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Blog

Policy and operational implications of the Change Healthcare cyberattack

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This week, our second In Focus explores a new Issue Brief published by Leavitt Partners, a Health Management Associates, Inc. (HMA) Company, which addresses the February 21, 2024, cyberattack on Change Healthcare. The cyberattack is one of the most significant on the healthcare industry and has had short-term effects on the entire healthcare sector, with potential for longer-term impacts across the industry.  

Because of the ransomware attack, more than 100 applications were taken offline, preventing medical professionals from conducting out many patient-facing activities, including filling prescriptions, managing care plans, and performing prior authorization checks. Six weeks after the crippling cyberattack on Change Healthcare, some systems are still only partially operational and many claims remain unpaid. This situation has disrupted patient access to care and placed significant financial strain on providers. 

Change Healthcare is maintaining a daily status report on operations on their website. In addition, the Department of Health and Human Services (HHS) provided the following resource to the healthcare provider community to work with payers directly. 

With billions of dollars in loans and advance payments already disbursed and ongoing investigations into Health Insurance Portability and Accountability Act (HIPAA) violations, the healthcare industry is bracing for long-term impact, while the Administration and Congress are just beginning to act. Leavitt Partners experts, an HMA Company, is monitoring and analyzing the impacts on payers and providers, as well as current and future policy implications.  

For more information and to obtain in-depth issue briefs, including “Cyberattacks: Health Care Industry Impacts and the Federal Response,” contact our featured experts.

Blog

Medicaid managed care enrollment update—Q4 2023

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This week, our In Focus section reviews recent Medicaid enrollment trends in capitated, risk-based managed care in 30 states.1 Many state Medicaid agencies post monthly enrollment figures by health plan for their Medicaid managed care population on their websites. These data allow for timely analysis of enrollment trends across states and managed care organizations. All 30 states highlighted in this review have released monthly Medicaid managed care enrollment data into quarter four (Q4) of 2023. The analysis that follows reflects the most recent data posted. HMA continues tracking enrollment as states work towards concluding their Public Health Emergency (PHE) unwinding-related redeterminations and resuming normal eligibility operations. 

Health Management Associates, Inc., (HMA) has reviewed the Q4 enrollment data (see Table 1) and offers the following observations:  

  • Across the 30 states tracked in this report, Medicaid managed care enrollment declined by 7.3 percent year-over-year as of December 2023. 
  • Of the 30 states, 26 experienced decreased enrollment in December 2023, compared with the previous year, as the result of Medicaid redeterminations. 
  • A total of 23 of the states—Arizona, California, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Virginia, Washington, and West Virginia—saw net Medicaid managed care enrollment decrease by 469,000 (0.9%) to 51.5 million members at the end of Q4 2023. (Note: North Carolina expanded Medicaid in December 2023 and was added to the expansion group, in part inflating the change). 
  • The seven states that had yet to expand Medicaid as of December 2022—Florida, Georgia, Mississippi, South Carolina, Tennessee, Texas, and Wisconsin—have seen Medicaid managed care enrollment decrease 25.2 percent to 13.9 million members at the end of Q4 2023.  

Table 1. Monthly MCO Enrollment by State, October 2023−December 2023 

Note: In Table 1, “+/- m/m” refers to the enrollment change from the previous month. “% y/y” refers to the percentage change in enrollment from the same month in the previous year.

It is important to note the limitations of the data presented. First, not all states report the data at the same time during the month. Some of these figures reflect beginning of the month totals, whereas others provide an end of the month snapshot. Second, in some cases the data are comprehensive in that they cover all state-sponsored health programs offering managed care; in other cases, the data reflect only a subset of the broader managed Medicaid population, making it the key limitation to comparing the data described below and figures that publicly traded Medicaid MCOs report. Consequently, the data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than a comprehensive comparison, which cannot be developed based on publicly available monthly enrollment information. 

Expand Your Awareness about Medicaid and Medicare Advantage via HMAIS 

If you are interested in gaining access to detailed information on the Medicaid managed care landscape, an HMAIS subscription is the key to unlock important data. The HMA Information Services (HMAIS) collects Medicaid and Medicare Advantage Special Needs Plan (SNP) enrollment data, health plan financials, as well as developments on expansions, waivers, and demonstrations. Your HMAIS login also provides access to a library of public documents all in one place, including Medicaid RFPs, responses, model contracts, scoring sheets and other procurement related materials. HMAIS combines this publicly available information along with HMA expert insights on the structure of Medicaid in each state, as well as a proprietary HMA Medicaid Managed Care Opportunity Assessment. 

For information on how to subscribe to HMA Information Services, contact our featured experts.

HMA Weekly Roundup

April 17, 2024

Health Management Associates’ CEO Douglas Elwell Retiring; COO Charles (Chuck) Milligan to Lead Firm

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HMA News

Health Management Associates’ CEO Douglas Elwell retiring; COO Charles (Chuck) Milligan to lead firm

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Today, Jay Rosen, founder, president, and chairman of Health Management Associates (HMA), announced Chief Executive Officer (CEO) Douglas L. Elwell is retiring. Chief Operating Officer (COO) Charles (Chuck) Milligan will succeed him as CEO effective May 17.

