This week, our In Focus section covers Congress’s and the Administration’s parallel efforts to finalize fiscal year (FY) 2024 spending bills and begin the budget process for FY 2025.
Congress approved a bipartisan package for some of the FY 2024 spending bills, and on March 9, 2024, President Biden signed the Consolidated Appropriations Act of 2024 into law (PL 118-42). Programs funded through this measure include the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and other federal nutrition supports, rental assistance for safe and affordable housing, and veterans medical care and benefits.
Several mandatory funding extensions of public health programs and health-related policies also found their way into the 2024 consolidated appropriations package, including extending the Community Health Center Fund, delaying reductions in the disproportionate share hospital allotments, defining Certified Community Behavioral Health Centers (CCBHCs) as a Medicaid service, extending incentive payments for certain Medicare providers, and mitigating the impact of cuts to the Medicare physician fee schedule.
These policies, however, addressed a narrower set of issues than the expansive and bipartisan legislation that has been moving through both chambers of Congress. For example, House and Senate members have worked on respective bipartisan policies affecting price transparency, pharmacy benefit managers, and Medicare site-neutral policies, among others.
Meanwhile, President Biden released the FY 2025 Budget proposal March 11, 2024, kicking off the annual budget process. Like the administration’s FY 2024 budget proposal, the FY 2025 plan emphasizes deficit reduction and continues to make equity and Medicare solvency cornerstones of the budget. Health-related priorities include expanding access to affordable healthcare services, lowering drug costs, improving maternal health, addressing the mental health and substance use disorder crises, and enhancing biodefense and preparedness activities.
Check out the FY 2025 budget analysis from Leavitt Partners, a Health Management Associates, Inc. (HMA), company, here, and a deeper dive into the Consolidated Appropriations Act of 2024 here.
What We’re Watching
Congress is continuing negotiations on the outstanding spending bills, including the one that funds the Departments of Health and Human Services, Labor, and Education through September 2024. Lawmakers are working to reach an agreement before the next funding deadline of March 22.
The administration’s FY 2025 budget proposals are generally being characterized as a blueprint for President Biden’s re-election campaign and, if successful, a policy agenda for his second term. Though Congress has already begun holding hearings on the budget request, members on both sides of the aisle will likely focus on issues that resonate in an election year.
Regardless of the outcome of the November elections, Congress has an opportunity to address unfinished business during the lame duck session later this year.
HMA and Leavitt Partners collaborate to monitor legislative and regulatory developments in healthcare and adjacent spaces and to assess the impact of policy changes on the healthcare industry.
When Love is Not Enough to Preserve a Forever Family for a Child
Families formed by adoption face unique challenges in their lifelong journey as adoptees, parents, and siblings. Adoption-competent mental health is a necessary resource for adoptive families. This November, we are honoring adoption as a vital permanency strategy and the importance of forever families in the lives of children and youth who need this sense of permanency, security, and wellbeing.
The Children’s Bureau, part of the U.S. Department of Health and Human Services Office of the Administration for Children and Families (ACF) created National Adoption month to increase national awareness of adoption issues, encourage the development of permanent relationships, and bring attention to the need for adoptive families to provide placement for teens in the U.S. foster care system. The theme for 2023, “Empowering Youth: Finding Points of Connection,” focuses on ways to provide opportunities and services that connect youth to their identity—including culture, background, interests, and ambitions – to support meaningful permanent relationships with adults.
In the U.S., as of September 30, 2021, there were 114,000 children and youth waiting to be adopted who were at risk of aging out of foster care without permanent family connections.
More than one in five children waiting for adoption were 13–17 years old.
The average age of all children waiting to be adopted was 7.5 years old.
The average time in care for all children waiting to be adopted was 33.7 months.
The average time in care for children waiting to be adopted after termination of parental rights was 19 months.
