Blog

New Jersey Shares its Five-Year Vision for the Latest 1115 Waiver Renewal Draft

This week, our In Focus reviews the the New Jersey Department of Human Services (DHS), Division of Medical Assistance and Health Services (DMAHS) draft proposal for the renewal of its 1115 Comprehensive Demonstration Waiver, released on September 10, 2021. The waiver was initially approved and implemented in October 2012. This demonstration is in its second five-year period and is slated to expire on June 30, 2022.

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Texas Releases STAR Health Draft RFP; Seeks Public Input on STAR+PLUS, STAR Kids ACO

This week, our In Focus reviews the Texas Health and Human Services Commission (HHSC) draft request for proposals (RFP) for Texas STAR Health, the state’s Medicaid managed care program for foster care kids. The state is also seeking public input for the STAR+PLUS and STAR Kids Accountable Care Organization (ACO) programs, in anticipation of the reprocurement of these Medicaid managed care programs.

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HMA Launches Novel Project ECHO for MOUD in County Jails

Aimed at shifting and improving the delivery of addiction treatment within county jails, Health Management Associates (HMA) will partner with the Washington/Baltimore High Intensity Drug Trafficking Area (W/B HIDTA) and Fairfax County Sheriff’s Office to deliver a novel Project ECHO clinic. Funded by W/B HIDTA to support county jails in their region, the Medication for Opioid Use Disorder (MOUD) in County Jails ECHO Clinic will provide participants with HMA training specifically focused on initiating or expanding the use of MOUD within their facilities. The project will broaden county knowledge and understanding of MOUD and its place in the criminal justice system, increase the use of MOUD with evidence-based and emerging promising practices, and promote a culture that supports MOUD in jails.

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Medicaid Non-Emergency Transportation Benefit: Stakeholder Perspectives on Trends and Innovations

This week, our In Focus section reviews key takeaways from the report, Medicaid Non-Emergency Transportation Benefit: Stakeholder Perspectives on Trends and Innovations, prepared by Health Management Associates (HMA) for the Medicaid and CHIP Payment and Access Commission (MACPAC).

The report was written by Principal Sharon Silow-Carroll, Principal Kathy Gifford, Senior Consultant Carrie Rosenzweig, Consultant Anh Pham, and former Managing Principal Kathy Ryland (retired).

States are required to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries with no other means of transportation. In December 2020, following the completion of this study, Congress added a requirement for states to provide NEMT to the Social Security Act (the Act) through the Consolidated Appropriations Act of 2021 (P.L. 116-260). Previously, NEMT was mandated by federal regulations derived from the general statutory requirement that states must “ensure necessary transportation” for Medicaid beneficiaries to assure access “to and from providers” (42 CFR 431.53). Within these guidelines, states have significant flexibility in how they deliver the NEMT benefit to best meet the unique challenges and needs of their beneficiaries, including the delivery system model, reimbursement approach, and transportation modes.

To better understand the state policy decisions, implementation challenges, and innovative practices related to this critical benefit, HMA conducted an environmental scan of all 50 states and the District of Columbia (DC), focusing on criteria including variation in NEMT delivery system models, geographic diversity, innovations, and notable quality requirements. Based on this scan, HMA and MACPAC selected six states: Arizona, Connecticut, Georgia, Indiana, Massachusetts, and Texas to study further through interviews with
51 NEMT stakeholders, including federal and state officials, NEMT providers, transportation broker representatives, MCO representatives, beneficiary advocates, and NEMT subject matter experts.

States use a variety of NEMT delivery system models and reimbursement approaches. These include: managing the benefit in-house (i.e., within the Medicaid agency) and paying for NEMT on a fee-for-service (FFS) basis; contracting with transportation brokers on a capitated or FFS basis (e.g., trip cost plus administrative fee) to manage all or some aspects of NEMT on a state’s behalf; and carving the NEMT benefit into a capitated managed care arrangement with a Medicaid managed care organization (MCO) that either administers the benefit directly or subcontracts with a broker. Approximately a dozen states employ more than one model, using, for example, different models for different Medicaid populations or for different geographic areas. The delivery system models for each of the six study states are outlined in Table 1 below.