Elwell assumed the role of HMA’s CEO in November 2020. He had rejoined the firm as COO in February of that year after serving as the Illinois Medicaid director. During his first tenure with HMA, Elwell was a principal and managing principal in the Indianapolis office from July 2003 through October 2014. Much of his career, prior to joining HMA, was dedicated to leading hospital systems in roles as CEO, COO, and CFO. Elwell was deputy chief executive officer for finance and strategy for the Cook County Health and Hospitals System from November 2014 until early 2019.

“Doug has been an exceptional leader, expertly guiding the expansion of HMA’s breadth and depth of expertise so we continue to meet our clients’ needs and exceed their expectations well into the future,” Rosen said. “His passion for serving our clients, supporting our colleagues, and improving the lives of others has made an indelible impact on not only our company but communities across the country.

Elwell will continue to provide consulting services as Senior Advisor to the firm.

Milligan joined HMA as COO in November 2020. A seasoned healthcare leader and consulting executive who has worked with health plans, states, and policy organizations, his contributions span both the public and private sectors.

The United States Government Accountability Office (GAO) appointed Milligan a commissioner to the Medicaid and CHIP Payment and Access Commission (MACPAC) in January 2015, and appointed him vice chairman in May 2019. He has served as the Medicaid director for two states, New Mexico and Maryland.

“Chuck has played an integral role in growing and shaping the multitude of ways we can serve clients by leveraging the varied expertise across all of the organizations within HMA,” Rosen said. “He is a trusted leader, who will spur innovation and propel our partnerships to develop solutions for the toughest healthcare and human services challenges.”

Prior to joining HMA, Milligan served as CEO for UnitedHealthcare’s Community Plan in New Mexico, with accountability for the Medicaid and DSNP lines of business in the state. He also served as interim CEO for UnitedHealthcare’s Community Plan in Maryland, and as national vice president for UnitedHealthcare’s Dual Special Needs Plans. Milligan’s career includes having been senior vice president of Enterprise Government Programs at Presbyterian Healthcare Services and executive director of The Hilltop Institute at University of Maryland, Baltimore County. He began his career as an attorney practicing healthcare law in California.

Meggan Christman Schilkie, currently senior vice president of HMA’s Practice Groups, will assume the role of COO at HMA. She joined HMA in 2014 and has held leadership roles in the firm’s Northeast Region and its New York office.

During her time at HMA, Schilkie has supported clients across the country including providers, associations, state and local governments, payers, large delivery systems and other stakeholders to expand the quality of and access to healthcare with a particular focus on developing new and innovative models of behavioral healthcare.

Prior to joining HMA, Schilkie served as chief program officer for Mental Health at the New York City Department of Health and Mental Hygiene where she oversaw a portfolio of behavioral health services. During her career she has been interim CEO for three health homes in New York serving individuals with serious behavioral health needs, chronic health conditions, intellectual and developmental disabilities and substance use disorders. Schilkie was the founding executive director of the Coalition of New York State Health Homes providing leadership for this statewide provider association.

Blog

HMA offers a new approach to grant funding for behavioral health providers

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Grants from both government and foundations can be an essential component of a community behavioral health provider’s growth strategy. Every year billions of dollars are distributed to support program growth, quality improvement, training, and other essential needs. Finding the right opportunities and applying for grants that are aligned with your organization’s strategic growth interests can be an essential catalyst for organizational development, service continuum growth, and quality improvements.

Behavioral health providers often struggle with identifying and applying for the right grant opportunities. It is time consuming and takes resources away from your mission to serve your communities. The deluge of notices of funding opportunities, requests for proposals, requests for applications, and requests for expressions of interest can overwhelm even the most sophisticated and well-resourced provider. Few organizations have the internal capacity to devote to wading through the hundreds of opportunities that are published each week.

That is why we created HMA Grant Prospector. HMA will do the work, so you don’t have to.

The HMA Grant Prospector is a tool that combines HMA’s deep subject matter expertise in community behavioral health care with understanding of the process of grant procurement. We have embedded this expertise in proprietary software that can sift through grant opportunities and pick out the gold nuggets from the mountain of information.

When your organization subscribes to Grant Prospector, we interview you to find out what services you have, the communities you serve, and what gaps in your care continuum you seek funding to fill. We collect information on grant opportunities as they are released, and the Grant Prospector matches your organization’s criteria with funding opportunities. We’ll send you only those opportunities for which your organization is eligible, that are aligned with your strategy and organizational objectives, and targeted to your population. You can rely on HMA to do the legwork so you can focus your efforts on improving lives in your community.

CLICK HERE TO LEARN MORE ABOUT THIS SERVICE

“HMA has helped us quickly and easily identify the best opportunities for grants for Horizon Health Services. With their help, we have been able to find the right opportunities, apply with precision, and expand our service continuum.”

