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May 29, 2024

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In Focus

Federal Healthcare Quality Initiatives: Recent Developments Reshaping the Landscape

This week, our In Focus section considers the increasing emphasis on quality at all levels of our healthcare system, especially for work that affects federally funded health insurance programs.  

The Universal Foundation Measure Set  

The 2024 Centers for Medicare & Medicaid Services (CMS) Quality Conference, April 8−10, in Baltimore, MD, continued to highlight the harmonizing of quality measures across CMS programs and promotion of CMS’s universal foundation measures. These metrics capture quality across six domains for adults and four domains for children. By promoting and integrating these well-established measures across all CMS programs, end users can align priorities across programs and help to reduce burden on providers and health plans being assessed.   

Medicaid has long been a leader in incorporating the universal foundation measures, having used many of them in managed care contracts, health homes, and other arrangements that include a quality assessment component for the past 20 years. Earlier this year, many universal foundation measures, including those pertaining to behavioral health, became part of the mandatory core measure set that all states must report to CMS as required in the SUPPORT for Patients and Communities Act—comprehensive federal legislation that addresses the opioid epidemic. Mandatory reporting will allow Congress, the Medicaid and CHIP Payment and Access Commission (MACPAC), and other stakeholders to better understand the impact of federal investments on quality of care for Medicaid and CHIP enrollees. 

New Developments in Medicaid’s Approach to Quality  

Forward momentum is evident in other areas of healthcare quality as well. A significant federal milestone in quality of care was included in the Medicaid Managed Care Rule released in April 2024, which required states to design a quality rating system (QRS) and submit their methodology to CMS for approval. The QRS is intended to be user-friendly and help Medicaid members to pick a plan and monitor its quality performance. States will be able to use the QRS as a monitoring and oversight tool to compare plan performance. Not only will a QRS help improve Medicaid’s accountability to states, enrollees, and policymakers, but it also promotes transparency for all end users and the public. At present, Medicaid quality measures are reported by state rather than by plan. Plan performance in Medicaid is typically captured in a state’s external quality review organization (EQRO) annual report, which may impede the ability of most users to extract, compare, and digest information.   

Another federal initiative is the Medicaid Access Rule, also released in April 2024, to help state Medicaid programs move toward public reporting of quality and compliance measures in home and community-based services (HCBS). In 2022, CMS released more than 90 measures that could be used to assess quality of care in Medicaid HCBS waiver populations. Under the rule, CMS will identify a subset of HCBS quality measures in 2026 and the technical specifications for these measures will be made available publicly and updated as needed. Similar to the CMS Child and Adult Core Sets, states will have an opportunity to implement these measures and CMS can use those outcomes to create HCBS scorecards by state. 

Medicare Advantage Star Ratings Program 

Finally, CMS is incorporating the health equity index (HEI) into the Medicare Advantage Star Rating system. The HEI contributes to a plan’s potential bonus and helps level the playing field for plans that enroll and provide services to underrepresented or at-risk populations. The HEI will account for enrollees who are dually eligible for Medicare and Medicaid, individuals with disabilities, or members with a low-income subsidy (LIS). The HEI also assesses plan-level performance for these specialized populations. Allowing plans to earn a better bonus for delivering high-quality services to these populations helps to mitigate adverse selection and reward plans for care that may be resource intensive. 

What’s Next 

Accountability for quality is beginning to emerge in the form of value-based contracting, incentive payments, and other forms of reimbursement focused on reducing disparities and improving outcomes. Health plans, providers, state agencies, vendors and other interested stakeholders need to have a strategy for quality improvement that reflects evolving federal and state quality priorities, reporting systems, and improvement processes.  

HMA’s quality and accreditation team includes experts in the quality space from a variety of backgrounds, including National Committee for Quality Assurance (NCQA) surveyors, former HEDIS auditors, health plan and provider senior quality staff (vice presidents and chief quality officers), and former Medicare/Medicaid leaders. To learn more about implementing quality programs or to explore options for leveraging quality measures to maximize your organization’s value-based contracts, win requests for proposals, increase membership, and optimize member experience, contact Caprice Knapp, PhD, Managing Director, Quality Accreditation.  

