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July 31, 2024

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Early Bird Registration Prices for the Unlocking Solutions in Medicaid, Medicare, and Marketplace Ends Today

Early bird pricing ends today, July 31, for Unlocking Solutions in Medicaid, Medicare, and Marketplace, HMA’s annual event being held Oct. 7-9 in Chicago, IL. New agenda details were added this week. Don’t delay to save up to $600 on your registration. Read More

 

In Focus

HMA Celebrates 59th Anniversary of Medicaid and Medicare

This week, Health Management Associates (HMA) shifts In Focus from a newsworthy development to commemorate a seminal event in the expansion and strengthening of healthcare access in the United States. On July 30, 1965 , Medicaid and Medicare were signed into law under Title XVIII and Title XIX of the Social Security Act. Today we celebrate the 59th anniversary of this pivotal moment in America’s healthcare journey.

Medicaid: A Critical Safety Net that Remains Strong

All states, the District of Columbia, and the U.S. territories have Medicaid programs designed to provide health insurance coverage for low-income individuals. As of March 2024[i], 82,751,338 people, including eligible low-income adults, children, pregnant women, older adults, and people with disabilities are covered under their state’s Medicaid program in accordance with federal requirements. The COVID-19 pandemic underscored just how important this safety net program is for American families, as it continued to deliver vital services during unprecedented times.

Beyond its traditional role, Medicaid also drives significant innovations in care for people with complex conditions and challenges. States have implemented various programs and initiatives to improve healthcare quality and outcomes. These include:

  • Managed Care Expansion: Many states have expanded Medicaid managed care programs to enhance care coordination and improve health outcomes.
  • Value-Based Care Models: Innovations in value-based care are being tested, aiming to link reimbursement to quality of care and patient outcomes rather than volume of services.
  • Integration of Behavioral Health: Several states are integrating behavioral health services into Medicaid to address mental health and substance use disorders more effectively.
  • Telehealth: The pandemic accelerated the adoption of telehealth services in Medicaid, expanding access to care and reducing barriers for patients.

Medicare: Leading in Innovation and Coverage

Medicare provides coverage to more than 60 million seniors and people with disabilities. In addition to being a lifeline for so many Americans, Medicare is a force for innovation in health policy, piloting changes to payment and care delivery through the Innovation Center and through Medicare Advantage plan design. Key innovations include:

  • Alternative Payment Models: The Innovation Center has been at the center of piloting various alternative payment models to improve quality and reduce costs.
  • Medicare Advantage Enhancements: Medicare Advantage plans continue to evolve, offering more comprehensive benefits that include mental health and substance use disorder services and integrating additional services such as dental, vision, and wellness programs.
  • Chronic Care Management: Medicare is expanding its focus on chronic care management, providing additional resources and support for individuals with chronic conditions.

HMA’s Commitment to Medicaid and Medicare

Since HMA’s founding, our experts have helped states, plans, providers, and other stakeholders deliver the full spectrum of Medicaid and Children’s Health Insurance Program (CHIP) services. As HMA has evolved, we have built a leading-edge Medicare team that includes former agency officials, plan leaders, policy and data analysts, and actuaries. Healthcare plans, providers, and innovators call upon our colleagues to anticipate policy and regulatory change, develop and support Medicare Advantage business, transform fee-for-service programs, and support access to new technologies and treatments that can both improve quality patient outcomes and reduce costs of care.

Our growing team of includes 10 former state Medicaid directors  and many more former state agency leaders, hospital and health plan executives, senior officials from the Centers for Medicare & Medicaid Services (CMS), and public health leaders.

HMA Colleagues Who Are Former Medicaid Directors Looking Ahead

HMA’s Top Medicare Experts

Looking Ahead

As Medicaid and Medicare near their seventh decade, the programs will continue to evolve and change, to better support covered individuals and meet the demands of policymakers and taxpayers. HMA experts are committed in service of this important mission, and we are excited about building their future together with our clients to create more innovative, high high-quality care that improves health outcomes for all.

 

[i] Centers for Medicare & Medicaid Services. March 2024 Medicaid & CHIP Enrollment Data Highlights.