– Erin DiGirolamo, CEO and Brandy Vandermark-Murray, President, Horizon Health Services, Buffalo, NY

Blog

Announcing HMA’s new VBP readiness assessment tool for behavioral health providers

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Dollars and Sense: Is Your Organization Positioned to Thrive in the World of Value-Based Payments?

As the healthcare system in the U.S. moves away from the costly and inefficient framework of fee-for-service to patient-centered structures focused on value and quality, every Behavioral Health organization finds itself with challenges ahead. Whether your organization stands at the forefront, poised for a full dive into value-based payment implementation, or is tentatively exploring initial steps, understanding your organization’s readiness on the VBP spectrum is paramount to success. Health Management Associates (HMA) is helping provider organizations in every phase of readiness move forward. We understand the detailed steps to help you focus on value, change payment structures, adapt clinical and operation workflows, and prepare and train your workforce to improve quality. Our tool is not just a promise but a practical solution to assess your current organizational readiness, providing valuable insights to focus your attention toward the next level of value.

VBP Readiness Assessment Tool

HMA’s VBP Readiness Assessment is a free, online survey tool that can help you gauge your organization’s preparedness across six pivotal domains of core functions necessary for successful participation in payment reform models. Completing the survey will provide a snapshot about a single provider or an entire organization and determine where you stand on the value-based payment spectrum.  The six domains encompass measuring outcomes, evaluating board and leadership readiness, assessing technological capabilities for capturing and sharing data, gauging partnerships, payer engagement strategies, and financial alignment.

Readiness Assessment Results

VBP graphic 1
VBP graphic 2

Example plot of a readiness assessment showing an organization’s scores on the VBP spectrum.
This organization has an overall Intermediate level of readiness with the highest levels demonstrated in
Board & Leadership Readiness and Partnership and lowest levels in Financial Readiness.

The journey toward successfully navigating the realm of value-based payments demands a strategic and informed approach. The crucial first step is a comprehensive assessment of organizational readiness, and the HMA VBP Readiness Assessment Tool stands as a valuable resource for this purpose. The ever-changing landscape of healthcare payments requires organizations to be adaptive and forward-thinking. With HMA’s team of experts offering guidance at every stage, providers, associations, health plans, and states can gain a profound understanding of the necessary organizational efforts required to engage in VBP successfully. The current landscape increasingly emphasizes value, therefore, the importance of transitioning from fee-for-service to value-based models cannot be overstated. As the demand for value continues to grow, organizations that proactively position themselves to meet these evolving expectations will not only thrive but contribute significantly to shaping the future of healthcare delivery. The HMA VBP Readiness Assessment Tool is not just a survey; it’s a compass guiding you through the dynamic terrain of value-based payments, serving as a way to identify meaningful progressive steps you can take to strengthen your organizational position within the VBP space.

Taking the survey and receiving one analyzed response is free, but you may find value in contracting with HMA for a more in-depth analysis of your organization. Click below for more details and to access the survey.

learn more about the Assessment Tool

For more information, please contact our featured experts.

Blog

Medicaid managed care final rule: what to watch for

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Our second In Focus section provides a refresher on the Medicaid and Children’s Health Insurance Program managed care access, finance, and quality proposed rule that the Centers for Medicare & Medicaid Services (CMS) published in May 2023. As Health Management Associates, Inc. (HMA), has noted, the final rule is expected to be published later this month. If finalized as proposed, several provisions in the rule will signal the start of a new era of accountability and transparency for the Medicaid program. 

The policy changes are expected to fall into the following major categories: in lieu of services (ILOS), the Medicaid and CHIP Quality Rating System (MAC QRS), medical loss ratios (MLRs), network adequacy, and state directed payments (SDPs). These revised policies will affect Medicaid coverage and reimbursement for years to come. Following is a summary of the proposed policy changes to watch for in the final rule.  

ILOS 

CMS has proposed to expand upon and codify the sub-regulatory guidance around ILOS outlined in State Medicaid Director Letter #23-001. The letter advised state that they have the option to use the ILOS authority in Medicaid managed care programs to reduce health disparities and address unmet health-related social needs, such as housing instability and nutrition insecurity. The final rule would expand upon and codify that guidance. 

For example, although the ILOS proposal adds reporting requirements and guardrails to address fiscal accountability, the proposed rule also noted that the substitution of an ILOS for a state plan service or setting should be cost-effective but does not need to meet budget neutrality requirements. States are also permitted to specify that an ILOS can be an immediate or longer-term substitute for a state plan service or setting. 

MAC QRS 

CMS has proposed a MAC QRS framework that includes: (1) mandatory quality measures, (2) a quality rating methodology, and (3) a mandatory website display format. State Medicaid agencies and managed care organizations (MCOs) will be required to adopt and implement the MAC QRS framework that CMS develops or adopt and implement an alternative but equivalent managed care quality rating system. CMS will update the mandatory measure set at least every two years. Any planned modifications to measures will be announced publicly through a call letter or similar guidance, with measures based on: (1) value in choosing an MCO; (2) alignment with other CMS programs; (3) the relationship to enrollee experience, access, health outcomes, quality of care, MCO administration, or health equity; (4) MCO performance; (5) data availability; and (6) scientific acceptability. 