StateModel/Risk ArrangementRecent or Planned Changes
ArizonaMCO Carve-In/MCOs at risk

In-house for American
Indian/Alaska Native
(AIAN) individuals not
enrolled in MCOs/State at
risk
N/A
ConnecticutStatewide Broker/Broker at
risk
2018: Shifted Broker Model
from FFS to capitation
GeorgiaRegional Brokers/Brokers at
risk
N/A
Indiana MCO Carve-In/MCOs at risk

Statewide Broker for FFS
population/ Broker at risk
2018: Transitioned FFS
population from in-house to
broker model
MassachusettsRegional Brokers
coordinating with human
service transportation/State
at risk
2021: New contracts will
reduce number of brokers,
increase performance
incentives
TexasRegional Brokers/Brokers at
risk

In-house for one region/State
at risk
2021: Shift from regional
brokersii to MCO carve-in
model
ii Exception: NEMT is administered by the state in one region.

Report findings and common themes include:

  • Policy Considerations: States consider a wide variety of factors when designing their NEMT program including financial and staff resources, known patterns of care, coordination with managed care or other
    human services transit programs, and a desire to incentivize targets outcomes.
  • NEMT Utilization: The most frequent NEMT utilizers are individuals with physical, intellectual, or developmental disabilities and who routinely attend medical appointments multiple times a week, such as
    those receiving dialysis, Medication for Opioid Use Disorder (MOUD), cancer treatment, or adult day health programs. While the COVID-19 pandemic significantly reduced NEMT utilization and may have long-term effects on NEMT service demand, many beneficiaries will continue to need transportation assistance for critical services that cannot be delivered virtually.
  • Performance Issues: Late pick-ups and no-shows were the primary reasons for complaints by beneficiaries, health care providers, and MCO care managers. Interviewees identified GPS tracking and other technologies as essential to improving timeliness, efficiency, and beneficiary satisfaction.
  • Program Integrity: While contracts for brokers, MCOs, and transportation providers often include NEMT performance standards and incentives, some advocates interviewed expressed frustration about the adequacy of state oversight and enforcement, stressing the need for greater consumer feedback and involvement. Most interviewees did not perceive NEMT fraud, waste, and abuse to be a significant problem, particularly with the shift to broker models and new technologies.
  • Transportation Network: NEMT programs often face significant challenges maintaining an adequate transportation network, particularly in rural areas. Interviewees cited the high cost of insurance as a substantial barrier to NEMT provider participation and reported that Transportation Network Companies (TNCs), such as Uber and Lyft, offer several advantages and opportunities for supplementing NEMT supply for able-bodied, independent beneficiaries. However, most agreed that TNCs are not appropriate for a large segment of the NEMT population, including those who have physical or intellectual and developmental disabilities.
  • Stakeholder’s View on the Value and Role of NEMT: All interviewees emphasized the importance of the NEMT benefit in helping Medicaid beneficiaries access the health care they need. Several highlighted the value or potential value of NEMT in improving health outcomes and reducing disparities, and some
    interviewees opined that NEMT would offer even greater value if beneficiaries and health care providers received more education about the benefit.

Arizona Releases Competitive Contract Expansion (CCE) RFP

This week, our In Focus section reviews the Arizona Health Care Cost Containment System (AHCCCS) Competitive Contract Expansion (CCE) request for proposals (RFP), released on August 4, 2021. The procurement will expand the current AHCCCS Complete Care (ACC) Medicaid contracts to include responsibilities as an ACC Contractor (health plan) with a Regional Behavioral Health Agreement (ACC-RBHA).  At least one incumbent Medicaid ACC Contractor will be selected in each of the state’s three Geographic Service Areas (GSAs).  The responsibilities will include management of:

  • An integrated Medicaid physical and behavioral health services benefit for individuals with serious mental illness (SMI),
  • Non-Medicaid behavioral health services for children and adults, and
  • A crisis system and services (ACC-RBHAs will jointly select and oversee a single statewide crisis phone vendor to operate a single, easy-to-use crisis phone line and crisis response system).

Implementation is slated to begin October 1, 2022.

