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August 7, 2024

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In Focus

FY 2025 Medicare Hospital Inpatient Final Rule Will Alter Hospital Margins and Change Administrative Procedures

This week, our In Focus section reviews the policy changes that the Centers for Medicare & Medicaid Services (CMS) finalized on August 1, 2024, in the fiscal year (FY) 2025 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Final Rule (CMS-1808-F). This year’s IPPS final rule will impact hospital margins and administrative processes beginning October 1, 2024. 

The remainder of our article delves into five of the key policy changes included in the final rule. 

Key provisions in the FY 2025 Hospital IPPS and LTCH Final Rule 

For FY 2025, CMS will modify several hospital inpatient payment policies. We highlight five of these policies because they will have the most significant impact on Medicare beneficiaries, hospitals and health systems, payors, and manufacturers:  

  1. The annual inpatient market basket update and changes to the standardized payment amount  
  2. New technology add-on payment (NTAP) policy changes 
  3. Implementation of the Transforming Episode Accountability Model (TEAM) bundled payment model in 2026 
  4. Hospital wage index changes and labor market adjustments 
  5. Severity of illness increase for housing insecurity social determinants of health (SDOH) codes  

Several of these and other policy changes for FY 2025 will become effective October 1, 2024.  

Market basket update  

Final rule: Overall CMS’s Medicare 2025 Hospital IPPS Rule will increase hospital inpatient payments to acute care hospitals by 2.9 percent from 2024 to 2025, an estimated increase of approximately $2.9 billion after other policy changes are included.  

Health Management Associates (HMA) analysis: CMS’s 2.9 percent increase is largely based on an estimate of the rate of increase in the cost of a standard basket of hospital goods—the hospital market basket. For beneficiaries, this payment rate increase will lead to a higher standard Medicare inpatient deductible and increase out-of-pocket costs. The finalized payment increase (2.9 percent) is larger than the increase included in CMS’s IPPS Proposed Rule (2.6 percent) but continues to fall below economy-wide inflation over the past year (3.5 percent).1,2 Importantly, after accounting for the various policy changes made within the final rule (e.g., wage index reclassifications) we anticipate individual cases will experience an average payment increase of 1.7 percent.  

Transforming Episode Accountability Model 

Final rule: CMS finalized the creation of a new mandatory episode-based CMS Innovation Center methodology—TEAM. Under TEAM, selected acute care hospitals will coordinate care for people with traditional Medicare who undergo one of the following surgical procedures: 

  • Lower extremity joint replacement 
  • Surgical hip femur fracture treatment 
  • Spinal fusion 
  • Coronary artery bypass graft 
  • Major bowel procedure 

Hospitals in the model will assume responsibility for the cost and quality of surgical care through the first 30 days after a Medicare beneficiary leaves the hospital. Hospitals also must refer patients to primary care services to support optimal long-term health outcomes. Hospitals will be assigned to different risk tracks to allow a graduated path to ease in to full-risk participation.  

HMA analysis: The mandatory nature of this model requires hospitals in the selected geographic areas to begin to prepare for implementation of the model requirements in 2026. TEAM builds on and combines previous models such as the bundled payment for care improvement (BPCI) and the comprehensive care for joint replacement (CJR) models. Hospitals in roughly 23 percent (188 of 925) of the nation’s core-based statistical areas (CBSAs) are required to participate in this advanced payment model, with some exceptions, such as hospitals in Maryland and Sole Community Hospitals. Participating hospitals will be required to report various quality measures, and payment will be based on spending targets and include retroactive reconciliation. Reimbursement under the model will follow four different tracks, which vary by the level of upside and downside risk that the hospital accepts and with a specific track for safety net hospitals. 

Hospital Wage Index Adjustments and Labor Market Changes  

Final rule: CMS finalized two wage index policies for FY 2025. First, CMS extended the temporary policy finalized in the FY 2020 IPPS/LTCH PPS final rule for three additional years to address wage index disparities affecting low wage index hospitals, which includes many rural hospitals. Second, as required by law, CMS revised the labor market areas used for the wage index based on the most recent CBSA delineations issued by the OMB based on 2020 Census data. 