The National Council for Adoption reports an 18 percent decrease in adoptions from FY19-FY21, with over 19,000 children who aged out of foster care without a permanent family. There has been a 24 percent decrease in domestic adoptions from 2019-2020 and 93 percent decline in intercountry adoptions since peaking in 2004.[1] . These data points reflect the urgency of revitalizing adoption as an important tool for the wellbeing of children who need permanent loving families.
Recognizing that adoption is just the beginning of the family’s journey and the fact that adoptive families need special attention, especially when the children who have been adopted have suffered the trauma of entering the child welfare system, mental health treatment and resources are critical to the wellbeing of these families and the children in them.
Importance of Identity
Research has shown that strong cultural identity can contribute to mental health resilience, higher levels of social well-being, and improved coping skills, greater self-esteem, higher education levels, better psychological adjustment, and improved coping abilities.[2] But many youth in foster care often have lower cultural identity strength than those who did not experience foster care. This can lead to higher levels of loneliness and depression, lower self-esteem, and difficult psychological adjustments that in turn affect coping skills and learning.[3]
In her book You Should be Grateful, Angela Tucker offers many practical insights and tools aimed at nurturing identity and helping transracial families and adoptees to center around the cultural norms and experiences of the adoptees themselves.[4]
A Changing Landscape
Many states now have safe-haven laws where parents can drop off their babies without penalty at hospitals, fire stations or police department if they are not able to care for them knowing their babies will be cared for and placed in families through the child welfare system. At the same time there are many children and youth who languish in foster care waiting for a ‘forever family’ to adopt them. Thousands of teens in foster care are looking for the love, support, and encouragement that families provide throughout their lives—not just until they turn 18. Youth who were adopted from the foster care system when they are 16 or older may be able to access Education and Training Vouchers (ETV) of up to $5,000 per year. Those who were adopted from foster care when they are 13 or older are more likely to qualify for federal financial student aid because they do not have to count family income when applying.[5]
When it comes to medical and mental health benefits, qualifying families may receive federally funded monthly maintenance payments, and other support, often until a child turns 18 or 21, depending on the state where they live, and medical assistance until age 26 if they were in foster care at a certain age depending on the state. Recognizing the need for adoption competent mental health, the Federal Administration for Children and Families has awarded the Center for Adoption Support and Education the grant to build a national Center to Support Mental Health Services in the Child Welfare System.[6]
The recent Biden-Harris regulations strengthen services and supports for children and families in the child welfare system. These regulations require additional support for kinship families, and protections for LGBTQI+ youth and expansion of access to legal services for children and families entering the child welfare system. Congress could use the momentum from these regulations to make the Adoption Tax Credit fully refundable and extend it to legal guardians to assist with the financial resources of raising children.
The recent Supreme Court Dobbs decision will likely impact adoption trends, but that trend is still evolving and will need to be monitored before conclusions can be drawn.
How HMA Can Help
HMA assists organizations working in child welfare and adoption, and grounds our work in human-centered design, lived expertise, and change management and leadership principles in state and county program development. We can help support organizations working with children and youth in foster care or with adoption agencies by:
Providing technical assistance to state and local government, and community-based organizations
Developing system redesign and strategic planning
Facilitating stakeholder engagement
Implementing workforce and leadership development strategies
Visit the ACF website to learn more about National Adoption Month and find tools and resources to educate yourself and your community about how we can achieve better outcomes for youth in foster care.
If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact:
Uma Ahluwalia, MSW, MHA, Managing Principal, Jon Rubin, Principal, or Caitlin Thomas-Henkel, Principal.
[2] Anderson, M., & L.O. Linares. “The Role of Cultural Dissimilarity Factors on Child Adjustment Following Foster Placement.” Children and Youth Services Review 34(4), 2012, 597-601.
HMA is releasing an agency-by-agency analysis of the impacts on several key healthcare programs and services in the event of the potential federal government shutdown in the coming days. As of September 27, 2023, the U.S. Congress has not approved any of the twelve appropriations bills for FY 2024 or a continuing resolution (CR) that would maintain federal funding at the FY 2023 level for a specified period of time into FY 2024 while Congress continues negotiating. If the shutdown is not averted before the deadline, look for a LinkedIn live at 10am Monday, October 2 to discuss the ramifications on the U.S. healthcare system. Go to the HMA LinkedIn page to watch.
