Weekly Roundup

HMA Weekly Roundup

Trends in Health Policy

View All Roundups

August 23, 2023

Print

This week's roundup:

In Focus

CMS Continues to Rollout New Initiatives, What to Watch for in the Fall

In this week’s In Focus, we continue our review of Medicare developments from this summer and look ahead at Centers for Medicare & Medicaid Services (CMS) activities to watch for this fall.

CMS ACO Strategy Update

In a July 31, 2023, Health Affairs Forefront blog, CMS leaders outlined the agency’s plan to further accelerate the growth and accessibility of accountable care organizations (ACOs), especially for beneficiaries in rural and underserved areas. The article signals the agency’s continued commitment to increasing participation in ACOs and future policy and model initiatives that CMS could undertake to achieve those goals.

In particular, the CMS Innovation Center is considering testing models and features to support Medicare Shared Savings Program (MSSP) ACOs in increasing investments in primary care. This initiative might include piloting ACO-based primary care models that provide prospective payments in an effort to reduce reliance on fee-for-service (FFS), support innovations in care delivery, and increase access to advanced primary care in underserved communities.

CMS leaders point to a second component of its ACO strategy in the calendar year (CY) 2024 proposed Medicare Physician Fee Schedule (PFS) rule. The proposed PFS includes technical updates to the Advance Investment Payment (AIP), which provides financial support for providers who participate in the MSSP. The proposed PFS rule also includes several opportunities for the public to inform CMS’s ongoing ACO work, including considerations for adding higher-risk participation options in the MSSP, ways to better support collaboration between ACOs and community-based organizations to meet health-related social needs, and other initiatives. HMA discussed the PFS changes in an earlier In Focus.

CMS also announced refinements to the ACO Realizing Equity, Access, and Community Health (REACH) Model on August 18. The agency’s three goals in making these changes are to:

  • Increase predictability for model participants (e.g., policies to change certain beneficiary alignment requirements and refinements to eligibility criteria for high-need ACOs
  • Protect against inappropriate risk score growth (e.g., revisions to the risk-adjustment methodology)
  • Advance health equity (e.g., revisions and expansions to the health equity benchmark adjustment)

These topics are of importance to CMS across its model portfolio and are, in part, based on experience the agency has gained in running the ACO REACH model. Below is a summary of several key policy changes that will take effect in 2024. The entire list can be found on the CMS website.

Finally, CMS released the request for applications (RFA) for the Innovation Center’s Making Care Primary (MCP) model previously announced in June. This voluntary model is scheduled to begin in June 2024 and run for 10.5 years. It will have three participation tracks that build upon previous Innovation Center primary care initiatives.

The MCP model is designed to improve care for beneficiaries by supporting the delivery of advanced primary care services. This framework provides a pathway for primary care clinicians who have varying levels of experience with value-based care to gradually adopt prospective, population-based payments while building the infrastructure to improve behavioral health and specialty integration and drive more equitable access to care. CMS is working with Medicaid agencies in eight states—Colorado, North Carolina, New Jersey, New Mexico, New York, Minnesota, Massachusetts, and Washington—to engage in full care transformation across payers, with plans to engage private payers in the coming months.

The RFA provides additional details about the model’s payment, care delivery, quality, and other policies. The application period opens September 4, 2023, and closes November 30, 2023. CMS plans to select participants in winter 2024. Onboarding for participants will take place April−July 2024.

The HMA team continues to review the RFA and is available to assist clients in determining whether this model may be a good fit as well as with assistance in submitting the application.

What to Watch

Comments on the Medicare CY payment rules (home health, end stage renal disease, physician, and outpatient hospital) are due in early fall. CMS will review the comments on each of the proposals and finalize each rule by November 1. Some stakeholders, such as physicians and home health suppliers, may seek congressional action to mitigate payment cuts that CMS has proposed.

In addition, CMS is expected to continue implementing the drug pricing related provisions of the Inflation Reduction Act (IRA). The agency already has released several guidance documents about the process. The list of the first 10 drugs to be negotiated is due to be published September 1, 2023, and manufacturers of selected drugs will have one month to sign agreements to participate in negotiations and provide information for CMS’s consideration in the negotiation process.