HMA analysis: The two wage index policy changes for FY 2025 will have important positive and potentially negative consequences on hospital payment. The policy to extend the low wage index policy for three more years will allow many hospitals with low wage indexes to increase their wage index and their payment rates across all Medicare severity diagnosis-related groups (MS-DRGs). 

Specifically, the roughly 800 hospitals with wage indexes below 0.9007 (the 25th percentile across all hospitals) will automatically receive an increase in their wage index and payment rates for all inpatient cases. This policy will bring additional millions of dollars to individual rural hospitals in FY 2025. The second policy is a statutorily required update to the labor markets used to establish CMS’s hospital wage indexes. To implement this policy, CMS will use US Census Bureau data to redefine urban and rural markets. As a result, CMS will redefine 53 urban counties as rural and will newly redefine 42 rural counties containing a hospital as urban. These changes will disrupt various hospital payment policies for hospitals in these counties. The overall impact of both geographic policy changes for FY 2025 will be to increase inpatient payment rates to rural hospitals.  

Revision to Social Determinants of Health Housing Insecurity Diagnosis Coding 

Final rule: CMS finalized a change in the severity designation of the seven ICD-10-CM diagnosis codes that describe inadequate housing and housing instability. Under the final rule, these codes are changing from non-complication or comorbidity (non-CC) to complication or comorbidity (CC) based on the higher average resource costs of cases compared with similar cases without these codes.  

HMA analysis: This new policy will enable hospitals to receive higher inpatient payment rates when they provide care for patients with inadequate housing or housing instability are served. Specifically, this policy change will result in assigning cases involving patients with one of these codes to a higher-level MS-DRG. Hospital staff will want to ask patients about their housing upon admission and discharge to accurately document this critical SDOH characteristic.  

New technology add-on payments 

Final rule: CMS finalized three changes to the NTAP program and approved several products for NTAPs in FY 2025.  

HMA analysis: CMS seems willing to increase NTAP payments in certain limited situations to boost selected policy goals but rejects comments seeking to increase the percentage for sickle cell products or expand the higher payments to other medical conditions. In addition, portions of the final rule indicate that CMS is applying some of the criteria for NTAPs more strictly than in recent years. If this trend continues, it may be more difficult for future new technologies to be approved for NTAPs. 

Connect with Us

HMA’s Medicare Practice Group works to monitor legislative and regulatory developments in the inpatient hospital space and assess the impact of inpatient payment, quality, and policy changes on the hospital sector. We will continue to follow these and other changes happening to hospitals and are available to provide additional detail on these or other policies in the final rule. If you have any questions, please contact Zach Gaumer ([email protected]), Amy Bassano ([email protected]), Kevin Kirby ([email protected]), or Clare Mamerow ([email protected]).  

HMA Roundup

California

California Submits Section 1115 BH-CONNECT Demonstration Addendum to Expand Behavioral Health Community Services. The Centers for Medicare & Medicaid Services announced on August 1, 2024, that California submitted an addendum to its pending section 1115 Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment (BH-CONNECT) demonstration, aiming to further expand community services for people with serious mental health and addiction treatment needs. The addendum would expand the continuum of care for individuals with significant behavioral health needs who are experiencing long stays in an institutional setting, who are homeless or who are at risk of experiencing homelessness, or who need recovery-oriented residential care. The public comment period will run through August 31. Read More

Florida

ImagineCare Drops Medicaid Managed Care Contract Award Protest. Florida Politics reported on August 6, 2024, that ImagineCare—a joint venture of Spark Pediatrics and CareSource—filed a notice of intent to drop its administrative challenge against the Florida Agency for Health Care Administration (AHCA) over the state’s Medicaid managed care contract awards. The two other plans challenging AHCA’s decision, AmeriHealth Caritas and Sentara, are proceeding with their protests. Read More