HMA Roundup

Alabama

Alabama Medicaid Spending, Share of State Budget Increases. The Alabama Reflector reported on May 28, 2024, that funding for the Alabama Medicaid agency has increased by 313 percent from $231 million in 2002 to more than $955 million in 2025. Funding for Medicaid and the Department of Corrections comprised more than half the state’s General Fund spending budget in 2024, up from a third of spending in 2002. The budget for the General Fund is projected to reach $3.36 billion in 2025, the largest in the state’s history. Read More

Arkansas

Arkansas DHS Collaborates with State University to Strengthen Medicaid HCBS Programs. Arkansas State University announced on May 23, 2024, that it has received funding to partner with the Arkansas Department of Human Services on several initiatives aimed at strengthening home and community-based services (HCBS) for Medicaid beneficiaries. Specific areas of collaboration will include developing the future workforce and research various strategies that would increase opportunities for individuals to receive services in their homes and communities. Read More

California

California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursements for Noncitizens, OIG Audit Finds. The Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) released an audit in May 2024 that found that California improperly claimed $52.7 million of the total $372.9 million in federal Medicaid reimbursement for capitation payments made on behalf of noncitizens with unsatisfactory immigration status. The proxy percentage that California applied to capitation payments was outdated and did not correctly account for the costs of providing nonemergency services to this population. California plans to provide the refund via a manual process and will collaborate with the Centers for Medicare and Medicaid Services (CMS) to identify improper reimbursements potentially claimed during other time periods. Read More

Delaware

Delaware Senate Passes Provider Tax to Support Medicaid. Delaware Online reported on May 28, 2024, that the Delaware Senate unanimously passed a bill, sponsored by Senator Sarah McBride (D-Bellefonte), that would impose a 3.58 percent tax on hospitals’ and behavioral facilities’ net patient revenues to generate approximately $100 million in new Medicaid funding for the state. The additional funds can be used to increase inpatient and outpatient payments to hospitals and develop funding for Medicaid initiatives. The bill now moves to the House. Read More

Illinois

Illinois House Passes State Budget Plan for Fiscal 2025. Health News Illinois reported on May 29, 2024, that the Illinois House approved a nearly $53.1 billion state budget plan for fiscal 2025, which includes $155 million to support safety-net hospitals serving low-income communities. The budget includes a $1 per hour wage increase for direct service professionals caring for individuals with intellectual and developmental disabilities and $290.3 million for the Department of Human Services to support homelessness services. It also includes $440 million for two programs that provide Medicaid-like coverage for some undocumented adults as well as a plan to direct $23 million to reduce the deaths of Black women during pregnancy. Governor JB Pritzker plans to sign the budget bill. Read More

Illinois Governor Poised to Sign Healthcare Legislation. Health News Illinois reported on May 28, 2024, that the Illinois General Assembly passed the Medicaid omnibus bill (SB 3268), sponsored by Representative Robyn Gabel (D-Evanston). The bill would create a gold card program, which would exempt highly rated hospitals and physicians from prior authorization for at least one year, beginning in 2026. The bill also establishes new reporting requirements for Medicaid pharmacy benefit managers, raises certain rates for providers, and expands the scope of practice for pharmacists, among other changes. The General Assembly also separately cleared legislation that prohibits insurers from using step therapy beginning in 2026 and prior authorization for crisis mental healthcare, and bans limited-duration plans that do not cover all essential benefits beginning in 2025. Governor JB Pritzker plans to sign the bills. Read More

Senate Considers Bill that Would Require Coverage of Doula, CPM Services. Health News Illinois reported on May 23, 2024, that the Illinois Senate is considering a bill, sponsored by Senator Lakesia Collins (D-Chicago), that would require insurers, including Medicaid plans, to cover all pregnancy, postpartum, and newborn care provided by perinatal doulas or licensed certified professional midwives. Insurers would also be required to cover home births, visits by board-certified lactation consultants, and products such as breast pumps and feeding aids. Specifically, the bill would allow policy limits to cover up to $8,000 for home visits by a perinatal doula. The bill currently awaits review by the full Senate. Read More

Indiana

Indiana Disenrolls 8,607 Medicaid Beneficiaries in April 2024. WFYI Indianapolis reported on May 28, 2024, that Indiana has disenrolled nearly 500,000 Medicaid beneficiaries since redeterminations began in April 2023. In April 2024, the state disenrolled 8,607 beneficiaries, including 3,579 due to ineligibility and 5,028 for procedural reasons. Read More

