HMA has published a white paper examining the use of risk mitigation strategies among state Medicaid programs and assessing their limiting impact on capitation’s incentives for managed care organizations (MCOs). This paper seeks to assist policymakers in designing future Medicaid program payment policies that advance state financial and programmatic goals. This paper offers a timely examination of this topic as state Medicaid programs emerge from the COVID-19 public health emergency (PHE) and navigate the unwinding of Medicaid continuous coverage. This paper also builds upon the Health Management Associates May 2021 white paper, Moving Beyond COVID-19 Public Health Emergency Risk Corridors, which more narrowly focused on appropriate and inappropriate use of risk corridors.
997 Results found.
Health Management Associates selected as CalAIM Technical Assistance vendor
One of only two firms selected in all seven domains out of 46 vendors.
The California Department of Health Care Services (DHCS) has developed a multi-year initiative whose goal is to improve health outcomes and health care quality through broad delivery, payment, and program reforms known as California Advancing and Innovating Medi-Cal (CalAIM). This includes the introduction of new programs and changes to existing programs that will occur over the span of five years. CalAIM further expands upon prior initiatives, such as Whole Person Care, the Health Homes Program, and the Coordinated Care Initiative, and strives to integrate California’s delivery systems to better facilitate the overall Medi-Cal program.
With the rollout of these programs and the vast requirements associated with them, DHCS and California’s Medi-Cal managed care health plans are now tasked with the challenge of implementing CalAIM and enabling the participation of community providers and partners in these opportunities. To support these partners, DHCS developed a funding initiative, known as Providing Access and Transforming Health (PATH) to aid in strengthening capacity and infrastructure of Community Based Organizations, public hospitals, county agencies, and others to stand up CalAIM. This five-year, $1.85 billion initiative includes the creation of a virtual Technical Assistance (TA) Vendor Marketplace that organizations can use to request resources and support from approved vendors through services that are fully paid for by the State.
Health Management Associates (HMA) is recognized as a valued partner to Payers, Community Based Organizations, public hospitals, and county agencies and has deep expertise in CalAIM policy, operations and implementation. Recognized for our extensive capabilities in the field, HMA is one of only two firms out of 46 vendors that received State approval to serve as a technical assistance vendor on the PATH Technical Assistance (TA) Marketplace for all seven domains:
- Domain 1: Building Data Capacity: Data Collection, Management, Sharing, and Use
- Domain 2: Community Supports: Strengthening Services that Address the Social Drivers of Health
- Domain 3: Engaging in CalAIM Through Medi-Cal Managed Care
- Domain 4: Enhanced Care Management (ECM): Strengthening Care for ECM Population of Focus
- Domain 5: Promoting Health Equity
- Domain 6: Supporting Cross-Sector Partnerships
- Domain 7: Workforce
HMA also has expertise in and hands-on experience with addressing the unique challenges experienced by providers and partner agencies serving rural communities. Please visit the PATH Technical Assistance (TA) Marketplace to access TA resources that can help strengthen capacity to provide high quality Enhanced Care Management (ECM) and Community Supports services for Medi-Cal members.
New Hampshire releases Medicaid managed care RFP
This week, our In Focus section reviews the New Hampshire Medicaid Care Management (MCM) request for proposals (RFP), which the state’s Department of Health and Human Services released on September 8, 2023. The new contracts will be worth approximately $1.1 billion and will provide full-risk, fully capitated Medicaid managed care services to approximately 190,000 beneficiaries. Implementation will begin September 2024.
MCM Program
The MCM program covers traditional Medicaid, the Children’s Health Insurance Program (CHIP), and the state’s adult Medicaid expansion Granite Advantage Health Care Program. MCM provides integrated acute care, behavioral health, and pharmacy services. Managed long-term services and supports are not included in the program.
Incumbents are AmeriHealth Caritas, Boston Medical Center/WellSense, and Centene/New Hampshire Healthy Families.
RFP
New Hampshire will award contracts to three Medicaid managed care organizations (MCOs). MCOs will cover the populations outlined in Table 1.