State Medicaid agencies will be required to collect from MCOs the data necessary to calculate ratings for each measure and ensure that all data collected are validated. In addition, state Medicaid agencies will be expected to calculate and issue ratings to each MCO for each measure. 

Lastly, state websites will be required to contain the following elements: (1) clear information that is understandable and usable for navigating the website itself; (2) interactive features that allow users to tailor specific information, such as formulary, provider directory, and ratings based on their entered data; (3) standardized information so that users can compare MCOs; (4) information that promotes beneficiary understanding of and trust in the displayed ratings, such as data collection timeframes and validation confirmation; and (5) access to Medicaid and CHIP enrollment and eligibility information, either directly on the website or through external resources. 

MLRs 

CMS has proposed three areas for revision to its existing MLR standards, which require MCOs to submit annual MLR reports to states, which, in turn, must provide CMS with an annual summary of those reports. Areas for revision include: (1) requirements for clinical or quality improvement standards for provider incentive arrangements, (2) prohibited administrative costs in quality improvement activity (QIA) reporting, and (3) additional requirements for expense allocation methodology reporting. 

With regard to provider incentive arrangements, CMS proposes to require that contracts between MCOs and providers: (1) have a defined performance period that can be tied to the applicable MLR reporting period(s), (2) include well-defined quality improvement or performance metrics that the provider must meet to receive the incentive payment, and (3) specify a dollar amount that can be clearly linked to successful completion of these metrics as well as a date of payment. MCOs would be required to maintain documentation that supports these arrangements beyond attestations. 

In terms of QIA reporting, CMS proposes to explicitly prohibit MCOs from including indirect or overhead expenses when reporting QIA costs in the MLR. CMS also intends to add requirements regarding how MCOs can allocate expenses for the purpose of calculating the MLR by requiring MCOs to offer a detailed description of their methodology. 

Network Adequacy 

CMS has proposed a range of new network adequacy requirements intended to improve timely access to care for managed care enrollees. Those related to appointment wait time standards and secret shopper surveys are among the most prominent. 

For appointment wait time standards, CMS proposes that state Medicaid agencies develop and enforce wait times associated with routine appointments for four types of services: (1) outpatient mental health and substance use disorder (SUD) for adults and children, (2) primary care for adults and children, (3) obstetrics and gynecology (OB/GYN), and (4) an additional service type determined by each state Medicaid agency using an evidence-based approach. The maximum wait times must be no longer than 10 business days for routine outpatient mental health and SUD appointments and no more than 15 business days for routine primary care and OB/GYN appointments. State Medicaid agencies could impose stricter wait time standards but not more lax ones. The wait time standard for the fourth service type will be determined at the state level. 

State Medicaid agencies also will be required to engage an independent entity to conduct annual secret shopper surveys to validate MCO compliance with appointment wait time standards and the accuracy of provider directories to identify errors, as well as providers that do not offer appointments. For an MCO to be compliant with the wait time standards, as assessed through the secret shopper surveys, it would need to demonstrate a rate of appointment availability that meets the wait time standards at least 90 percent of the time.  

SDPs 

CMS has proposed several important changes to the requirements governing the use of SDPs, strengthening both the accountability required of and flexibility afforded to states. For example, CMS proposes to require that provider payment levels for inpatient and outpatient hospital services, nursing facility services, and the professional services at an academic medical center not exceed the average commercial rate. Furthermore, states would be required to condition SDPs upon the delivery of services within a contract rating period and prohibited from using post-payment reconciliation processes. 

With regard to flexibility, CMS proposes to remove unnecessary regulatory barriers to support the use of SDPs by states to implement value-based payment arrangements and include non-network providers in SDPs. The proposal also permits states to implement, without prior approval, minimum fee schedules in Medicaid consistent with Medicare provider rates. 

What’s Next  

CMS is expected to publish the final rule in April. In addition, CMS plans to publish a separate final rule addressing new regulations pertaining to access to care, which will have equally significant impacts on states, MCOs, and providers. If you have questions about how HMA can support your efforts related to the managed care final rule’s implications and the context of other federal regulations for states, MCOs, or providers, contact our featured experts.

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CMS finalizes major changes to Medicare Advantage and Part D for 2025

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This week, our In Focus section reviews a wide-ranging and comprehensive final rule released April 4, 2024, by the Centers for Medicare & Medicaid Services (CMS). The regulation revises and updates policies that affect Medicare Advantage (MA) and Medicare Part D coverage beginning in the upcoming plan year. 