Florida Plan Files Lawsuit Over Tax Credit Refunds From Unsuccessful Merger. Health Payer Specialist reported on August 5, 2024, that Humana filed a lawsuit against the Florida Department of Revenue over tax credit refunds, linked to its unsuccessful 2015 merger with Aetna. The lawsuit argues that Florida should not have considered $848.8 million in capital gains from 2017 in its tax calculations for Humana. The money came from Aetna’s $1 billion termination fee after a federal judge blocked the union, and therefore was not generated due to Humana’s “ordinary course of business.” Humana seeks a total of $17.3 million in tax refunds and tax credit carryovers. Read More

Illinois

Illinois Proposed Individual Marketplace Rates Vary Widely for 2025. Health News Illinois reported on August 7, 2024, that Illinois health plans are pursuing rate changes ranging from a 4.1 percent decrease to an 11.7 percent increase for individual Marketplace plans, according to 2025 rate filings. Proposed rate changes include a 6.6 percent increase for Blue Cross and Blue Shield of Illinois Affordable Care Act exchange plans; a 7.7 percent decrease for Aetna Health; a 6.4 percent increase for Cigna; and a 4.1 percent decrease for Centene’s Celtic Insurance Company. Read More

Kentucky

Kentucky Allocates Additional HCBS Waiver Program Slots for Fiscal 2025. The Kentucky Cabinet for Health and Human Services (CHFS) announced on July 31, 2024, that it will begin gradually allocating additional waiver slots for the 1915(c) Home and Community Based Services Waiver programs for fiscal 2025, beginning in August. The additional waiver slots include 25 for acquired brain injury long term care; 125 for supports for community living; 250 for the Michelle P. waiver; and 250 for home and community based. House Bill 6 provided state funding for the additional waiver slots.

Louisiana

Louisiana to Submit Application for New Section 1115 Re-entry Demonstration. The Louisiana Department of Health released on August 1, 2024, a draft Section 1115 Re-entry demonstration application to provide certain services for Medicaid-eligible individuals who are incarcerated during the 90-day pre-release period. Those participating in the demonstration will have access to services including case management, medication-assisted treatment and counseling for substance use disorders, and a 30-day supply of all prescription medications. Eligible carceral settings will include all state prison facilities and up to 13 parish jails. The public comment period will run through August 30. Read More

Louisiana Medicaid Audit Finds Dental Plan Failed to Meet MLR, Network Requirements. The Center Square reported on August 5, 2024, that the Louisiana Legislative Auditor’s analysis of DentaQuest—one of Louisiana’s two Medicaid dental benefit program managers—found the plan did not spend at least 85 percent of its dental coverage allocation on Medicaid beneficiaries in 2021 and 2022, failing to meet the medical loss ratio (MLR) requirement. The audit found that of the $408 million paid by the health department to DentaQuest from January 1, 2021, through March 31, 2024, only $232.7 million was provided in dental services. DentaQuest did improve its MLR from 2021 to 2022. The audit also found that DentaQuest was not meeting network requirements as of June 2023 or June 2024; however, the audit notes that Louisiana has a general shortage of dental providers. DentaQuest’s contract runs through December 31, 2024. Read More

Michigan

Michigan Seeks Resident Participation in Racial Health Equity Think Tank to Improve SDOH. The Michigan Department of Health and Human Services announced on August 6, 2024, that it is seeking applications from state residents interested in participating in the Michigan Racial Health Equity Think Tank (MiRHETT), which aims to improve social determinants of health (SDOH) for marginalized and racially diverse individuals. MiRHETT is part of Michigan’s SDOH strategy, currently in Phase III. Participants will share knowledge from their backgrounds and join other public health and community leaders in virtual workshops to improve health equity in Michigan. Applications must be submitted by August 23, and the program is expected to begin in September and continue through January 2025. Read More