HMA Roundup

California

California Marketplace Health Insurance Premiums To Increase by 8 Percent in 2025. Newsweek reported on July 26, 2024, that California is projecting an average 8 percent rate increase in premiums for health insurance sold through the state’s marketplace in 2025. The increase is attributed to rising pharmacy costs, labor shortages and wage increases in the health care industry. Aetna/CVS, Anthem Blue Cross and Blue Shield, and Anthem Blue Cross, will see the largest upticks at 15.4, 12.7 and 8.4 percent, respectively. Read More

Connecticut

Connecticut Governor Considers Transitioning Medicaid Program to Managed Care. CT Mirror reported on July 25, 2024, that Connecticut Governor Ned Lamont is considering transitioning the state’s Medicaid program from its current managed fee-for-service model to a managed care model. The state Department of Social Services announced at a Medical Assistance Program Oversight Council meeting that it is seeking consultant services to provide a landscape analysis of different Medicaid models. Read More

District of Columbia

District of Columbia Releases IV&V Medicaid Management Information System RFP. The District of Columbia Department of Health Care Finance (DHCF) released on July 23, 2024, a request for proposals (RFP) for a single contractor to oversee the implementation and certification of Independent Verification and Validation (IV&V) services to support the District’s new modularized Medicaid Management Information System (MMIS). The IV&V contract will be for the MMIS Enterprise Modules, including the Clinical Case Management System (CCMS), Provider Data Management System (PDMS), Medicaid data warehouse, and MMIS Core System and Supporting Services solution. Conduent LLC is the current incumbent administrating the District’s MMIS and Fiscal Agent services since July 2002. To accommodate anticipated timelines provided under this IFB, the Centers for Medicare & Medicaid Services approved the current Fiscal Agent contract extension through September 30, 2024. The contract will run for one year from the date of award, with four one-year renewal options. Read More

Florida

Florida Plan Files Motion to Stop Medicaid Contract Award Lawsuit. Florida Politics reported on July 26, 2024, that Florida Community Care (FCC) has filed a motion to halt a lawsuit filed by ImagineCare—a joint venture of Spark Pediatrics and CareSource—that aims to prevent the Florida Agency for Health Care Administration (AHCA) from proceeding with its new Medicaid managed care contracts until its protest has been addressed. FCC, which was awarded a contract in July, claims ImagineCare’s lawsuit will cause harm to the plan. ImagineCare, along with Sentara and AmeriHealth Caritas, filed protests against AHCA after not receiving a Medicaid contract award in the agency’s April and July award decisions. Read More

Florida Receives Three Protests Over Medicaid Contract Awards. Florida Politics reported on July 25, 2024, that Sentara, AmeriHealth Caritas, and ImagineCare, a joint venture between CareSource and Spark Pediatrics, have notified the Agency for Health Care Administration (AHCA) of their intent to challenge the state’s July and April Medicaid contract award decisions in administrative court. ImagineCare has filed a separate lawsuit against AHCA in a circuit court to prevent the agency from proceeding with its current contracts until protests have been resolved. Read More

Illinois

Illinois to Release Medicaid Managed Care Contract Opportunities in August 2024. The Illinois Department of Healthcare and Family Services (HFS) announced that it anticipates contract opportunities for managed care to be available in August 2024. The current HealthChoice Illinois (HCI) and Medicare Medicaid Alignment Initiative (MMAI) dual demonstration contracts expire on December 31, 2025. Read More

Illinois Governor Signs Legislation Allowing Medicaid Coverage for Pregnancy, Postpartum Services. ABC Chicago reported on July 29, 2024, that Illinois Governor JB Pritzker signed legislation requiring Medicaid coverage for pregnancy and postpartum services, including midwife services, doula visits, and lactation consultants for before, during, and one year after birth. Coverage will include home births and home visits. Licensed or certified midwife services will be covered starting 2025, while all other services must be covered by January 2026. Read More

Montana

Montana Proposes to Boost Oversight of Nonprofit Hospitals. KFF Health News reported on July 25, 2024, that Montana has proposed new rules mirroring federal requirements to increase nonprofit hospital oversight. Montana’s proposal aligns with a national trend by states to ensure nonprofit hospitals provide community benefits when they claim tax-exempt status. Montana officials expect to adopt the new rules in August. The state health department plans to collect hospital data over a three-year period and to begin establishing standards in 2026. Read More

New Mexico

New Mexico Receives Federal Approval for Section 1115 Turquoise Care Demonstration Extension. The Centers for Medicare & Medicaid Services (CMS) announced on July 25, 2024, that it has approved a five-year extension of New Mexico’s Turquoise Care section 1115 demonstration, which was previously called Centennial Care 2.0. The state received new authority to provide health-related social needs (HRSN) services to eligible individuals and pre-release services for certain eligible incarcerated individuals for up to 90 days immediately prior to their expected date of release. The demonstration is effective through December 31, 2029. Read More