The policies adopted in the final rule aim to strengthen consumer protections and guardrails, promote fair competition, and ensure MA and Part D plans can best meet the healthcare needs of Medicare beneficiaries, including individuals dually eligible for Medicare and Medicaid. In addition, the final rule includes important new policies to expand access to behavioral health providers, promote equity in healthcare coverage, and improve access to and use of Medicare Advantage supplemental benefits. These policy changes complement payment policy changes that were recently finalized in the April 1, 2024, CMS CY 2025 Rate Announcement and will take effect June 3, 2024.  

Below HMA experts walk through the major policies CMS finalized. 

Expanding Access to Behavioral Health Providers 

CMS finalized several regulatory changes to improve Medicare beneficiaries’ access to behavioral health services through strengthened MA network adequacy standards. These changes include: 

  • Establishing network evaluation standards for a new facility-specialty provider category, called outpatient behavioral health. This category includes a range of behavioral health providers, including marriage and family therapists (MFTs), mental health counselors (MHCs), opioid treatment programs, community mental health centers, addiction medicine specialists and facilities. Outpatient behavioral health will be included in network adequacy evaluations. 
  • Permitting MFTs and MHCs to enroll and start billing Medicare—as a result of statutory changes established in the Consolidated Appropriations Act (CAA) of 2023—and establishing corresponding changes to network adequacy standards for MA plans. 
  • Requiring MA plans to independently verify that behavioral health providers added to their network furnish services to at least 20 patients within a 12-month period. 
  • Adding outpatient behavioral health facility-specialty to the list of the specialties that will receive a 10 percent credit toward meeting network adequacy time and distance standards. 

Impact: Adding the outpatient behavioral health category is expected to enhance Medicare beneficiaries’ access to a broader scope of behavioral health specialists. As result of the new policy and network expectations, MA plans may need broaden their networks, and providers that contract with MA plans may need to strengthen their capacity to address Medicare billing and reporting requirements, including quality reporting initiatives.  

Require Mid-Year Enrollee Notification of Supplemental Benefits 

The number of MA plans that offer supplemental benefits to beneficiaries is increasing, with the most frequently offered supplemental benefits including coverage for vision, dental, and hearing services.  Moreover, many MA plans also are offering supplemental benefits to address unmet social determinants of health needs, including home meal delivery, transportation, and in-home services and supports. At the same time, use of these benefits is reportedly low, and there are gaps in research and data analysis about how these benefit offerings are affecting beneficiaries’ cost and health outcomes.   

As a result, CMS is finalizing policies that require MA plans to engage in outreach to beneficiaries. Specifically, the final rule requires MA plans to send enrollees a mid-year notification regarding their unused supplemental benefits. The notification must include information on the scope of the benefit, patient cost-sharing, and detailed instructions on how beneficiaries can access their unused benefits.  

Impact: This change is intended to improve beneficiary awareness of plans’ supplemental benefit offerings and encourage greater use of these benefits. As a result of the regulatory changes, MA plans may look to further refine and adjust their MA supplemental benefit offerings to further improve the healthcare experience for Medicare beneficiaries. 

New Standards for Supplemental Benefits under SSBCI 

MA plans also offer supplemental benefits to beneficiaries through the Special Supplemental Benefits for the Chronically Ill (SSBCI) program, whereby people with ongoing and complex chronic conditions can receive supplemental benefits that are tailored to their specific health and social needs. In the final rule, CMS establishes new requirements for MA plans to demonstrate the value of these services by submitting evidence that the item or service will improve or maintain the overall health of chronically ill beneficiaries.   

Impact: This new reporting requirement is intended to ensure that SSBCI items and services are evidence-based and meaningful. As these regulatory changes are implemented under tight timelines, plans will need to move quickly to compile clinical data and evidence on the effectiveness of these targeted benefits, while also considering changes in their benefit offerings to better meet the needs of beneficiaries with complex and chronic conditions. 

MA Star Rating Changes 

In the final rule, CMS describes its ongoing work to streamline quality measures, including the agency’s progress in moving toward the Universal Foundation of core quality measures that are aligned across CMS’s quality and value-based programs. CMS notes that MA plans are beginning to report additional measures that are part of the Universal Foundation. Under previous regulations, CMS proposed to make the following changes to specific measures in the Star Ratings system: 

  • Remove the standalone Part C medication reconciliation post-discharge measure
  • Add the updated Part C colorectal cancer screening measure with the NCQA (National Committee for Quality Assurance) specification change 
  • Add the updated Part C care for older adults−functional status measure with the NCQA specification change. 

Impact: These changes build on earlier CMS efforts to improve the Star Rating system, including adding a health equity index and reducing the weight of patient experience and access measures to better align with the CMS Quality Strategy. 

Ensure More Dual-Eligible Managed Care Beneficiaries Receive Medicare and Medicaid Services from the Same Organization 

CMS finalized several significant changes designed to improve access to integrated care for dually eligible beneficiaries, including the following:  

  • CMS is limiting enrollment in certain Dual Eligible Special Needs Plans (D-SNPs) to individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO).  
  • CMS also limits the number of D-SNP benefit packages that an MA organization can offer in the same service area as an affiliated Medicaid MCO. If a state Medicaid agency requires it, MA plans may offer more than one D-SNP for full-benefit dually eligible individuals in the same service area as the MA organization’s affiliated Medicaid MCO.  
  • Dually eligible beneficiaries will have an opportunity to enroll in an integrated D-SNP monthly under a new integrated care special enrollment period (SEP). 
  • CMS is lowering the D-SNP look-alike threshold from 80 percent to 70 percent for plan year 2025 and to 60 percent for plan year 2026 and into the future.  