Kansas

Kansas to Face Protest from Aetna Over KanCare Awards. The Kansas Reflector reported on May 22, 2024, that Aetna plans to protest the KanCare Medicaid capitated managed care procurement after losing its contract. Contracts went to incumbents Centene/Sunflower Health Plan and UnitedHealthcare, and non-incumbent Elevance/Healthy Blue. The state did award a contract to U-Care, another non-incumbent bidder. Read More

Michigan

Michigan Disenrolls 18,316 Medicaid Beneficiaries During April Redeterminations. The Michigan Department of Health & Human Services announced on May 24, 2024, that it has disenrolled 18,316 Medicaid beneficiaries during April eligibility redeterminations. Of those disenrolled, 15,737 lost coverage due to ineligibility and 2,579 lost coverage for procedural reasons. Read More

Minnesota

Minnesota Medicaid Managed Care Program Will Stop Contracting with For-profit Insurers in 2025. The Star Tribune reported on May 28, 2024, that the Minnesota legislature passed an omnibus bill which includes the requirement that Minnesota’s Medicaid managed care program no longer award managed care contracts to for-profit health plans, beginning with contracts that take effect on or after January 1, 2025. UnitedHealthcare is the only for-profit incumbent and covers 31,724 Medicaid enrollees in the state. The new law also prevents the state from contracting with for-profit health plans in the State Employee Group Insurance Program. Read More

New Hampshire

New Hampshire Senate Committee Advances Legislation to Alter Medicaid Enhancement Tax. New Hampshire Public Radio reported on May 22, 2024, that the New Hampshire Senate Finance Committee has advanced legislation to increase the share of funding hospitals receive from the state’s hospital provider tax — Medicaid Enhancement Tax – from 91 percent to 93 percent. The amended bill now heads to the full Senate. Read More

New York

New York to Invest $30 Million at Increasing Inpatient Psychiatric Capacity. Crain’s New York Business reported on May 23, 2024, that New York Governor Kathy Hochul has allocated more than $30 million to build 109 inpatient psychiatric beds at community hospitals, with up to $5 million going to nine hospitals to build psychiatric beds for adults and children. Five New York City hospitals are set to receive $19.1 million. The remaining $11.7 million will be allocated to hospitals in upstate New York. Read More

New York Delays Talks to Expand 340B Drug Program. Spectrum Local News reported on May 28, 2024, that New York are still debating pending proposals that impact certain aspects of the state’s Medicaid 340B Drug program, which allows safety-net hospitals and community health centers to pay discounted prices for drugs. The proposed legislation, the 340B Prescription Drug Anti-Discrimination Act, would ban pharmaceutical companies from imposing administrative requirements that discourage providers from participating in the program. Some lawmakers want to include new policies to support health centers. Talks are slated to restart next year. Read More

The Lifetime Healthcare Companies to Acquire CDPHP. Capital District Physicians’ Health Plan (CDPHP) announced May 23, 2024, that New York-based, not-for-profit The Lifetime Healthcare Companies plans to acquire CDPHP. If the affiliation is approved by state and federal regulators, the Lifetime Healthcare Companies would become the parent company of CDPHP, though each plan would remain local. The Lifetime Healthcare Companies is currently the parent company of Excellus BlueCross BlueShield and Univera Healthcare. As of December 2023, CDPHP served 102,000 New York Medicaid members, while Excellus served 227,000 New York Medicaid members. Read More

New York Plan Accused of Fraudulent Behavior. Health Payer Specialist reported on May 24, 2024, that home-health provider Premier Home Health Care Services has filed a complaint against Centene’s New York subsidiary, Fidelis Care. Premier Home Health filed the complaint with the Westchester Supreme Court and is seeking $500,000 for alleged fraud and $622,000 for breach of contract and violation of New York’s prompt payment laws. Specifically, Premier Home Health Care Services alleges that Fidelis Care attempted to delay reimbursement and improperly refused to accept claims for dual eligibles. Read More