This week, our In Focus section reviews the new Guiding an Improved Dementia Experience (GUIDE) Model, announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) on July 31, 2023.
In addition to announcing the Innovation Center’s GUIDE Model, CMS released five final fiscal year (FY) 2024 payment rules this past week. Of note, these regulations set higher than anticipated reimbursement rates for many providers:
CMS also released the 2024 projected Medicare Part D premium and bid information, which may provide early indications on the effects of the Inflation Reduction Act’s drug pricing policies.
GUIDE Model: Parameters and Opportunities
President Biden signed an Executive Order in April 2023 on Increasing Access to High-Quality Care and Supporting Caregivers. The order directed the Innovation Center to develop a payment and delivery system model for dementia care. The program is intended to improve the quality of life for people living with dementia, reduce strain on unpaid caregivers, and help people remain in their homes and communities through improved care coordination and management, caregiver education and support, and respite services.
The announcement this week outlines the basic parameters of the model, which track with CMS’s focus on reducing health disparities, supporting innovation, and addressing affordability. CMS expects that the model’s additional support for caregivers will reduce federal spending on hospitalizations and post-acute care. Notably, CMS projects savings will come from reduced long-term nursing facility placement through a decrease in Medicaid spending on the federal medical assistance percentage (FMAP). Helping Medicare enrollees stay in their homes may also lower state spending on long-term care.
Additional information, including the application to participate, will be available this fall. In the meantime, CMS is accepting letters of interest through September 15, 2023. The model will begin on July 1, 2024, and run for eight years.
HMA’s experts identified the below list of policies that will be important for provider organizations, caregivers, and other stakeholders considering participation in the model:
GUIDE Model participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, that are eligible to bill for Medicare physician fee schedule services and agree to meet the care delivery requirements.
The GUIDE Model comprises two tracks for participation—one for established programs and another for new programs.
Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record (EHR) platform that meets the standards for certified EHR technology, and meet other care delivery requirements as outlined in the request for applications.
If a participant cannot meet the GUIDE healthcare delivery requirements alone, CMS will allow the provider or supplier to partner with other Medicare organizations, to meet the mandates.
The model also includes policies designed to reduce disparities in dementia care. For example, CMS plans to conduct outreach with organizations that do not yet offer comprehensive dementia care or lack prior experience with alternative payment models such as safety net providers. Participants also will need to develop health equity plans, and a “health equity adjustment” will be made to payments for providers that serve disadvantaged beneficiaries.
CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for participation.
CMS will test an alternative payment methodology for participants that deliver key care management and coordination services to people with dementia and their family caregivers, including comprehensive, person-centered assessments and care plans; 24/7 access to a helpline; and caregiver support and education, such as training on how to best care for a relative with dementia. CMS clarifies that GUIDE is not a shared savings or total cost of care model and does not address coverage of novel Alzheimer’s drugs.
Participants will assign Medicare fee-for-service beneficiaries, including people who are dually eligible for Medicare and Medicaid, living with dementia and their caregivers to a care navigator. This individual will help people access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants will also help caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities. Evidence demonstrates that respite enables caregivers to care for individuals with dementia at home for a longer period, thereby forestalling institutional placement.
CMS will host a webinar with more details about the model on Thursday, August 10, from 2:00−3:00 pm.
The HMA team will continue to evaluate the GUIDE model and other Innovation Center opportunities. If you have any questions about the model, contact Amy Bassano, Barry Jacobs, or Maddy Shea.
We also can assist with questions about any of the new regulations. Contact Zach Gaumer, Andrea Maresca or Amy Bassano.
We also would like to remind our readers that the HMA team hosted a webinar last week on the Medicare Behavioral Health proposed changes. We previously discussed those changes in the July 19, 2023 In Focus. If you missed the webinar, you can find the recording and slides on the HMA website.
Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth
Pre-Conference Workshop: October 29, 2023 Conference: October 30−31, 2023 Location: Fairmont Chicago, Millennium Park
Health Management Associates has announced the preliminary lineup of speakers for its sixth annual conference, Innovations in Publicly Sponsored Healthcare: How Medicaid, Medicare, and Marketplaces Are Driving Value, Equity, and Growth.
Hundreds of executives from health plans, providers, state and federal government, investment firms, and community-based organizations will convene to enjoy top-notch content, make new connections, and garner fresh ideas and best practices.
A pre-conference workshop, Behavioral Health at the Intersection of General Health and Human Services, will take place Sunday, October 29.
Confirmed speakers to date include (in alphabetical order):
Jacey Cooper, State Medicaid Director, Chief Deputy Director, California Department of Health Care Services
Kelly Cunningham, Administrator, Division of Medical Programs, Illinois Department of Healthcare and Family Services
Karen Dale, Chief Diversity, Equity, and Inclusion Officer, AmeriHealth Caritas
Peter Lee, Health Care Policy Catalyst and former Executive Director, Covered California
John Lovelace, President, Government Programs, Individual Advantage, UPMC Health Plan
Julie Morita, MD, Executive Vice President, Robert Wood Johnson Foundation
Anne Rote, President, Medicaid, Health Care Service Corp.
Drew Snyder, Executive Director, Mississippi Division of Medicaid
Tim Spilker, CEO, UnitedHealthcare Community & State
Stacie Weeks, Administrator/Medicaid Director, Division of Health Care Financing and Policy, Nevada Department of Health and Human Services
Lisa Wright, President and CEO, Community Health Choice
Publicly sponsored programs like Medicare, Medicaid, and the Marketplaces are leading the charge in driving value, equity, and growth in the U.S. healthcare system. This year’s event will highlight the innovations, initiatives, emerging models, and growth strategies designed to drive improved patient outcomes, increased affordability, and expanded access.
Early bird registration ends July 31. Questions may be directed to Carl Mercurio. Group rates, government discounts, and sponsorships are available.
HMA is pleased to welcome new experts to our family of companies in April 2023.
Jed Abell – Consulting Actuary Wakely
Jed Abell is a professional health insurance actuary with over 20 years of experience focusing on Medicare Advantage, Part D, and commercial employer group plans.
Surah Alsawaf – Senior Consultant HMA
Surah Alsawaf is a senior consultant with experience in creating and implementing regulatory strategies and workflows, conducting reviews and audits, and leading cross-functional teams to complete complex deliverables.
Elrycc Berkman – Consulting Actuary Edrington
Elrycc Berkman is experienced in Medicaid managed care rate development including managed long-term services and supports (MLTSS) and program of all-inclusive care for the elderly (PACE) rate development.
Monica Bonds – Associate Principal HMA
Monica Bonds is an experienced managed care professional with over 15 years of experience working in large and diverse organizations.
Yucheng Feng – Senior Consulting Actuary Wakely
Yucheng Feng has over 15 years of experience providing actuarial support for Medicare Advantage clients, including bid preparation, reserve, actuarial analytics and providing strategic recommendations. Read more about Yucheng.
Melanie Hobbs – Associate Principal HMA
Melanie Hobbs is an accomplished healthcare executive, consultant, and thought leader specializing in Medicare, Medicaid, and Special Needs Plans (SNPs).
Daniel Katzman – Consulting Actuary Wakely
Daniel Katzman is experienced in Medicare Advantage bid pricing and modeling as well as claims trend analytics and affordability/cost-savings analysis. Read more about Daniel.
Supriya Laknidhi – Principal HMA
Supriya Laknidhi has over 20 years of experience in the healthcare industry and a proven track record in driving growth and innovation for companies.
Donald Larsen – Principal HMA
Dr. Donald Larsen is a C-suite physician executive with over 30 years of experience spanning complex academic medical centers, community health systems, acute care hospitals, and research institutes.