The HMA team will continue to evaluate Innovation Center opportunities, CMS payment regulations, and IRA implementation. If you have questions about these topics, contact Amy Bassano ([email protected]), Kevin Kirby ([email protected]), or  Andrea Maresca ([email protected]).

HMA Roundup

Connecticut

Connecticut Residents, Officials Ask Insurance Regulators to Reject Proposed 12.4 Percent Individual Health Plan Rate Increases. The Connecticut Mirror reported on August 21, 2023, that Connecticut residents and officials called on state insurance regulators to reject a proposed 2024 rate increase of 12.4 percent for individual health plans both on and off the Exchange. Individual rates rose 20.4 percent in 2023. State officials are expected to decide by late August or early September. Read More

Florida

Florida Residents File Federal Lawsuit Challenging Their Disenrollment from Medicaid. Health Payer Specialist reported on August 23, 2023, that three Florida residents have filed a federal class action lawsuit alleging they did not receive sufficient information or a hearing before losing Medicaid coverage as part of the state’s eligibility redeterminations process. Florida has disenrolled 408,000 Medicaid beneficiaries, including half for procedural reasons. Read More

Georgia

Georgia Medicaid Expansion Program Sees Slow Enrollment. The Associated Press reported on August 19, 2023, that the Georgia Medicaid expansion program is experiencing slow enrollment. The program, which includes work requirements, is called Pathways to Coverage. The Biden Administration continues to monitor the program. Read More

Hawaii

Hawaii Halts Medicaid Eligibility Redeterminations on Maui For Remainder of 2023. Health Payer Specialist announced on August 23, 2023, that Hawaii received federal approval to halt Medicaid eligibility redeterminations on Maui for the remainder of 2023 in the aftermath of wildfires this month. About a third of Maui County’s population of nearly 168,000 is on Medicaid. Read More

Indiana

Indiana Disenrolls 33,708 Medicaid Beneficiaries Following July Redeterminations. The Indiana Department of Health announced on August 8, 2023, the disenrollment of 33,708 Medicaid beneficiaries during July redeterminations, including 28,767 for procedural reasons.

Iowa

Amerigroup Iowa Names Teresa Hursey President. Elevance Health announced on August 10, 2023, that subsidiary Amerigroup Iowa named Teresa Hursey president. Hursey was most recently president of Amerigroup New Jersey. Read More

Kansas

Kansas Disenrolls 31,444 Medicaid Beneficiaries During July Redeterminations. The Kansas Department of Health & Environment reported on August 8, 2023, the disenrollment of 31,444 Medicaid beneficiaries during July redeterminations. Coverage was renewed for 7,336 beneficiaries.

Louisiana

Department of Health Pays Millions of Dollars to Cover Out-of-State Medicaid Beneficiaries, Audit Finds. WAFB Channel 9 reported on August 21, 2023, that Louisiana made capitated payments of $109.5 million to cover 13,391 Medicaid members with out-of-state driver’s licenses from September 2016 to February 2023, as well as $3 million to cover 380 recipients identified as living out of state from June 2019 to February 2023, according to an audit by the Louisiana Legislative Auditors Office. Auditors recommended better use of motor vehicle data and review processes to ensure ineligible members are removed from the program. Read More

Lawmakers Push to Delay Sale of BCBS Louisiana to Elevance Health. Becker’s Payer Issues reported on August 17, 2023, that three Louisiana Senators and the state attorney general are pushing to delay the sale of Blue Cross Blue Shield (BCBS) of Louisiana to Elevance Health. Independent actuarial firms commissioned by the Louisiana insurance commission questioned the structure of the deal. The transaction requires approval from the state insurance commissioner and two-thirds of BCBS policyholders; hearings are scheduled for August 21 and August 22. Read More

Maryland

Maryland Disenrolls 37,066 Medicaid Beneficiaries Following July Redeterminations. The Maryland Department of Health announced the disenrollment of 37,066 Medicaid beneficiaries following July redeterminations. Approximately 24,326 lost coverage due to procedural reasons and 96,856 were renewed. Read More