New York Medicaid MLTC Plans to Pay $10 Million to Federal, State Medicaid Programs After Failing to Provide Services. The Brooklyn Daily Eagle reported on May 23, 2024, that Medicaid managed long-term care non-profit organizations RiverSpring Living Holding Corp. and ElderServe Health, which does business as RiverSpring at Home, must pay $10 million in restitution to federal and state Medicaid programs after failing to provide services to seniors in New York City and surrounding counties between 2012 and 2018. Under the settlement reached with New York Attorney General Letitia James, $6 million will be returned to the state’s Medicaid program. Read More

Oklahoma

Oklahoma Aetna Health Plan Appoints Interim CEO. Health Payer Specialist reported on May 29, 2024, that Aetna’s Oklahoma-based health plan, Aetna Better Health of Oklahoma, appointed Bob Nutini as interim chief executive, while it undertakes a search for a permanent CEO. Aetna Better Health of Oklahoma was awarded a Medicaid contract for the new SoonerSelect Medicaid managed care program that began April 1. Read More

Oregon

Oregon Names Emma Sandoe as Medicaid Director. The Oregon Health Authority announced on May 23, 2024, that Emma Sandoe has been named director of Oregon’s Medicaid program, known as the Oregon Health Plan, and will officially take over in July. Sandoe previously served as the Deputy Director of Medicaid Policy for North Carolina Medicaid. The Oregon Health Plan serves 1.4 million beneficiaries. Read More

South Carolina

South Carolina Lawmakers Propose Study Committee to Examine Medicaid Expansion. WLTX reported on May 22, 2024, that South Carolina Senator Tom Davis (R-Beaufort) is leading an effort to create a legislative committee which would examine options for improving healthcare access. Expanding Medicaid is one of the options the committee would consider along with increasing the number of physicians, lowering drug prices, and relieving medical debt. The proposed committee, which would consist of members from the House, Senate, and medical professionals, would be required to report its recommendations by December 1, 2024. The legislative committee is included in the pending budget plan, which lawmakers are scheduled to negotiate in the coming weeks. SC Governor Henry McMaster is opposed to spending state funds to study a Medicaid expansion. Read More

South Dakota

South Dakota Medicaid Expansion Rollout Slower Than Projected. SiouxlandProud.com reported on May 22, 2024, that South Dakota Social Services Secretary Matt Althoff reported that the number of individuals enrolling in Medicaid post-expansion remains lower than initially projected. As of April, Medicaid expansion enrollment had reached a monthly average of 22,607, while enrollment was previously projected to reach 52,000 to 57,000. This past winter, officials projected enrollment to surpass 35,000 by July 2024. Read More

West Virginia

West Virginia Legislators Debate Restoration of Funding for Medicaid Program. West Virginia Public Broadcasting reported on May 21, 2024, that the West Virginia House of Delegates and Senate have yet to reach agreement on whether to restore funding for the state’s fiscal 2025 Medicaid budget. Earlier this year, state lawmakers approved a budget with line item reductions in funding for the Medicaid program totaling $150 million, including a more than $10 million decrease in the line item for the intellectual and developmental disabilities waiver program. Read More

National

Medicaid Covers 41 Percent of All Births in U.S., CMS Finds. The Centers for Medicare & Medicaid Services (CMS) released on May 28, 2024, the release of the 2024 Medicaid & Children’s Health Insurance Program (CHIP) Maternal Health Infographic, which details the demographics, health outcomes, risk factors, access and utilization, and disparities among beneficiaries seeking prenatal or postpartum care. The infographic includes several key findings, including that Medicaid pays for 41 percent of all births in the U.S. The infographic also shows the disparity in maternal mortality rates per 100,000 live births in 2021 across race and ethnicity, which was 69.9 for Black, non-Hispanic/Latina mothers, 26.6 for white, non-Hispanic/Latina mothers, and 28 for Hispanic/Latina mothers. The infographic further details leading causes of pregnancy-related deaths, data regarding health care access by region, and the percentage of beneficiaries receiving behavioral health treatment. Read More

Native American Communities Face Heightened Health Disparities Amid Medicaid Eligibility Redeterminations Process. The South Dakota Searchlight reported on May 28, 2024, that Native American communities in Alaska, Arizona, Idaho, Montana, New Mexico, and other states have been significantly impacted by the Medicaid eligibility redeterminations process, which has further exacerbated existing health disparities. Tribal leaders have indicated a lack of information and data regarding the process or the eligibility status of individuals living on reservations. Approximately 30 percent of Native American and Alaska Native people under age 65 utilize Medicaid, according to a survey by the Tribal Self-Governance Advisory Committee of the Indian Health Service. Tribal health systems typically rely on Medicaid reimbursement due to the chronic underfunding of the Indian Health Service. Read More