Florida Disenrolls 59,332 Medicaid Beneficiaries During June Redeterminations. Health News Florida reported on August 1, 2024, that the state disenrolled 59,332 Medicaid beneficiaries during the post-pandemic June redeterminations. In total, 4,363,948 people remain enrolled in the program, down from 4,423,280 in May 2024. Read More

Minnesota

Minnesota Faces Lawsuit From UnitedHealthcare Over For-profit Insurer Ban in Medicaid Program. The Star Tribune reported on August 5, 2024, that UnitedHealthcare has filed a lawsuit against Minnesota over an omnibus bill which bans the Medicaid managed care program from awarding or renewing contracts with for-profit health plans, beginning in 2025. The state sent a letter to UnitedHealthcare, which is the only for-profit incumbent covering about 32,000 Medicaid enrollees, stating that the department would not renew its existing Medicaid contract in 2025. The lawsuit also alleges that the law blocks UnitedHealthcare from offering two health plans it runs for dual eligibles. Read More

Nevada

Nevada Releases Section 1332 Public Option Program RFP. The Nevada Department of Health and Human Services released on August 5, 2024, a request for proposals (RFP) for health carriers to offer a new public option program, with coverage options referred to as the Battle Born State Plans (BBSPs), which will be certified as Qualified Health Plans. The new program is contingent on federal approval of the state’s Section 1332 Market Stabilization application, and BBSPs must be offered to consumers for purchase on and off the Nevada Health Link no later than Plan Year 2026. The state plans to release the second step of this RFP, which will detail additional requirements for receiving an award, no later than September 2024. Letters of interest must be submitted by August 23, 2024. Contracts are expected to run from 2025 through December 31, 2030, with a one-year renewal option. Read More

New York

New York Section 1115 Medicaid Redesign Team Pilot Program to Take Effect in August. Crain’s New York Business reported on August 1, 2024, that New York’s Medicaid Redesign Team Section 1115 pilot program is set to take effect this month. Nine social care networks administering the program will receive $500 million in contracts from the state in August. The three-year, $7.5 billion demonstration, which runs through March 2027, is expected to screen the state’s 7 million Medicaid members for social determinants of health and provide services to address their housing, nutrition and transportation needs. Read More

Oregon

Oregon Health Authority Releases Strategic Plan For 2024-27. The Oregon Health Authority (OHA) released on August 6, 2024, its 2024-27 strategic plan which includes a goal to eliminate health inequities and to outline a comprehensive plan for progress, by 2030. The plan identifies five key areas of focus which include transforming behavioral health; strengthening access to affordable care for all; fostering healthy families and environments; achieving healthy Tribal communities; and building OHA’s internal capacity and commitment to eliminate health inequities. Read More

Oregon Lowers Insurer-proposed Rate Increases For Five Individual Marketplace Plans. Oregon Capital Chronicle reported on July 31, 2024, that Oregon insurance regulators have lowered rate increases proposed by insurers from a weighted average of 9.3 to 8.1 percent for five companies offering plans on the individual market, while keeping the rate for the Kaiser Foundation Health Plan of the Northwest at 5 percent. The five companies include Moda Health Plan, Providence Health Plan, PacificSource Health Plans, BridgeSpan Health Company, and Regence BlueCross BlueShield of Oregon. Public comments on the rate review will begin in early August, and a final decision will be made later in the month. Read More

Pennsylvania

Pennsylvania to Receive $58 Million MFP Funding. Lehigh Valley Business reported on August 6, 2024, that Pennsylvania will receive $58 million from the Centers for Medicare & Medicaid Services to support the state’s Money Follows the Person (MFP) program, which provides services to individuals with disabilities to help them transition out of an institutional setting. The funding will support more MFP activities including transitional training for nursing home providers, shared affordable housing, trauma awareness, and intervention programs. Read More

Tennessee

Tennessee Medicaid Diaper Benefit is Scheduled to Begin August 7. Tennessee Governor Bill Lee announced on August 6, 2024, that TennCare’s new diaper benefit will begin on August 7. The benefit is part of the governor’s Strong Families Initiative and will provide approximately 100 diapers per month for children under two that are enrolled in CoverKids or TennCare. Read More