New Mexico Reinstates Medicaid Coverage for 21,000 Children Retroactive to May 2023. ABC reported on July 30, 2024, that New Mexico will be reinstating Medicaid coverage for approximately 21,000 children, retroactive to May 1, 2023, as part of a new policy allowing for continuous Medicaid coverage for children. Of those, approximately 3,700 children six and under will have continuous coverage. Children ages six to 19 who have yet to turn 19 upon reinstatement will be reinstated for a minimum of 12 months. Read More

New York

New York Faces Lawsuit Over Medicaid Reimbursement Rates. WBNG reported on July 29, 2024, that more than 200 nursing homes have filed a lawsuit against the New York State Department of Health over the validity of Medicaid reimbursement rates. The lawsuit claims the agency did not make the legally-required case-mix adjustment to the rates it promoted between January 1 and March 31, which were outlined in a letter issued on June 20. The plaintiffs aim to have the rates outlined in the letter revoked and recalculated. Read More

New York Faces Lawsuit Over Changes to the Consumer Directed Personal Assistance Program. Rochester First reported on July 24, 2024, that a group of independent living centers has sued the New York Department of Health (DOH) and its commissioner, claiming the agency illegally changed the Consumer Directed Personal Assistance Program (CDPAP) by reducing reimbursement rates without following proper procedures. The plaintiffs—which are all CDPAP fiscal intermediaries (FIs)—allege the DOH privately told Medicaid managed care organizations that FI reimbursements would decrease by about 10 percent, and then implemented the changes without notice and without holding a public comment period. Read More

Nevada

Anthem Names Joy Thomas President of Nevada Medicaid Plan. Anthem announced on July 23, 2024, that Joy Thomas has been named President of the company’s Nevada Medicaid plan. Thomas previously served as the Regional Vice President of Provider Solutions for Anthem’s Nevada health plan. Read More

North Carolina

North Carolina Receives Federal Approval for Patient Medical Debt Initiative. WSPA reported on July 29, 2024, that the U.S. Centers for Medicare & Medicaid Services (CMS) approved a North Carolina proposal which increases Medicaid funding to hospitals that relieve medical debt dating back to early 2014 for Medicaid enrollees and low and middle-income individuals. The program, which is estimated to help 2 million individuals get rid of $4 billion in debt, would also establish policies to prevent the accumulation of medical debt. Debt relief under the program is expected to occur in 2025 and 2026. Read More

Medicaid to Cover FDA-approved Weight Loss Drugs. Health Payer Specialist reported on July 26, 2024, that North Carolina will allow Medicaid coverage for medications approved for weight loss by the Food and Drug Administration (FDA), including GLP-1s Saxenda and Zepbound, effective August 1. The state estimates a $21 million increase in Medicaid drug costs related to GLP-1 coverage in 2025 and a $15 million increase in 2026. Read More

Oklahoma

Oklahoma Plan Invests in Community Based Organizations to Improve Healthcare Access. Humana Healthy Horizons announced on July 24, 2024, that it has invested resources in four Community Based Organizations (CBOs) across Oklahoma. Humana’s initiative aims to enhance healthcare access, particularly for maternal and behavioral health services in rural regions. The organizations receiving support include Volunteers of America Oklahoma, CREOKS Behavioral Health Center, the Rural Health Innovation Challenge, and Variety Care Clinic. Read More

Oregon

Oregon Disenrolls 221,260 Medicaid Beneficiaries During Redetermination Process. The Oregon Health Authority (OHA) announced on July 24, 2024, that it has disenrolled 221,260 people from Medicaid as of July 19. OHA renewed coverage for 1,114,627 beneficiaries and reduced benefits for 11,321 beneficiaries. Most of the beneficiaries with reduced coverage were removed from the full Oregon Health Plan but are able to continue in Medicare Savings Programs. The state has completed 92.7 percent of its redeterminations. Read More

Rhode Island

Rhode Island Disenrolls Nearly 75,000 From Medicaid, Completing Redetermination Process. Rhode Island Current reported on July 25, 2024, that Rhode Island has completed its post-pandemic Medicaid redetermination process, disenrolling 74,949 beneficiaries, around 75 percent of which were terminated procedurally. The state renewed coverage for 296,803 beneficiaries, 59 percent of which were completed through automated renewals. During the unwinding, 25 percent of those terminated from Medicaid were able to continue their coverage with a qualified health plan (QHP) through the state’s insurance marketplace, and almost half of the people eligible for advance premium tax credits also enrolled in a QHP. Read More