Impact: These are considerable changes that are designed to increase the percentage of dually eligible beneficiaries enrolled in MA plans that also are contracted to cover Medicaid benefits. In addition, these changes will expand access to integrated member materials, unified appeals processes across Medicare and Medicaid, and continued beneficiary access to Medicare services during an appeal.  

Require Health Equity Assessments of Utilization Management Practices and Procedures 

CMS finalized several regulatory changes to the composition and responsibilities of MA plans’ utilization management (UM) committees, including the following:  

  • At least one member of the UM committee must have expertise in heath equity. 
  • The UM committee must conduct an annual assessment of UM practices and procedures on health equity, with a particular focus on the impact on beneficiaries who are low-income, dually eligible for Medicare and Medicaid, or have a disability. 
  • MA plans must make the health equity analysis publicly available on the plan’s website. 

Impact: These policy changes are aimed at assessing the impact of utilization management through a health equity lens and ensuring that these policies and procedures do not have a disproportionate impact on access to medically necessary care for underserved populations.  

Other Provisions 

The final rule makes several other notable regulatory changes to MA and Part D, which include: 

  • Allowing Part D plans to substitute biosimilars for the reference biologic product during the plan year as part of formulary maintenance changes, which is expected to expand access to lower cost biosimilars for Medicare beneficiaries  
  • Limiting out-of-network cost sharing for D-SNP PPOs 
  • Standardizing the MA risk adjustment data validation appeals process 
  • Establishing new guardrails for plan compensation to agents and brokers to prevent anti-competitive steering of beneficiaries and new requirements to third-party marketing organizations   
  • Changes to Medicare Part D medication therapy management (MTM) eligibility criteria 

What’s Next  

CMS continues its work to incorporate requirements for consumer engagement and transparency of data to address health equity. This final rule is poised to have a significant impact on plan benefit design and the landscape of health insurance markets in states and regions of states. CMS has created additional opportunities for states to advance integrated care initiatives that align with Medicaid, which will have downstream implications for MA and Medicaid plans, providers, and partnering organizations.  

The Health Management Associates team will continue to analyze and assess these regulatory changes that CMS has finalized. We have the depth, experience, and expertise to assist in tailored analysis and model policy impacts of the recently finalized changes.  For more information or questions about the policies described, contact our featured experts.

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Opportunities for expanding and enhancing certified community behavioral health clinics

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Opportunities related to Certified Community Behavioral Health Clinics (CCBHCs) continue to expand for both states and providers. With this increased investment in the model comes the need for continued refinement and improvement. CCBHCs enable government and other payors and providers to increase capacity and move towards a transformed behavioral health system that is responsive to local community needs. This article summarizes a number of new developments that will impact CCBHCs, including a few opportunities for expansion that you may not want to miss.

Background

CCBHCs provide integrated and coordinated community-based care for individuals across the lifespan who are living with and/or at risk for behavioral health conditions. The model is designed to increase access to behavioral health services; provide a comprehensive range of services, including crisis services, that respond to local needs; incorporate evidence-based practices; and establish care coordination as a linchpin for service delivery. To date, CCBHCs have demonstrated positive outcomes, such as: [i]

  • Significant reductions in client hospitalizations
  • Increased access to high quality community-based care, including services like Medication Assisted Treatment and care coordination
  • Mitigation of the challenges related to the national health care workforce shortage
  • Innovative and strengthened partnerships with cross-system partners, such as law enforcement, schools, and hospitals

SAMHSA CCBHC Demonstration Grant Opportunity Releases for States

Earlier this month, SAMHSA released its CCBHC Demonstration Program opportunity for states who currently or have previously held a CCBHC Planning Grant. The Demonstration RFP (request for proposals) will allow selected states to initiate a CCBHC Demonstration Program starting on July 1, 2024. In 2016, Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania were selected by the U.S. Department of Health and Human Services (HHS) to participate in the initial CCBHC Demonstration Program. In August 2020, Kentucky and Michigan were selected as two new CCBHC Demonstration States through the Coronavirus Aid, Relief, and Economic Security Act (P.L. 116-136). Through this most recent 2024 CCBHC Demonstration opportunity, SAMHSA will select up to 10 additional states to participate in the CCBHC Demonstration, as outlined by the Bipartisan Safer Communities Act of 2022 (P.L. 117-259).