Virginia

Virginia Submits Extension Request for 1115 BTCSSHV Waiver Demonstration. The Centers for Medicare & Medicaid Services announced on July 26, 2024, that Virginia submitted a five-year extension request for its Section 1115 Building and Transforming Coverage, Services, and Supports for a Healthier Virginia (BTCSSHV) demonstration, which seeks to provide substance use disorder (SUD) treatment services to individuals who are short-term residents in residential treatment facilities that meet the definition of an IMD. The extension would also provide Medicaid coverage for Former Foster Care Youth (FFCY) up to age 26 and remove authority for the High Needs Supports component of the demonstration. The federal public comment period will run through September 4. Read More

Wisconsin

Wisconsin Directs $258 Million in Funding Toward HCBS Minimum Fee Schedule. Wisconsin Governor Tony Evers announced on August 1, 2024, that he is directing the state’s Department of Health Services (DHS) to invest $258 million in American Rescue Plan Act funds allocated for home and community based services (HCBS) into creating a minimum fee schedule for HCBS services. This will require Medicaid managed care organizations to meet the minimum pay for certain adult long-term care services. DHS estimates the minimum fee schedule will result in a 15 percent pay increase for supportive home care service providers, and a 40.5 percent rate increase for services provided at residential facilities. The affected programs include Family Care, Family Care Partnership, and the Program of All-Inclusive Care for the Elderly (PACE), and the minimum rates will begin October 1, 2024. Read More

National

NCQA Updates HEDIS Quality Measures. Modern Healthcare reported on August 2, 2024, that the National Committee for Quality Assurance (NCQA) is adding three new measures to the Healthcare Effectiveness and Data Information Set (HEDIS), which will additionally track plans’ documentation of mammogram results, follow-up with patients after abnormal breast cancer screenings, and control of blood pressure for patients with hypertension. NCQA will retire its measures on pain assessment indicators, antidepressant medication management, and data source reporting requirements. It will also update its measures on mental illness follow-up and chlamydia screenings. Read More

CMS Releases ACO REACH Reach Model Updates. The Centers for Medicare & Medicaid Services (CMS) released in August 2024, updates to the Accountable Care Organizations (ACO) Realizing Equity, Access, and Community Health (REACH) Model which include reducing the Standard ACO regional blend adjustment ceiling from 5 to 3 percent for Payment Year (PY) 2025 and increasing the benchmark discount for ACOs in the global risk sharing option from 3.5 to 4 percent in PY 2026. The updates aim to improve the model test by adjusting the financial methodology to improve model sustainability based on the findings in the PY 2022 Evaluation Report; responding to feedback from interested parties on improvements to the accuracy of benchmarks; and strengthening operational flexibility and risk management. The National Association of ACOs anticipates some ACOs will drop out or struggle to participate due to the changes. Read More

CMS Finalizes 2.9 Percent Increase for Medicare Inpatient Hospital Reimbursement Rates. The Centers for Medicare & Medicaid Services (CMS) released on August 1, 2024, a final rule that is projected to increase reimbursement rates by 2.9 percent in federal fiscal year 2025 for acute care hospitals that are under the Medicare Inpatient Prospective Payment System (IPPS), participate in the Hospital Inpatient Quality Reporting Program, and are meaningful users of electronic health records. Additionally, CMS will increase the standard federal payment rate for long-term care hospitals (LTCHs) under the LTCH PPS by three percent, which the agency estimates will increase actual reimbursement for LTCHs by two percent due in part to a decrease in high-cost outlier payments. The rule will also require LTCHs to report on data relating to social determinants of health, provide additional funding for CMS’ graduate medical education program, and increase technology add-on payments to expand access to gene therapy for sickle cell disease. Read More