Ryan McEntee – Senior Consultant Wakely
Ryan McEntee is an experienced managed care executive specializing in strategic leadership within Medicare Advantage plans. Read more about Ryan.
Nicole Oishi – Principal HMA
Nicole Oishi has over 30 years of experience in senior leadership roles as a healthcare clinician and executive.
This week our In Focus section reviews President Joseph R. Biden’s 2023 State of the Union Address (SOTU) to Congress. The President highlighted specific actions that Congress, and the Administration have taken over the last two years to advance his health care priorities.
During his first SOTU address in 2022, President Biden announced the creation of a “Unity Agenda”, which included priority policy areas with potential for bi-partisan support. The President highlighted several steps the Administration has taken to advance the “Unity Agenda” including:
The bipartisan effort to enact the Mainstreaming Addiction Treatment (MAT) Act, which removed the federal requirement for practitioners to have a waiver (known as the X-waiver) to prescribe medications, like buprenorphine, for the treatment of opioid use disorder
The Cancer Moonshot announcements for almost 30 new programs, policies, and resources to close the screening gap, tackle environmental exposure, decrease preventable cancers, advance cutting-edge research, support patients and caregivers, and more.
Addressing mental health needs through the expansion of Certified Community Behavioral Health Clinics and launch of the 988-suicide prevention hotline.
In his SOTU and accompanying White House materials, the President also proposed new policies and initiatives to further advance his health care agenda. These actions include a combination of issues that would require Congressional approval as well as actions regulatory agencies can already advance. Congress and the Administration are expected to build on previous bipartisan achievements to tackle the nation’s dual crises with addiction and mental health.
Notably, the policies outlined in the SOTU foreshadow an active regulatory agenda over the next 18 months as the Administration seeks to solidify key aspects of the President’s health care agenda ahead of the next Presidential election.
The Administration’s planned actions include the following:
Opioids
Calling on Congress to pass legislation to permanently schedule all illicitly produced fentanyl-related substances into Schedule I.
SAMHSA will provide enhanced technical assistance to states who have existing State Opioid Response funds, and will host peer learning forums, national policy academies, and convenings with organizations distributing naloxone beginning this spring.
By this summer, the Federal Bureau of Prisons will ensure that each of their 122 facilities are equipped and trained to provide in-house medication-assisted treatment (MAT).
This spring CMS will provide guidance to states on the use of federal Medicaid funding to provide health care services—including treatment for people with substance use disorder—to individuals in state and local jails and prisons prior to their release. California is the first state to receive approval for a similar initiative.
Mental Health
CDC plans to launch a new campaign to provide a hub of mental health and resiliency resources to health care organizations in better supporting their workforce.
The Department of Education (ED) will announce more than $280 million in grants to increase the number of mental health care professionals in high-need districts and strengthen the school-based mental health profession pipeline.
HHS and ED will issue guidance and propose a rule to make it easier for schools to provide health care to students and more easily bill Medicaid for these services.
The Administration is scheduled to propose new mental health parity rules this spring.
HHS will improve the capacity of the 988 Lifeline by investing in an expansion of the crisis care workforce; scaling mobile crisis intervention services; and developing additional guidance on best practices in crisis response.
HHS also plans to promote interstate license reciprocity for delivery of mental health services across state lines.
HHS intends to increase funding to recruit future mental health professionals from Historically Black Colleges and Universities and to expand the Minority Fellowship Program.
The Department of Veterans Affairs (VA), working with HHS and Defense, will launch a program for states, territories, Tribes and Tribal organizations to develop and implement proposals to reduce suicides in the military and among veterans.
VA will also increase the number of peer specialists working across VA medical centers to meet mental health needs
Cancer Moonshot
The President called on Congress to reauthorize the National Cancer Act to overhaul cancer research and to extend the funding for biomedical research established in the 21st Century Cures Act.
The Administration will take steps to ensure that patient navigation services are covered by insurance. This could require legislation depending on which type on insurance an individual has.