For those interested in this RFP:

  • Eligibility: States selected for the 2016 or 2023 CCBHC Planning Grant (that are not currently participating in the Demonstration Program) are eligible to apply for this RFP.
  • Due Date: Applications are due March 20, 2024, at 11:59pm EST and must be submitted by email to [email protected]. Awarded states will be announced in June 2024.  
  • Evaluation Criteria: As outlined in the Protecting Access to Medicare Act (PAMA) of 2014, state applications will be scored on their ability to:
    • Provide the most complete scope of services
    • Improve availability of, access to, and participation in, CCBHC services
    • Improve availability of, access to, and participation in assisted outpatient mental health treatment in the state
    • Demonstrate the potential to expand available mental health services in a demonstration area and increase the quality of such services without increasing net federal spending

For additional context and background on this opportunity, HMA and the National Council hosted a webinar on October 6, 2022, on “Developing a Strategy for the CCBHC State Demonstration RFP.” During this webinar, we engaged representatives from New York and Michigan to share information about their demonstration program implementation to date.

Other CCBHC Updates of Note

In addition to this state Demonstration RFP, there have been several recent updates to CCBHC-related guidance documents that are worth noting for anyone who is currently participating and/or interested in the CCBHC model:

Updates to the Prospective Payment System (PPS) Guidance

Under the state CCBHC Demonstration Program, CCBHCs are paid a daily or monthly Prospective Payment System (PPS) rate. In 2023, in preparation for issuing an updated guidance, CMS held a forum for states, providers, and other stakeholder input on newly proposed PPS changes. In February 2024, the updated PPS Guidance was released, reflecting gathered feedback incorporating payment flexibilities and alignment with revisions to the CCBHC criteria. One major change was the addition of two PPS options for states, which addresses the high-cost and specialized care delivered through mobile and on-site crisis intervention services provided directly to individuals. Specifically:

  • PPS-3 offers states the option to reimburse CCBHCs on a daily basis, including daily Special Crisis Services rates, which allow states to set separate PPS rates for crisis services provided by CCBHCs.
  • PPS-4 offers states the option to reimburse CCBHCs on a monthly basis, including monthly Special Crisis Services rates. Quality Bonus Payments are also required under this PPS-4 structure.

Additionally, the metrics for Quality Bonus Payments (which are required as part of the PPS-2 and PPS-4 monthly rate structures and optional for the PPS-1 and PPS-3 daily rate structures) have been modified to align with the revised CCBHC Quality Metrics. Additionally, CMS added new guidance related to payments to CCBHCs that are also certified as FQHCs (Federally Qualified Health Centers) and other provider types operating within the Medicaid program.

Overall, this updated PPS Guidance is effective on or after January 1, 2024 for existing CCBHC Demonstration States and on or after July 1, 2024 for newly selected states added to the program under the above CCBHC Demonstration Program RFP.

CCBHC Quality Metrics: Final Specifications Released

Further, when SAMHSA revised the CCBHC criteria in March of last year, they also updated the required and optional quality measures for both CCBHC providers and states operating a Demonstration program. The revised guidance specifies that all CCBHCs, including those participating in a State Demonstration Program as well as providers funded by a SAMHSA CCBHC Grant, must begin collecting and reporting on the required provider-specific measures starting in calendar year 2025. Similarly, states participating in the CCBHC Demonstration Program must transition to reporting on the new state-specific measures as well, with their first measurement year for the new measures running from January 1, 2025 – December 31, 2025.

Earlier this month, SAMHSA released the final specifications for each of the required and optional CCBHC quality measures. Providers and states alike are currently working hard to prepare their quality processes and systems to report on these new measures. With the inclusion of SAMHSA-funded CCBHCs in these quality measure reporting requirements, the hope is that the expanded data will assist us all in better understanding the impact of the CCBHC initiative as it relates to access to care and outcomes.

Guidance for States on CCBHC Criteria Customizations

Finally, SAMHSA recently released updated guidance for states looking to customize the federal CCBHC criteria as part of their CCBHC Demonstration Programs, to align with updates they made to the federal criteria in March of 2023. The guidance outlines, for a variety of criteria, how states may add or customize the requirements. Importantly, all CCBHCs operating either under a SAMHSA CCBHC Grant Program or a state-run CCBHC Demonstration Program must meet all of the revised federal CCBHC Criteria on or before July 1, 2024. Building on the federal criteria, many states are strategically taking advantage of customization opportunities to better align the CCBHC model with their system-wide goals and address gaps within their current behavioral health system’s capacity.

Upcoming opportunities for CCBHC expansion

In addition, there are several upcoming opportunities on the horizon for both states and providers looking to enter the CCBHC space.

New CCBHC-Expansion Grants for Behavioral Health Providers

SAMHSA’s Fiscal YeaGr 2024 budget requested $552.5 million for the CCBHC Expansion Program, which is a $167.5 million increase above the FY 2023 enacted level. The CCBHC-Expansion Grant Program includes both “Improvement and Advancement” grants for existing CCBHCs looking to enhance their programs, as well as “Planning, Development, and Implementation” grants for providers looking to establish a new grant-funded CCBHC.