Black Americans Are Underrepresented in Residential Care Communities, Overrepresented in Nursing Homes. CNHI News reported on May 22, 2024, that Black Americans comprise 4.9 percent of residential care community populations despite making up 9.1 percent of the United States population over 65, according to an analysis conducted by the Associated Press and CNHI News that examined the 2020 National Post-acute and Long-term Care Study. Black residents were also overrepresented in nursing homes, totaling 16 percent of residents. The research found that financial barriers such as discrepancy in salary and cost of care contribute to the disparity. Read More

Industry News

Elevance Health Foundation to Provide $10 Million in Funding to Address Health-related Social Needs. Fierce Healthcare reported on May 24, 2024, that Elevance’s philanthropic organization, the Elevance Health Foundation, will provide $10 million in loans to small businesses to address social needs such as access to care, food insecurity, and health disparities. Loans will be offered at below prime rates to businesses that focus on equity, such as those owned by women or people of color. Initially, investments will be focused in California, Florida, Georgia, Indiana, Nevada, Missouri, and Texas. The Elevance Health Foundation has also selected California-based organization, Mission Driven Finance, to manage $8 million of the $10 million commitment, and will provide further details on the remaining funding in the future. Read More

Express Scripts to Collaborate with CPESN USA to Improve Healthcare Access at Independent Pharmacies. Cigna Group’s pharmacy benefits manager Express Scripts announced on May 23, 2024, that it will collaborate with CPESN USA, a network of 3,500 pharmacies in 44 states that deliver health services, to broaden access to care for individuals at independent pharmacies. Initially, the collaboration will focus on improving care coordination and offerings for Medicare beneficiaries with hypertension and diabetes. The new partnership is a part of Express Scripts’ IndependentRx Initiative, which strives to involve pharmacists in care delivery. Read More

InnovAge launches New Florida PACE Center. InnovAge announced on May 29, 2024, that it has launched a Program of All-inclusive Care for the Elderly (PACE) center in Orlando, Florida. The new center is a joint venture with Orlando Health and will provide integrated healthcare and support services to dual eligible seniors. Read More

RFP Calendar

Company Announcements

MCG White Paper:

The Framework and Utilization of Observation Care in Inpatient Admission Decisions. In this new white paper download, MCG Health’s Associate Vice President and Managing Editor, William Rifkin, MD, FACP, explores the framework and utilization of observation care in inpatient admission decisions. Read More

HMA News & Events

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

Medicaid Data

Medicaid Enrollment:

  • Delaware Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Georgia Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Iowa Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Kentucky Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • Louisiana Medicaid Managed Care Enrollment is Down 4.7%, Mar-24 Data
  • Maine Medicaid Fee for Service vs. Managed Care Penetration, 2014-23
  • New Hampshire Medicaid Managed Care Enrollment is Down 25.6%, 2023 Data
  • New Jersey Medicaid Managed Care Enrollment is Down 7.6%, Apr-24 Data
  • New York Medicaid Managed Care Enrollment is Down 1.8%, Jan-24 Data
  • New York CHIP Managed Care Enrollment is Up 2.8%, Jan-24 Data
  • Pennsylvania Medicaid Managed Care Enrollment is Down 4.2%, Mar-24 Data
  • West Virignia Medicaid Managed Care Enrollment is Down 7%, May-24 Data

Public Documents: 

Medicaid RFPs, RFIs, and Contracts:

  • Vermont Case Management Services for Individuals with Developmental Disabilities, Brain Injuries RFI, May-24
  • Wisconsin DHS External Advocacy and Independent Ombudsman Services RFP, May-24

Medicaid Program Reports, Data, and Updates:

  • Florida PHE Medicaid Redeterminations Monthly Report to CMS, Mar-24
  • Indiana PHE Medicaid Redeterminations Monthly Report to CMS, Apr-24
  • Updated Kansas State Overview
  • Oregon Health Care Cost Growth Trends Annual Report and Databook, 2021-22

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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