CMS Finalizes 4.2 Percent Medicare Rate Increase for Nursing Homes. Modern Healthcare reported on July 31, 2024, that the Centers for Medicare & Medicaid Services (CMS) finalized a rule to increase Medicare reimbursement rates by 4.2 percent for skilled nursing facilities in fiscal 2025, which begins October 1, 2024. The same rule also tightened staffing regulations, allowing CMS and state regulators to fine nursing homes on a per instance and per day basis for health and safety violations. In separate final rules, CMS increased Medicare inpatient rehabilitation facility reimbursement rates by 3 percent, and inpatient psychiatric facility rates by 2.8 percent. Read More

SAMHSA Announces CCBHC Planning Grant Opportunity. The Substance Abuse and Mental Health Services Administration (SAMHSA) announced on July 29, 2024, a $15 million planning grant opportunity for up to 15 states interested in adopting the Certified Community Behavioral Health Clinic (CCBHC) model. The planning grants, which are the first phase of a two-phase process, will support developing and implementing infrastructure for the CCBHC model, including certification systems, establishing a Prospective Payment System, and preparing an application for the CCBHC demonstration. At the end of the planning grant period, 10 states will be selected to join the CCBHC Demonstration for a four-year period starting on or after July 1, 2026. Applications are due September 12, 2024. Read More

Medicaid, CHIP Enrollment Drops by Nearly 1.1 Million in April 2024. The Centers for Medicare & Medicaid Services (CMS) released on July 31, 2024, that enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) was nearly 81.7 million in April 2024, a decrease of nearly 1.1 million since March 2024. Medicare enrollment was nearly 67.3 million, up 113,182 from March 2024, including 33.9 million in Medicare Advantage plans. Nearly 12 million Medicare-Medicaid dual eligibles are counted in both programs. Read More

Medicaid Coverage for Vision Care Services Varies Widely Across States, NIH Study Finds. The National Institutes of Health (NIH) announced on August 6, 2024, a study which found that 6.5 million Medicaid enrollees, or 12 percent, lived in states without coverage for routine adult eye exams and 14.6 million, or 27 percent, resided in states without coverage for eyeglasses, based on coverage policies in 2022 and 2023. In 20 states, fee-for-service Medicaid policies did not cover glasses at all, and seven states had no coverage for exams or glasses under both fee-for-service and managed care policies. In states that offered vision care coverage, copays and restrictive policies were still a barrier with two-thirds of states requiring enrollees to cost share. Read More

Uninsured Rate Rises to 8.2 Percent in 2024, CDC Data Shows. Stat News reported on August 6, 2024, that the uninsured rate rose from a record low of 7.7 percent—25 million—in 2023, to 8.2 percent—27 million—by March 2024, according to recent data released by the Centers for Disease Control and Prevention (CDC). Over one million adults lost coverage as well as 700,000 children under 18. The 2023 uninsured rate did not factor in those who lost coverage during the post-pandemic Medicaid unwinding, where more than 25 million were disenrolled from the program. The majority of those people found coverage elsewhere through avenues such as the federal marketplace or workplace plans, but the data implies millions of people never found coverage after Medicaid disenrollment. Read More

CMS Releases 2024 Hospital Star Ratings; 60 Percent Received Three Stars or Less. Modern Healthcare reported on August 1, 2024, that the Centers for Medicare & Medicaid Services (CMS) released its hospital star ratings for 2024, giving 60 percent of the 2,834 hospitals it reviewed three stars or less. More hospitals performed poorly in this year’s ratings, which were based on data from April 2019 to March 2023, though it excluded quality metrics from the first half of 2020. Almost 10 percent of hospitals received a one star rating, 21 percent received two stars, 29 percent received three stars, 27 percent four stars, and 13 percent five stars. Read More

More Than 700 Rural Hospitals At Risk of Closing. Modern Healthcare reported on August 6, 2024, that over 700 rural hospitals are at risk of closure and 360 are at risk of immediate closure due to debt and revenue loss, according to a recent report by the Center for Healthcare Quality and Payment Reform. Since the start of 2023, 28 rural hospitals have eliminated their inpatient services to qualify for higher pay as emergency rural hospitals and 12 have closed their doors completely. The report found that insufficient private health plan payments are the biggest contributor to rural hospitals’ financial losses. Read More