Table 1. New Hampshire MCM Program Enrollment as of July 1
The state outlines several key areas of focus within the RFP, including introducing a primary care and preventive services model of care—an approach centered on patient-provider relationships and provider-delivered care coordination. The RFP also will have a greater emphasis on priority populations, such as individuals with inpatient admissions for behavioral health diagnoses; children in the child welfare system; babies with low weight or neonatal abstinence syndrome; and people who are incarcerated and eligible for the Community Reentry demonstration program, pending approval from the Centers for Medicare & Medicaid Services.
Timeline
Mandatory letters of intent are due September 18, 2023, and a mandatory conference will take place September 21. Proposals are due October 30, 2023. An award date has yet to be announced, but the state contract discussions with selected MCOs will occur November 20−December 11, 2023. Contracts will run from September 1, 2024, through August 31, 2029.
Evaluation
MCOs will be scored on their ability to meet a possible 2,160 points. The technical proposal comprises a possible 1,510 points, as shown in Table 2.
Table 2. Technical Proposal Scoring
The cost component sections will make up 650 points, as shown in Table 3.
Table 3. Cost Component Scoring
September 13, 2023
New Hampshire Releases Medicaid Managed Care RFP
Virginia releases Cardinal Care Medicaid managed care RFP
This week, our In Focus section reviews the request for proposals (RFP) for the Virginia Cardinal Care Medicaid managed care program, released by the Department of Medical Assistance Services (DMAS) on August 31, 2023. The RFP includes a new foster care specialty plan. Implementation is scheduled to begin July 1, 2024.
Cardinal Care
Cardinal Care launched in January 2023 as a rebranding of the state’s Medicaid program and Children’s Health Insurance Program—Family Access to Medical Insurance Security Plan (FAMIS). Cardinal Care Managed Care (CCMC) will combine the state’s existing Medallion 4.0 managed care program for traditional Medicaid and the Commonwealth Coordinated Care Plus (CCC Plus) managed long-term services and supports (MLTSS) program to serve 1.9 million Medicaid managed care members.
RFP
The state will award statewide fully capitated, risk-based contracts to a maximum of five health plans. A separate foster care specialty plan contract will also be awarded to one of the winners. If none of the plans win the separate foster care specialty program, all plans awarded a CCMC contract will be required to cover all services.
Selected plans will provide acute care, behavioral health, and MLTSS services to all Virginians who are eligible for Medicaid, including children, adults, and pregnant women in low-income households; children and adults with disabilities; low-income older adults; and individuals receiving LTSS, including dual-eligible populations. The foster care plan will cover children in foster care, individuals younger than 26 years old who were formerly in foster care, and children eligible for adoption assistance.
The RFP contains several targeted focus areas and changes to the managed care program. For example, it emphasizes improvements to the state’s behavioral health care system and improved health outcomes through a focus on health-related social needs such as housing stability and food insecurity for CCMC members.
Contracted plans will be required to operate a dual-eligible special needs plan (DSNP) in Virginia.
Market
CVS/Aetna, Elevance/Anthem, Sentara/Optima Health, Molina, and UnitedHealthcare are the current incumbents. Effective with the new RFP, DMAS intends to reassign most CCMC members as part of an enrollment process. At present, Optima holds the largest market share of enrollment at 37 percent, followed by Anthem at 30 percent.
Timeline
Letters of intent are due by September 20 and proposals are due on October 27. As previously mentioned, new contracts will begin July 1, 2024. Contracts will have a six-year initial term, with two two-year renewal options. Award dates have not been announced.
Evaluation
Plans will be awarded up to 1,000 points during the evaluation process based on the categories shown below.