Michigan

New Medicaid Managed Care Contracts Will Take Effect October 2024. The Michigan Department of Health and Human Services (MDHHS) announced on August 22, 2023, that responses will be due January 2024 and new contracts will be effective October 1, 2024, for the state’s Medicaid managed care request for proposals (RFP), which is expected to be released in fall 2023. The RFP will cover the state’s Comprehensive Health Care Program for traditional Medicaid members. MDHHS also released new Medicaid health plan network standards and requirements that plans must abide by in order to qualify for review under the bid. Read More

Michigan Seeks Bids for Substance Abuse Recovery Incentives Pilot Program. The Michigan Department of Health and Human Services (MDHHS) announced on August 18, 2023, that it is seeking bids from vendors to provide training to health plans and providers participating in an evidence-based treatment program for substance use disorders being offered by the state for Medicaid and Healthy Michigan enrollees. The Recovery Incentives Pilot is set to launch in October 2024. Responses are due August 25. The contract period is expected to be from January 1, 2024, through September 30, 2026. Read More

CareSource, HAP Receive Approval to Form Medicaid Joint Venture. Health plans CareSource and Health Alliance Plan (HAP) announced on August 17, 2023, that they received regulatory approval to form a joint venture with combined Medicaid offerings and a planned re-entry into the Exchange. CareSource is an Ohio-based Medicaid plan, and HAP is a Michigan Medicaid, Medicare, and commercial plan. Read More

Minnesota

Minnesota Extends Deadline for Medicaid Eligibility Renewal Forms. The Minnesota Department of Human Services announced on August 23, 2023, that it has extended the deadline for Medicaid eligibility renewal forms by one month through January 2024. The state is redetermining eligibility for enrollees in its Medical Assistance and MinnesotaCare programs. Read More

Mississippi

Mississippi Disenrolls 22,507 Beneficiaries During July Redeterminations. The Mississippi Department of Medicaid reported on August 8, 2023, that the state disenrolled 22,507 Medicaid enrollees during July redeterminations. Coverage was renewed for 37,029 beneficiaries.

Missouri

Missouri Disenrolls 54,160 Medicaid Beneficiaries During June, July Redeterminations. KCUR reported on August 18, 2023, that Missouri has disenrolled 54,160 Medicaid beneficiaries during June and July redeterminations. Of those who lost coverage, 74 percent were disenrolled for procedural reasons and half were children. More than 52,000 renewal applications are still pending. The state renewed coverage for 116,418 beneficiaries. Read More

Montana

Montana May Be Non-compliant With Federal Requirements on Medicaid Eligibility Redeterminations, CMS Says. KTVH reported on August 16, 2023, that Montana is experiencing long wait times and high call abandonment rates at call centers handling Medicaid eligibility redeterminations, according to a letter from the Centers for Medicare & Medicaid Services (CMS). About 36 percent of the state’s disenrollments were procedural reasons, which CMS says “raises concerns that eligible individuals, including children, may be losing coverage.” Read More

New Jersey

Cover All Kids Coverage Grows to 24,000 Undocumented Children. NJ Spotlight News reported on August 18, 2023, that the New Jersey Cover All Kids Medicaid initiative covers at least 24,000 children who are undocumented or whose legal residency is in flux. The program took effect this year. Read More

New Mexico

New Mexico Releases $80 Million Rural Health Care Delivery Fund RFA. The New Mexico Human Services Department announced on August 21, 2023, the release of the Rural Health Care Delivery Fund Request for Applications (RFA), which will provide $80 million through fiscal 2026 to help rural facilities develop and expand clinical services. Applications are due on October 6. Read More

New York

New York Lawmaker Introduces Bill to Allow Dental Therapists to Provide Certain Care. News 10 reported on August 18, 2023, that New York Assemblywoman Carrie Woerner (D-Round Lake) introduced a bill to allow the credentialing of dental therapists to provide dental evaluations, preventive and restorative care, and minor surgeries. The bill is now in a Senate committee. Read More