Current ACC plans are:

  • Health Choice Arizona (subsidiary of Blue Cross Blue Shield of Arizona)
  • Banner University Family Care
  • Arizona Complete Health (subsidiary of Centene)
  • Care 1st Health Plan (subsidiary of Centene)
  • Mercy Care Plan,
  • Molina Complete Care
  • UnitedHealthcare Community Plan

ACC plans provide physical health and behavioral health services to Medicaid members, including adults with General Mental Health/Substance Use (GMH/SU) needs and children, including those with Special Health Care Needs (SHCN).

Plans must already serve the GSA in order to win the expanded contracted in that GSA. For example, only plans that already serve the North GSA will be eligible to bid for the CCE in the North GSA. ACC plans will not be awarded more than two of the three GSAs.

Winning plans will need to implement Whole Personal Care Initiative (WPCI) strategies, including addressing Social Determinants of Health (SDOH) and utilizing the Statewide Closed-Loop Referral System (CLRS). Plans will actively promote provider network utilization of the CLRS to properly refer members to Community Based Organizations (CBOs) providing services addressing social risk factors of health.

Additionally, plans will use health information technology in electronic health records (EHRs), e-prescribing, and a Health Information Exchange (HIE) infrastructure. They will be required to contract with the state designated Health Information Exchange (HIE) organization, Health Current, a non-profit organization which provides a secure network for the exchange of clinical health information.

Background

The procurement will replace the state’s current Regional Behavioral Health Authorities (RBHAs) with ACC-RBHAs. AHCCCS currently contracts with three RBHAs –Arizona Complete Health (Centene), Mercy Care Plan, and Health Choice Arizona (Blue Cross Blue Shield of Arizona)– for behavioral health benefits for individuals with SMI. Other changes include in October 2021, the Arizona Behavioral Health Corporation began administering the AHCCCS Housing Program for individuals with mental health issues who are experiencing homelessness.

Below is each plan’s Medicaid SMI enrollment:

There will also be non-Medicaid grant funded program lives.

Timeline

Proposals are due October 4, 2021, with awards expected to be announced November 15, 2021.

For questions and additional RFP information, please contact HMA Senior Consultant Suzanne Rabideau.

Link to RFP

Senate Infrastructure Bill Has Both Direct, Indirect Impact on U.S. Health Care System, Leavitt Partners Analysis Shows

President Biden and Senator Majority Leader Schumer have been pursuing a two-track strategy to advance major policy objectives in 2021. The first track, the bipartisan “Infrastructure Investment and Jobs Act,” passed the Senate 69-30. Attention now turns to the House, where Speaker Pelosi has indicated she will not consider the bill until the Senate passes a Democratic-only reconciliation bill – which is the second track in Democrats’ policy strategy. While the Senate vote reflects a major bipartisan milestone, the bill still faces a trip through the House of Representatives before it gets to President Biden’s desk.

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HMA Prepares Issue Briefs Exploring MLTSS Impacts on State Medicaid Programs

This week, our In Focus section highlights a recent pair of reports prepared for Arizona for Better Medicaid. HMA colleagues examined the impact of managed long-term services and supports (MLTSS) in state Medicaid programs. The first report, Growth in MLTSS and Impacts on Community-Based Care, examines the historical increase in the adoption of LTSS by state Medicaid programs and how that has contributed to a shift in long-term care from institutions to the community. The second report, Managed LTSS Improves Quality of Care, describes the evidence on the impact of managed LTSS in state Medicaid programs on the quality of care.

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Vermont Proposes Risk-Bearing, State-Run Medicaid Managed Care Entity

This week our In Focus section reviews Vermont’s Global Commitment to Health Section 1115 waiver renewal application. In the proposed five-year demonstration extension, Vermont seeks to move the Medicaid population to a new a risk-bearing public, state-run managed care organization (MCO). Under the arrangement, the Department of Vermont Health Access (DVHA) would transition into the new entity and accept capitated risk for the state’s Medicaid population, covering physical and mental health, pharmacy services, substance use disorder (SUD) services, and long-term services and supports (LTSS) beginning January 1, 2022.

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