National

CMS Increases Hospice Provider Medicare Reimbursement by 2.9 Percent in Fiscal 2025. Modern Healthcare reported on July 30, 2024, that Medicare reimbursement will increase by a net 2.9 percent for hospice providers in fiscal 2025 under a final rule issued by the Centers for Medicare & Medicaid Services (CMS). Hospice providers that do not report quality data will receive a 1.1 percent reimbursement cut. The regulation also includes finalized modifications to the Hospice Quality Reporting Program and an updated Hospice Consumer Assessment of Healthcare Providers and Systems survey. Read More

Biden Administration Releases Regulatory Agenda for Remainder of Presidency. Modern Healthcare reported on July 30, 2024, that the White House Office of Management and Budget released an agenda detailing the Biden administration’s regulatory plans set to take place during the remainder of the president’s term. The Centers for Medicare & Medicaid Services (CMS) plans to release final rules on Medicare reimbursement rates and a mental health parity regulation, as well as proposed rules addressing public health emergency preparedness requirements, non-physician provider reimbursement rates, and prescription drug prior authorization policies. CMS is also set to publish its annual Medicare Advantage policy early in September. Additionally, the administration plans to publish a proposed rule on the organ donation system, publish a final rule on reporting requirements for cyberattacks, and update rules on remote prescribing of controlled substances. Read More

CMS Releases Fiscal 2025 Medicare Part D Bid Information, Premium Stabilization Demonstration. The Centers for Medicare & Medicaid Services released on July 29, 2024, preliminary Medicare Part D bid information for contract year 2025 so plan sponsors can prepare for open enrollment and finalize their Medicare Advantage and Part D offerings. Additionally, CMS released a voluntary Part D Premium Stabilization Demonstration, which will allow the agency to test if premium stabilization for stand-alone prescription drug plans (PDPs) will improve the efficiency of Medicare Part D program services. The demonstration has three main components, including a $15 reduction to the beneficiary premiums for PDPs, a year-over-year $35 increase limit on a plan’s Part D premium total, and a change to the risk corridors so the government shares more risk to account for possible plan losses. Read More

CMS Considering Changes to Medicaid Policies, Oversight Following Post-Pandemic Redeterminations. Modern Healthcare reported on July 25, 2024, that the Centers for Medicare & Medicaid Services (CMS) is considering ways it can strengthen its role in overseeing Medicaid renewals after the post-pandemic redetermination process. CMS may make permanent some of the temporary fixes it adopted through waivers during the unwinding—such as enrollment data collection, improved automatic renewals, and temporary pauses on procedural terminations. CMS expects to release more information on its plans as well as new guidelines on renewals later this year. Read More

Marketplace Insurers to Pay $10.3 Billion In Risk-Adjusted Payments, CMS Says. Modern Healthcare reported on July 24, 2024, that federal marketplace health insurers will have to pay out $10.3 billion in risk-adjusted payments for 2023, according to the Centers for Medicare & Medicaid Services (CMS). The risk-adjustment program is meant to incentivize insurers to cover high-cost high-risk patients. These insurers receive payments from other insurers who have more low-risk members. Aetna, Kaiser Permanente, and Oscar Health each owe more than $1 billion, while Florida Blue, Blue Shield of California, and Health Care Service Corporation, will each receive over $1 billion in risk-adjusted payments. Read More

Report Examines Coordination of Care for Dual-eligibles. KFF released on July 30, 2024, an issue brief that analyzed federal data from 2021 to determine how Medicaid and Medicare dually-eligible beneficiaries were receiving their benefits. Most full-benefit dual-eligible individuals—94 percent—received benefits through separate Medicare and Medicaid coverage arrangements, including 28 percent enrolled in traditional Medicare and Medicaid fee-for-service, 24 percent in traditional Medicare and Medicaid managed care, 24 percent in Medicare Advantage and Medicaid managed care, and 19 percent in Medicare Advantage and Medicaid fee-for-service. Only six percent of individuals received benefits through a single coverage arrangement, either through Medicare-Medicaid Plans or the Program of All-Inclusive Care for the Elderly (PACE). Read More