SAMHSA’s FY24 funding will support 360 continuation grants, as well as award a new cohort of 158 grants, and a technical training assistance center grant to continue the improvement of mental disorder treatment, services, and interventions for children and adults. The budget also proposes to establish “an accreditation process [that] would ensure consistent adherence to the CCBHC model and create capacity to confirm adherence to the criteria and the model.”

While the new CCBHC-Expansion Grant RFPs are not currently posted on SAMHSA’s list of projected RFPs, we can expect (based on prior rounds) they are likely to be released sometime in the spring.

Expected Upcoming CCBHC Planning Grant for States

In addition to seeding the selection of a new cohort of 10 states to participate in the CCBHC Demonstration Program starting through the above Demonstration Program RFP and then every two years thereafter, the 2022 Bipartisan Safer Communities Act also earmarked funding for SAMHSA Planning Grants to support states looking to join the Demonstration. For states who are not selected to participate in the CCBHC Demonstration Program starting on July 1, 2024, we expect another CCBHC Planning Grant RFP to be released in the fourth quarter of this calendar year, with another round of 15 Planning Grants to be awarded to selected states in 2025.

States looking to prepare for the next Planning Gant RFP can review HMA’s summary of the most recent Planning Grant opportunity and watch HMA’s webinar co-hosted with the National Council for Mental Wellbeing that provides an overview of the previous RFP.

Interested in Learning More?

Reach out to our experts! HMA offers a deeply informed yet neutral perspective on CCBHC development, with team members who specialize in operations, quality, and fiscal components of the CCBHC model. We have helped 17 states successfully write their CCBHC Planning Grant applications, and in 2023 alone, we helped behavioral health providers secure approximately $80 million in expansion grant funding they are using to support their communities. Our team of experts brings extensive experience supporting both states and providers to leverage the CCBHC model to support their overall system transformation goals.

Click here to learn more about our work with CCBHCs or contact our featured experts.

[i] https://www.thenationalcouncil.org/wp-content/uploads/2022/06/22.06.06_HillDayAtHome_CCBHC_FactSheets.pdf

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Substance Use Disorder (SUD) Ecosystem of Care Webinar Series: Pivoting to Save Lives

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Over the coming weeks, HMA is presenting a 3-part webinar series describing a whole person, integrated, solutions-based approach to the ongoing overdose epidemic. It is time to reconsider standard attempts to solve this crisis. Leaders need to be willing to pivot away from approaches that have not yielded the level of impact that this crisis demands, and to be ready to try new ideas and solutions.

“An ideal Ecosystem of Care is person-centered, and parts of the system work together to eliminate stigma, overcome barriers, and prevent people from falling through the cracks that are currently pervasive,” says Dr. Jean Glossa, Managing Director. “Stakeholders participating in SUD care, prevention, and treatment may need to expand their services and work together with other partners in ways they have not before.” 

Each webinar in this series will share HMA’s nuanced understanding of the many paths available for those seeking recovery or a different relationship to addictive behaviors. Experts in the field will share valuable insights, shedding light on the various interventions and strategies that contribute to a holistic and effective approach to supporting individuals on their journey to lasting recovery. Whether you are a healthcare professional, caregiver, or someone personally affected by substance use, this webinar offers a roadmap for navigating the complexities of the Substance Use Care Continuum, fostering hope and resilience in the pursuit of sustained well-being.

By attending this series of webinars, you will learn how to:

  • Describe ongoing overdose crisis as a national public health emergency.
  • Recognize where certain solutions didn’t create the desired impact.
  • Consider new approaches and solutions to overcome ingrained stigma.

Part 1: Overview and The Role of Health Promotion and Harm Reduction Strategies
Part 2: Empowering Change in the SUD Ecosystem
Part 3: Building Systems-Thinking in the SUD Ecosystem

HMA expert consultants have deep expertise, and professional on-the-ground lived experience, with supporting efforts nationwide to build an evidence-based, patient-centered, and sustainable addiction treatment ecosystem. No matter the scope or size of the project, HMA has experience working with states, and community organizations to develop impactful, sustainable responses to SUD. Our team is ready to help clients create, disseminate, and implement actionable and sustainable programs, to address substance use, overdose, and addiction.

Check out these related resources:

If you have other questions or want to speak to someone about how HMA can help your organization with some of these ideas, please contact our featured experts.

Webinar

Webinar replay: Equity considerations for addressing opioid use disorder

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This webinar was held on April 23, 2024.

This webinar examined three projects that demonstrate how HMA partnered with states and counties to address opioid use disorder with an equity focus. HMA experts were joined by representatives from partner organizations to discuss their efforts to reduce disparities, which have been trending upward nationally, in opioid use disorder prevalence and overdose deaths—whether it be in brown and black communities or with pregnant and parenting people.

The learning objectives covered in this webinar included sharing how states could implement strategies to engage non-traditional partners to address equity; highlighting the critical role of partnering with community organizations and community leaders in addressing inequities in substance use disorder (SUD); and discussing how HMA could support states, counties, and municipalities in these efforts.

Speakers: