthcare Grant Distributes $11.1 Million Among 12 States to Address Social Determinants of Health. Fierce Healthcare reported on August 1, 2023, that UnitedHealthcare will distribute a $11.1 million grant among 66 not-for-profit organizations across 12 states (Colorado, Georgia, Kansas, Massachusetts, Michigan, Minnesota, Mississippi, New York, Pennsylvania, Rhode Island, Texas and Washington) in order to address social determinants of health and improve healthcare for underserved populations. The program will target issues such as food insecurity, social isolation, behavioral health issues, and health literacy. Read More

Elevance to Rebrand Amerigroup as Wellpoint in January 2024. Elevance Health announced on July 31, 2023, that its subsidiary Amerigroup Health Plans will rebrand as Wellpoint, effective January 2024, following regulatory approval in Arizona, Iowa, New Jersey, Tennessee, Texas and Washington. Read More

Sanford Health, Fairview Health Services Scrap Merger Plans. Modern Healthcare reported on July 27, 2023, that Sanford Health and Fairview Health Services have called off plans to merge in the face of opposition from “certain Minnesota stakeholders.” It was the second attempt at a merger, which faced scrutiny from Minnesota Attorney General Keith Ellison and the University of Minnesota. Read More

RFP Calendar

HMA News & Events

Upcoming HMA Webinar: 

Medicaid 1115 Justice Waivers and Special Populations: Meeting the Needs of Justice-Involved Youth. Youth in detention often have complex medical, behavioral health, developmental, social, and legal needs and have been exposed to adverse childhood experiences. Part 5 of this series on 1115 Medicaid Justice Demonstration Waivers: Bridging Healthcare, will delve into differences of care and services for youth so that a whole-person approach can be applied to their successful reentry to the community. Thursday, August 17, 2 pm ET. Click here to register.

Medicaid Data
Medicaid Enrollment:

  • Iowa Medicaid Managed Care Enrollment is Down 1.8%, Jun-23 Data
  • Kentucky Medicaid Managed Care Enrollment is Flat, Jun-23 Data
  • Kentucky Medicaid Managed Care Enrollment is Down 2.5%, Jul-23 Data
  • Mississippi Medicaid Managed Care Enrollment is Up 2%, Jun-23 Data
  • Missouri Medicaid Fee for Service vs. Managed Care Penetration, 2014-22
  • Montana Medicaid Fee for Service vs. Managed Care Penetration, 2014-22
  • New York Medicaid Fee for Service vs. Managed Care Penetration, 2014-22
  • North Carolina Medicaid Fee for Service vs. Managed Care Penetration, 2014-22
  • North Dakota Medicaid Expansion Enrollment is Up 2.1%, Jun-23 Data
  • North Dakota Medicaid Fee for Service vs. Managed Care Penetration, 2014-22
  • Oklahoma Medicaid Enrollment is Up 1%, Jan-23 Data
  • Oklahoma Medicaid Enrollment is Up 1.5%, Feb-23 Data

Public Documents: 

Medicaid Program Reports, Data, and Updates:

  • Alabama Section 1115 Substance Use Disorder Waiver Demonstration Application, Jul-23
  • Colorado PHE Medicaid Unwinding Monthly Report to CMS, May-23
  • Florida Section 1915c Comprehensive Intellectual and Developmental Disabilities Managed Care Pilot Draft Application, Jul-23
  • Massachusetts MassHealth Redeterminations Dashboard Update, Jul-23
  • Minnesota PHE Medicaid Redeterminations Monthly Report to CMS, Jun-23
  • Nebraska PHE Medicaid Unwinding Monthly Report to CMS, Jun-23
  • Texas Medicaid CHIP Data Analytics Unit Quarterly Reports, 2018-23
  • Texas OIG Quarterly Reports, 2019-23

A subscription to HMA Information Services puts a world of Medicaid information at your fingertips, dramatically simplifying market research for strategic planning in healthcare services. An HMAIS subscription includes:

  • State-by-state overviews and analysis of latest data for enrollment, market share, financial performance, utilization metrics and RFPs
  • Downloadable ready-to-use charts and graphs
  • Excel data packages
  • RFP calendar

If you’re interested in becoming an HMAIS subscriber, contact Carl Mercurio.

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Weekly Roundup