Senate Committee Advances Reauthorization of $15 Billion Older Americans Act. Modern Healthcare reported on July 31, 2024, that the Senate Health, Education, Labor, and Pensions (HELP) Committee advanced a bill that would reauthorize the Older Americans Act for five more years. The OAA authorization expires on September 30, 2024. The bill would increase funding by 40 percent, dedicating $15 billion toward preventative care, caregiver support, and community services such as senior centers and Meals on Wheels. Additionally, the total includes $140 million to fund ombudsman programs that investigate poor services and elder abuse at long-term care facilities. The measure now heads to the full Senate. Read More

Medicaid Usage Per Member is Up While Enrollment is Down, Data Shows. Health Payer Specialist reported on August 7, 2024, that across the insurance landscape, beneficiaries are seeking out more services, with a 9.9 percent increase in outpatient doctor visits in the first quarter of 2024 compared to the same quarter last year, according to S&P Capital IQ Pro data. While some outliers exist, Medicaid usage is up as well—despite Medicaid enrollment dropping nationwide—with three-quarters of the 20 largest payers in the country seeing an increase in hospital patient days per member. UnitedHealth Group saw a 23 percent increase in Medicaid hospital patient days per member and Sentara Health Plans saw a 38 percent increase. Medicaid outpatient visits per member have also gone up, with UnitedHealth Group seeing a 21 percent increase and Centene seeing a 12 percent increase. Read More

Industry News

Centene to Exit Medicare Advantage Market in Six States For 2025. Modern Healthcare reported on August 6, 2024, that Centene will exit the Medicare Advantage markets in Alabama, Massachusetts, New Hampshire, New Mexico, Rhode Island, and Vermont for 2025. Centene will not sell its Wellcare Medicare Advantage plans in the states but will continue to offer Medicare Part D prescription drug plans. Centene covers about 37,300 Medicare Advantage enrollees between the six states. Read More

Tenet Healthcare Sells Majority Stake in Brookwood Baptist Health to Orlando Health. Modern Healthcare reported on August 5, 2024, that Tenet Healthcare is selling its majority stake in Alabama-based Brookwood Baptist Health to Orlando Health in a $910 million cash deal. The transaction, which is expected to close this fall, includes five Alabama hospitals, affiliated physician practices, and other operations. Orlando Health will manage the day-to-day operations in partnership with Baptist Health System, and the name of the system will transition from Brookwood Baptist Health to just Baptist Health. Read More

Jefferson Health, Lehigh Valley Health Network Complete Merger. Modern Healthcare reported on August 1, 2024, that Jefferson Health and Lehigh Valley Health Network completed a merger, creating a $15 billion nonprofit health system serving Pennsylvania and New Jersey. The company, which will operate under the Jefferson Health brand, plans on integrating the organization’s 32 hospitals and more than 700 locations over the next several years. Read More

The Pennant Group Completes Purchase of Signature Healthcare at Home Assets in Idaho, Washington. The Pennant Group announced on August 1, 2024, that it has completed its purchase of the Washington and Idaho assets of Signature Healthcare at Home. A second purchase agreement for Signature’s Oregon business is expected to close on January 1, 2025. The Pennant Group operates 117 home health and hospice agencies and 54 senior living communities nationwide through its subsidiaries. Read More

Health Insurers Collect Nearly $15 Billion in Extra MA Payments During Home Visits. The Wall Street Journal reported on August 4, 2024, findings from its investigation of Medicare Advantage (MA) payments to health insurers. According to the WSJ investigation insurers collected an extra $1,818 per visit in Medicare Advantage (MA) payments due to nurses making inaccurate diagnoses during home visits to patients in 2019 through 2021. Payers, including UnitedHealth Group, CVS Health/Aetna, and Humana, received nearly $15 billion in total extra payments during that period for conditions that no doctor or hospital treated. The diagnoses added after home visits accounted for about 30 percent of the total and more than 700,000 peripheral artery disease cases diagnosed only during home visits added $1.8 billion in payments. Read More