U.S. Senator Introduces Legislation to Criminally Charge Fraudulent Marketplace Brokers. KFF Health News reported on July 24, 2024, that U.S. Senator Ron Wyden (D-OR) proposed legislation which would subject health insurance agents who fraudulently enroll consumers in Affordable Care Act (ACA) health plans to criminal charges and civil penalties of $10,000 to $200,000. The Centers for Medicare & Medicaid Services (CMS) sent a letter to Wyden outlining steps the agency has taken to increase oversight and protect consumers, including suspending 200 agents in recent weeks from enrolling clients in ACA plans. CMS also claimed that more than 200,000 people have complained about unauthorized ACA enrollment or plan switches in 2024. Read More

Industry News

Ascension to Sell 9 Illinois Hospitals to Prime Healthcare. Crain’s Business Chicago reported on July 25, 2024, that St. Louis-based Ascension has signed a definitive agreement to sell nine of its hospitals in Illinois to California-based Prime Healthcare, as well as four other care sites. Prime Healthcare plans to invest $250 million into the acquired properties, including Ascension Holy Family in Des Plaines, Ascension Mercy in Aurora, and Ascension Resurrection in Chicago. The deal is expected to close in the first quarter of 2025. It is subject to Federal Trade Commission review and still must be approved by the Illinois Health Facilities & Services Review Board. Read More

Community Health Systems to Sell Three Pennsylvania Hospitals to WoodBridge Healthcare. Modern Healthcare reported on July 30, 2024, that Tennessee-based Community Health Systems is selling its three Pennsylvania hospitals to WoodBridge Healthcare for $120 million. The deal, which is expected to close in the fourth quarter, includes 186-bed Regional Hospital of Scranton, 122-bed Moses Taylor Hospital in Scranton, and 369-bed Wilkes-Barre General Hospital. Read More

Centene CEO of Markets, Medicaid to Leave in December 2024. Health Payer Specialist reported on July 30, 2024, that Centene’s chief executive officer of markets and Medicaid, Dave Thomas, will be leaving the company December 2. Nathan Landsbaum, plan president and chief executive of Centene’s Sunshine Health, will take over Thomas’s role later this year. Read More

RFP Calendar

HMA News & Events

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

HMAIS Reports

  • Updated Medicaid Managed Care RFP Calendar: 50 States and DC
  • Updated Alaska State Overview
  • Updated Iowa Overview
  • Updated Kansas State Overview

Medicaid Data

Medicaid Enrollment:

  • Alabama SNP Membership at 164,440, Mar-24 Data
  • Alabama Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Delaware Medicaid Managed Care Enrollment Down 5.7%, Mar-24 Data
  • Minnesota Medicaid Managed Care Enrollment is Down 13.5%, Jul-24 Data
  • Missouri Medicaid Managed Care Enrollment is Down 9.6%, Jun-24 Data
  • Rhode Island Medicaid Managed Care Enrollment is Down 2.7%, Nov-23 Data
  • Rhode Island SNP Membership at 18,687, Mar-24 Data
  • Rhode Island Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Tennessee Medicaid Managed Care Enrollment is Down 10.1%, May-24 Data
  • West Virginia SNP Membership at 38,125, Mar-24 Data
  • West Virginia Medicaid Fee for Service vs. Managed Care Penetration, 2014-23

Public Documents: 

Medicaid RFPs, RFIs, and Contracts:

  • Alaska Behavioral Health Provider Support Organization RFP, Jul-24
  • Alaska Medicaid School-based Services Implementation Support RFP, Jul-24
  • Arkansas Medicaid Third-Party Liability RFP and Related Documents, 2023-24
  • District of Columbia IV&V Medicaid Management Information System (MMIS) RFP, Jul-24
  • Iowa Medicaid Quality Improvement Organization Services RFP and Awards, 2023-24
  • Iowa D-SNPs Contracts, 2017-25

Medicaid Program Reports, Data, and Updates:

  • Kansas Medical Assistance Reports, FY 2014-24
  • New Mexico Turquoise Care (Formerly Centennial 2.0) Waiver Documents, 2017-24
  • Texas HHSC Medicaid Rate Setting Reports and Revised Rates, FY 2024
  • Texas Medicaid CHIP Data Analytics Unit Quarterly Reports, 2018-24
  • Washington Medicaid Managed Care External Quality Review Reports, 2012-23
  • Washington Medicaid Managed Care Comparative Analysis HEDIS Reports, 2013-23
  • Washington Apple Health Adult Medicaid CAHPS Reports, 2020-23
  • West Virginia Managed Care Quality Strategy, 2024-27
  • Wyoming HealthStat Final Report, 2023

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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