Health care costs
Urging Congress to pass legislation to cap insulin prices in all health care markets. Expanding the $35 insulin cap to commercial markets will require the 60 votes in the Senate.
Home and community services
Working with Congress to approve legislation to ensure seniors and people with disabilities can access home care services and to provide support to caregivers.
HMA and HMA companies are closely monitoring these federal policy developments. We can assist healthcare stakeholders in responding to the immediate opportunities and challenges that arise and contextualize these actions for longer-term strategic business and operational decisions.
If you have questions about these or other federal policy issues and how they will impact your organization please contact Andrea Maresca ([email protected]) or Liz Wroe ([email protected]).
Join us on Monday, March 6, 2023, at the Fairmont Chicago, Millennium Park, for “Healthcare Quality Conference: A Deep Dive on What’s Next for Providers, Payers, and Policymakers,” where Lee Fleisher, MD, chief medical officer and director of CMS’ Center for Clinical Standards and Quality, will deliver the keynote titled A Vision for Healthcare Quality: How Policy Can Drive Improved Outcomes.
HMA’s first annual quality conference will provide organizations the opportunity to “Focus on Quality to Improve Patients’ Lives.” Attendees will hear from industry leaders and policy makers about evolving health care quality initiatives and participate in substantive workshops where they will learn about and discuss solutions that are using quality frameworks to create a more equitable health system.
In addition to Fleisher, featured speakers will executives from ANCOR, CareOregon, Commonwealth Care Alliance, Council on Quality and Leadership, Intermountain Healthcare, NCQA, Reema Health, Kaiser Permanente, United Hospital Fund, and others.
Working sessions will provide expert-led discussions about how quality is driving federal and state policy, behavioral health integration, approaches to improving equity and measuring the social determinants of health, integration of disability support services, stronger Medicaid core measures, strategies for Medicare Star Ratings, value-based payments, and digital measures and measurement tools. Speakers will provide case studies and innovative approaches to ensuring quality efforts result in lasting improvements in health outcomes.
“What’s different about this conference is that participants will engage in working sessions that provide healthcare executives tools and models for directly impacting quality at their organizations,” said Carl Mercurio, Principal and Publisher, HMA Information Services.
View the Full Agenda
Early Bird registration ends January 30. Visit the conference website for complete details or contact Carl Mercurio at 212-575-5929/[email protected]. Group rates and sponsorships are available.
The holiday season is grounded in gratitude. At HMA, we are grateful for successful partnerships that have fueled change to improve lives.
We are proud to be trusted advisors to our clients and partners. Their success is our success. In 2022 our clients and partners made significant strides tackling the biggest healthcare challenges, seizing opportunities for growth and innovation, and shaping the healthcare landscape in a way that improves the health and wellness of individuals and communities.
HMA partnered with the Colorado Department of Human Services to support the planning and implementation of a new Behavioral Health Administration (BHA). HMA provided technical research and extensive stakeholder engagement, drafted models for forming and implementing the BHA, employed an extensive change management approach, and created a detailed implementation plan with ongoing support. Today the BHA is a cabinet member-led agency that collaborates across agencies and sectors to drive a comprehensive and coordinated strategic approach to behavioral health.
Wakely Consulting Group, an HMA Company, was engaged to support the launch of a Medicare Advantage (MA) joint venture partnership between a health plan and a provider system. Wakely was responsible for preparing and certifying MA and Medicare Part D (PD) bids, a highly complex, exacting, and iterative effort. The Wakely team quickly became a trusted advisor and go-to resource for the joint venture decision makers. The joint venture has driven significant market growth over its initial years, fueled by a competitive benefit package determined by the client product team.
In 2021 Indiana Governor Eric Holcomb appointed a 15-member commission to assess Indiana’s public health system and make recommendations for improvements. The Indiana Department of Health (IDOH) engaged HMA to provide extensive project management and support for six workstreams. HMA prepared a draft report summarizing public input as well as research findings and recommendations. The commission’s final report will form the basis of proposed 2023 legislation, including proposals to substantially increase public health service and funding across the state.