RFP Calendar

HMA News & Events

HMA Webinars:

The new administrative state: implications of recent landmark Supreme Court rulings for federal regulations, agency deference, and state implementation. Tuesday, August 13, 2024, 1 PM ET. While legal experts assess the recent U.S. Supreme Court rulings, federal and state agency leaders face significant questions about how their agencies and their responsibilities will be impacted. Join us for an insightful webinar with former federal and state agency leaders exploring the known and yet-to-be determined impacts of recent rulings on federal regulations, rulemaking and actions, and agency deference, and also explore the impact on state agencies implementing federal rules. The webinar will address the impact of the pivotal Loper Bright Enterprises v. Raimondo and West Virginia v. EPA decisions. Together these decisions overturned the longstanding Chevron deference doctrine, are pushing Congress to craft more specific legislation, and are directing courts to interpret ambiguous statutes. The discussion will explore the most appropriate responses of agency leaders, anticipate the ways that these decisions impact federal and state agency decision-making, and identify areas of growing uncertainty. Register Here

Integrating behavioral health into whole-person care. Wednesday, August 21, 1 PM ET. Whether you insource or outsource your behavioral health benefits, the integration of behavioral health and medical care continues to emerge as a critical strategy to improve health and reduce healthcare costs. This webinar is designed to help organizations begin to navigate this important shift in expectations and ultimately be a part of successful change in this area. By focusing on the value of a whole-person care approach to behavioral health, HMA experts will describe the different models for integrating behavioral health and provide a training framework to support the behavioral health aspects of whole-person care. Register Here

NEW THIS WEEK ON HMA INFORMATION SERVICES
(Exclusive Access for HMAIS Subscribers):

HMAIS Reports

  • Updated Section 1115 Medicaid Demonstration Inventory
  • Updated Arkansas State Overview
  • Updated Delaware State Overview
  • Updated Florida State Overview
  • Updated Louisiana State Overview

Medicaid Data

Medicaid Enrollment:

  • Idaho SNP Membership at 17,053, Mar-24 Data
  • Louisiana Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Maryland Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Maryland SNP Membership at 42,113, Mar-24 Data
  • Louisiana SNP Membership at 170,178, Mar-24 Data
  • Nebraska Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Nebraska SNP Membership at 20,740, Mar-24 Data
  • South Dakota Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • South Dakota SNP Membership at 4,500, Mar-24 Data
  • Tennessee Medicaid Managed Care Enrollment is Down 12.5%, Jun-24 Data

Public Documents: 

Medicaid RFPs, RFIs, and Contracts:

  • Nevada BBSP Private Option Health Program Step One RFP, Aug-24

Medicaid Program Reports, Data, and Updates:

  • Arkansas Monthly Enrollment and Expenditures Report, CY 2024
  • California BH-CONNECT Section 1115 Waiver Documents, 2023-24
  • Louisiana Section 1115 Reentry Waiver Demonstration Draft Application, Aug-24
  • Louisiana Department of Health Business Plan Outcomes Report, FY 2023
  • Louisiana CHIP Annual Reports, SFY 2010-24
  • Louisiana Developmental Disabilities Council Report, Apr-24
  • Michigan Social Determinants of Health Strategy, 2022-24
  • Nebraska Heritage Health External Quality Review Technical Reports, 2021-24
  • Ohio Medicaid External Quality Review Reports, 2017-23
  • Oregon Health Authority Strategic Plan, 2024-27
  • Texas HHS Presentation to House Committee on Medicaid and Behavioral Health, Jul-24
  • Virginia BTCSSHV 1115 Waiver Documents, 2021-24

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 Andrea Maresca at [email protected].

Edited by:

Alona Nenko
Andrea Maresca
Mary Goddeeris
Gabby Palmieri
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