New York Uninsured Rate Falls to 5.2 Percent in 2021. The Office of the New York State Comptroller announced on August 16, 2023, that the uninsured rate in New York fell to 5.2 percent in 2021, compared to 11.9 percent in 2010, with publicly funded health insurance programs driving the improvement. However, coverage disparities remain, with the uninsured rate at three percent for whites, 10 percent for Hispanics, and six percent for blacks and Asians. Read More

North Carolina

Governor Stresses Need to Implement Medicaid Expansion During Roundtable Discussion. North Carolina Governor Roy Cooper hosted on August 16, 2023, another in a series of roundtable discussions to address the urgency of implementing Medicaid expansion on October 1. Expansion cannot be implemented until the state passes a budget. Read More

Ohio

Ohio Renews Contract with Medicaid EVV Company. Sandata Technologies announced on August 16, 2023, the renewal of its Medicaid electronic visit verification (EVV) contract with the Ohio Department of Medicaid. Read More

Ohio Disenrolls 78,506 Medicaid Beneficiaries Following July Redeterminations. The Ohio Department of Medicaid announced the disenrollment of 78,506 Medicaid beneficiaries following July redeterminations. A total of 61,123 lost coverage due to procedural reasons and 17,383 lost coverage due to ineligibility.

Ohio Sees Growing Enrollment in OhioRISE Behavioral Health Program for Youth. The Dayton Daily News reported on August 17, 2023, that enrollment in OhioRISE (Resilience through Integrated Systems and Excellence), a Medicaid behavioral health wraparound program for youth, topped 22,000 this year, up from 5,000 when the program launched in 2022. The program covers behavioral health services such as in-home counseling visits, in part to reduce utilization of costly inpatient care. Read More

Oklahoma

Law Regulating PBMs Is Invalidated by Federal Appeals Court. Modern Healthcare reported on August 16, 2023, that a federal appeals court has invalidated key provisions of a 2019 Oklahoma law regulating pharmacy benefit managers (PBMs), overturning a lower court ruling. The Patient’s Right to Pharmacy Choice Act, which the three-judge appeals panel found violated the Employee Retirement Income Security Act, sought to regulate PBM pharmacy networks and ban discounts for individuals shopping at preferred pharmacies, among other controls. Read More

Oregon

Oregon to Implement Mandatory Annual Audits of Medicaid PBMs. The Oregon Capital Chronicle reported on August 21, 2023, that the Oregon Health Authority plans to enact requirements for mandatory, independent annual audits of pharmacy benefit managers (PBMS) by January 2025. Audits are currently voluntary. The change was recommended by an audit from the Secretary of State’s office, which found a lack of transparency and oversight of PBMs. Auditors also called for legislation requiring PBMs to provide annual reports, including information about costs and profits. Read More

Texas

Texas to Restore Medicaid Coverage of 90,000 Disenrolled Individuals. Bloomberg Law reported on August 22, 2023, that Texas is expected to restore Medicaid coverage to 90,000 individuals erroneously disenrolled, according to an official from the Centers for Medicare & Medicaid Services (CMS). Anonymous whistleblowers from the Texas Health and Human Services Commission sent a letter to CMS alleging system errors and violations of federal guidelines in the state’s redeterminations process. Democratic House members from Texas are also asking CMS to investigate. Read More

Texas Secures $984 Million in HARP, GME Funding for Private Hospitals. Texas Governor Greg Abbott announced on August 17, 2023, that the state Health and Human Services Commission secured $984 million in Medicaid Graduate Medical Education (GME) supplemental payments and Hospital Augmented Reimbursement Program (HARP) funds for private hospitals serving Medicaid beneficiaries. Hundreds of hospitals will receive funds, including those serving rural and border areas. Read More

Vermont

Vermont Disenrolls 489 Medicaid Beneficiaries Following July Redeterminations. The Vermont Department of Health announced on August 8, 2023, the disenrollment of 489 Medicaid beneficiaries following July redeterminations. Only one disenrollment was for procedural reasons. Read More

Virginia

Virginia Delays Release of Medicaid Managed Care RFP to September 1. The Virginia Department of Medical Assistance Services has delayed the release date for the state’s Medicaid managed care request for proposals (RFP) until September 1, 2023. Read More