In early 2022 HMA and Wakely Consulting Group, an HMA Company, assisted multiple clients with their applications to participate in the new CMS ACO REACH model. The purpose of this model is to improve quality of care for Medicare beneficiaries through better care coordination and increased engagement between providers and patients including those who are underserved. The team tailored their support depending on each client’s needs. The application selection process was highly competitive. Of the 271 applications received, CMS accepted just under 50 percent. Notably, nine out of the 10 organizations HMA and Wakely supported were accepted into the model.
HMA, and subsidiaries The Moran Company and Leavitt Partners, were selected by a large pharmaceutical manufacturer to analyze the current pipeline of innovative therapies, examine reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process. The project equipped the client with a holistic understanding of future potential impacts and actions to address challenges in a detailed pipeline analysis of innovative therapies.
This week, our In Focus reviews the Oklahoma Medicaid managed care SoonerSelect Program request for proposals (RFP) and the SoonerSelect Children’s Specialty Program RFP released by the Oklahoma Health Care Authority (OHCA) on November 10, 2022.
Background
Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state’s 1.3 million Medicaid members are in SoonerCare Choice, a Primary Care Case Management (PCCM) program in which each member has a medical home. Other programs include SoonerCare Traditional (Medicaid fee-for-service), SoonerPlan (a limited benefit family planning program), and Insure Oklahoma (a premium assistance program for low-income people whose employers offer health insurance).
Prior efforts to transition to Medicaid managed care have encountered roadblocks, starting in 2017 with a failed attempt to move aged, blind, and disabled members to managed care.
More recently, in June 2021, the Oklahoma Supreme Court struck down a planned transition of the state’s traditional Medicaid program to managed care, ruling that the Oklahoma Health Care Authority does not have the authority to implement the program without legislative approval.
Contracts had been awarded to Blue Cross Blue Shield of Oklahoma, Humana, Centene/Oklahoma Complete Health, and UnitedHealthcare. Centene/Oklahoma Complete Health also won an award for the SoonerSelect Children’s Specialty Program.
In May 2022, Governor Kevin Stitt signed a new Oklahoma law to implement Medicaid managed care by October 1, 2023.
SoonerSelect RFP
Oklahoma will award contracts to at least three entities to provide medical, behavioral, and pharmacy coverage to nearly one million eligible children, pregnant women, newborns, parents and caretake relatives, and the expansion population. However, enrollment in these populations is expected to drop following the end of the public health emergency (PHE).
At least one of the contracts may be awarded to a provider-led entity (PLE). PLEs would need to provide proof that a majority of their ownership is held by Oklahoma Medicaid providers or the majority of the governing body is composed of individuals who have experience serving Medicaid members and are licensed providers. PLEs would also be able to bid on urban regions if the PLE agrees to develop statewide readiness within a timeframe set by the OHCA. If no PLEs meet OHCA standards, Oklahoma can choose not to award a PLE.
Goals of the program will include:
Improve health outcomes for Medicaid members and the state as a whole
Ensure budget predictability through shared risk and accountability
Ensure access to care, quality measures, and member satisfaction
Ensure efficient and cost-effective administrative systems and structures
Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.
Timeline
Proposals will be due on February 8, 2023, and contract implementation is scheduled for October 1, 2023. The contract is expected to run through June 30, 2024, with five, one-year options.
Evaluation
Bidder’s technical proposals will be scored out of a total 1550 points. OHCA will award PLEs an additional 50 points for qualifying, bringing the total up to 1600 points. OHCA may also choose to conduct oral presentations for an extra total of 50 points.
SoonerSelect Children’s Specialty Program RFP
Oklahoma will select one of the awarded SoonerSelect plans for a separate statewide contract to provide comprehensive integrated health coverage to foster children, former foster children up to 25 years of age, juvenile justice-involved children, and children receiving adoption assistance. Contract terms will be the same as the main SoonSelect procurement, running from October 1, 2023, through June 30, 2024, with five one-year renewal options.