Virginia Disenrolls 140,000 Medicaid Beneficiaries Since Redeterminations Began in April. The Virginia Department of Medical Assistance Services reported in August 2023, that Virginia has disenrolled about 140,000 Medicaid beneficiaries since redeterminations began. Read More

Washington

Washington Allocates Over $100 Million to Apple Health, Homes Program. Stateline reported on August 21, 2023, that the Washington state legislature has allotted more than $100 million to Apple Health and Homes, a multi-agency state program that utilizes Medicaid funds to provide housing to people with medical and behavioral health conditions. The program, which launched in 2022, received $41 million last year from the Department of Commerce. The demand for housing is expected to surpass available funding. Read More

Washington Provides Additional Details on 2024 Medicaid Managed Care Provider Rate Increases Across Certain Provider Categories. The Washington State Health Care Authority has released additional details regarding legislatively mandated 2024 Medicaid managed care provider rate increases across certain services, including applied behavior analysis, behavioral health, developmental screening, home and birthing centers, dialysis, pediatric palliative care, newborn screening. The state cautions that “whether or not these rate increases translate directly into payment increases to your organization depends on your specific contract terms with each MCO.” Read More

Washington Disenrolls 111,181 Medicaid Beneficiaries Following July Redeterminations. The Washington State Health Care Authority announced on August 9, 2023, the disenrollment of 111,181 Medicaid beneficiaries following July redeterminations. Read More

Wisconsin

Wisconsin Disenrolls 44,000 Medicaid Beneficiaries During July Redeterminations. The Wisconsin State Journal reported on August 19, 2023, that Wisconsin has disenrolled 44,000 Medicaid beneficiaries during July redeterminations, including 30,000 for procedural reasons. The state renewed coverage for another 44,000 beneficiaries. Read More

National

CMS Releases Draft Guidance for Medicare Prescription Payment Plan. The Centers for Medicare & Medicaid Services released on August 21, 2023, draft guidance on the structure of the Medicare Prescription Payment Plan, which will give Medicare Part D beneficiaries the option of paying out-of-pocket costs in monthly installments over a year beginning in 2025. Public comments will be accepted until September 20, 2023, and announcement of the final guidance is expected in early 2024. Additional guidance on enrollee outreach and education, bid information, and compliance will be released for public comment in early 2024. Read More

5.2 Million Medicaid Beneficiaries Are Disenrolled from Medicaid Following Redeterminations, Analysis Finds. KFF reported on August 21, 2023, that approximately 5.2 million Medicaid beneficiaries have now lost coverage across 45 states and the District of Columbia since the reinstatement of eligibility redeterminations. Of enrollees who applied for Medicaid coverage renewals, 38 percent were disenrolled and 62 percent maintained coverage. Overall, 74 percent of those disenrolled lost coverage for procedural reasons. Read More

CMS Warns States That Call Center Wait Times, Dropped Calls Are Impeding Medicaid Coverage Renewals. The Associated Press reported on August 17, 2023, that 16 states have received warnings from federal Medicaid officials that long wait times and high call abandonment rates at call centers are impeding individuals from renewing Medicaid and Children’s Health Insurance Plan coverage. Read More

U.S. Representative to Investigate Medicaid Plan Prior Authorization Denial Rates. MedCityNews reported on August 17, 2023 that U.S. Representative Frank Pallone, Jr. (D-New Jersey) has announced an investigation into high prior authorization denial rates by Medicaid managed care health plans. The announcement follows the release of a report from the Office of Inspector General that found that Medicaid plans denied one out of every eight prior authorization requests in 2019. Read More

Hospital-At-Home Providers Push for Medicaid Coverage by More States. Modern Healthcare reported on August 18, 2023, that hospital-at-home providers are pushing for more state Medicaid programs to cover their services. Currently, Arizona, Arkansas, Massachusetts, Michigan, Oregon, Oklahoma, South Dakota and Texas cover hospital-at-home services for Medicaid beneficiaries; New York is considering coverage. The Centers for Medicare & Medicaid Services is currently reviewing the effectiveness of the hospital-at-home model under Medicare. Read More

Industry News

Centene to Challenge Tricare Contract Loss in Federal Claims Court. Health Payer Specialist reported on August 18, 2023, that Centene subsidiary HealthNet Federal Services will challenge the loss of its Tricare western region contract in the U.S. Court of Federal Claims. The U.S. Government Accountability Office recently upheld a decision by the Department of Defense to award the contract to TriWest Healthcare Alliance. Read More

RFP Calendar

HMA News & Events

Upcoming HMA Webinar: 

Medicare Policy Changes Impacting Behavioral Health Services Workforce and Population Health. With recent rule changes proposed by the Centers for Medicare and Medicaid Services (CMS) addressing expanding access to behavioral health services, this webinar will focus on how those changes will impact the already strained workforce, and corresponding impacts on population health. HMA Experts will dive deeper into approaches to handle workforce shortages while expanding access. Tuesday, September 12, 12pm ET. Click here to register.

Wakely, an HMA company, White Paper:

Potential Changes Coming to Mental Health Parity Requirements. In 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) that required Insurers to cover mental health benefits in a way that is at least equal to what they cover physical health care benefits, if mental health benefits are offered. Recently, the Biden Administration released a proposed rule that would change what data would be evaluated as part of demonstrating compliance with MHPAEA. The regulation, if finalized as proposed, would take effect for the 2025 plan year in the group market and 2026 plan year for the individual market; the regulation also impacts Medicaid managed care and the Children’s Health Insurance Program (CHIP) but does not impact Medicare or Medicaid fee-for-service plans. Read More

NEW THIS WEEK ON HMA INFORMATION SERVICES (HMAIS):
Medicaid Data
Medicaid Enrollment:

  • Illinois Medicaid Managed Care Enrollment is Up 2.4%, Jun-23 Data
  • Illinois Dual Demo Enrollment is Down 1.4%, Jun-23 Data
  • Indiana Medicaid Managed Care Enrollment Is Up 2.8%, Mar-23 Data
  • Indiana Medicaid Managed Care Enrollment Is Up 2.1%, Feb-23 Data
  • Minnesota Medicaid Managed Care Enrollment is Up 3.9%, Jun-23 Data
  • New Jersey Medicaid Managed Care Enrollment is Up 3.9%, Jun-23 Data
  • Tennessee Medicaid Managed Care Enrollment is Up 1.9%, Jul-23 Data
  • Tennessee Medicaid Managed Care Enrollment is Up 2.8%, Jun-23 Data
  • Tennessee Medicaid Managed Care Enrollment is Up 2.8%, May-23 Data
  • Tennessee Medicaid Managed Care Enrollment is Up 2.2%, Apr-23 Data
  • Texas Medicaid Managed Care Enrollment is Up 3.5%, May-23 Data
  • Texas Dual Demo Enrollment is 32,103, May-23 Data

Public Documents: 

Medicaid RFPs, RFIs, and Contracts:

  • Michigan Electronic Visit Verification RFP, Award, and Scoring, 2022-23
  • Mississippi Medicare Advantage D-SNP Model Contract, 2024
  • Missouri Medicare Advantage D-SNP Model Contract, 2024
  • Washington Accountable Care Organization RFI, Aug-23

Medicaid Program Reports, Data, and Updates:

  • Kansas PHE Medicaid Redeterminations Monthly Report to CMS, Jul-23
  • Maryland PHE Medicaid Unwinding Report, Jul-23
  • Mississippi PHE Medicaid Redeterminations Monthly Reports to CMS, Jul-23
  • Tennessee Medicaid Redeterminations Renewals Reports, May-23
  • Vermont PHE Medicaid Redeterminations Monthly Report to CMS, Jul-23
  • Virginia Cardinal Care Rate Books, FY 2025
  • Virginia Cardinal Care Data Books, CY 2021
  • Virginia Medallion 4.0 Rate Reports, 2019-24
  • Washington Apple Health Unwinding Data Reports, Jul-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 at [email protected].

Edited by:

Alona Nenko

Mary Goddeeris
View All Roundups

Get the free HMA
Weekly Roundup