September 6, 2023
Virginia Releases Cardinal Care Medicaid Managed Care RFP
Leading ideas and solutions for long-term services and supports
Dedicated to supporting the effectiveness of publicly financed healthcare programs, Health Management Associates (HMA) is committed to promoting the design, financing and operation of effective models of person-centered long-term services and supports (LTSS) which:
Support an individual’s ability to receive services in the most integrated setting
Promote successful community living
Improve integration of LTSS with quality physical and behavioral healthcare
Support Medicare and Medicaid integration and coordination
Address the social determinants of health for people with support needs
Support direct care workforce initiatives for states, managed care organizations and long-term care providers
Support strategic planning focused on long-term care
Support managed care readiness initiatives
What we offer
With deep expertise in the field, our colleagues and the work we do help to shape current system trends. In addition, we support improved outcomes for beneficiaries and successful participation for the wide range of LTSS providers including managed care organizations, states offering critical services, and purchasers through:
LTSS Models of Care
Developing and promoting person-centered integrated, and holistic LTSS models of care
LTSS Quality Standards
Supporting the development of LTSS quality standards and metrics, including technical assistance for NCQA and other accreditation and credentialing
LTSS Regulatory Compliance
Facilitating readiness and compliance with federal and state regulations, including home and community-based settings of care, Medicaid managed care, the Fair Labor Standards Act, and the Americans with Disabilities Act
LTSS Integration
Implementing care management and service delivery models that promote integration of services across physical, behavioral, and LTSS providers and between Medicare and Medicaid including those developed under PACE, managed LTSS, and managed fee-for-service
LTSS Stakeholder Engagement
Supporting effective community engagement by public policy makers, and empowering advocacy organizations and other stakeholders in understanding, shaping, and responding to change
LTSS Delivery and Payment Models
Assisting organizations and providers to prepare and respond to payment and structural changes in LTSS (e.g., managed care, accountable care, value-based purchasing)
LTSS and Social Determinants Design
Designing innovative approaches to addressing the social determinants of health, including improved strategies for affordable and accessible housing, competitive employment for persons with disabilities, access to technology, and social equity-based care delivery models
LTSS Market Analysis
Providing expert market analysis for investors relating to LTSS providers, managed care organizations, service vendors, or emerging trends in the LTSS landscape
LTSS Research and Evaluation
Enabling the use of data to uncover opportunities for improvement and to demonstrate value to ACOs, hospital systems, payers, and funders
Our wide-ranging expertise includes:
Medicaid LTSS waiver and state plan authority options
Operation and oversight of managed LTSS
Public procurements
LTSS provider operations
Federal and state compliance
Care management and care coordination
Workforce development
Strategic planning and practice redesign
LTSS policy analysis
Value-based purchasing
Quality monitoring, evaluation and research
Community capacity and network adequacy
Readiness reviews
Our Clients Include:
Federal, state and local governments
For-profit, not-for-profit and public health plans
Institutional and home and community-based services providers and their associations
National, state and local advocacy organizations
National and regional foundations
Direct care workforce representatives
Investment services entities
Contact our experts:
Sharon Lewis
Principal
Susan McGeehan
Associate Principal
Rural Health and Challenges with Health Equity
There are 47 to 60 million people residing in rural areas in the U.S. Many rural residents must navigate healthcare system challenges people living in urban and suburban areas generally do not face. While workforce shortages, lack of consumer choice in health plans and providers, travel distance, transportation issues, social isolation, and increased inequity for people in marginalized communities do impact urban and suburban healthcare services, these issues are exacerbated in most rural communities. Developing and supporting rural health programs requires understanding the unique characteristics of rural settings and how these dynamics influence healthcare policy, providers, payers, consumers, and health equity.
Health Management Associates (HMA) brings together industry-leading policy, program, financial, community, and clinical experts to provide comprehensive solutions that make healthcare and human services work better for people living in rural and frontier areas across the country. We offer a full suite of professional health and human services consulting services to clients serving rural and frontier communities. This includes state agencies, county health departments, critical access and rural hospitals, federally qualified health centers (FQHCs) and rural health clinics, skilled nursing facilities, home and community-based service providers, behavioral health providers, oral health providers, and pharmacies/pharmacists. We also work with human services organizations and public health agencies, supporting their direct services, as well as assisting them in connecting with healthcare systems and providers. Our national, multisector, multisystem experience in healthcare and human services enhances our ability to support rural clients in making sustainable, positive impacts in their local communities.
PROJECT SPOTLIGHT
Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit
With funding from Arnold Ventures, HMA created the HEARD Toolkit, a robust discussion of the access challenges facing dually eligible individuals in rural areas and a portfolio of actionable solutions to address these challenges. Dually eligible individuals in rural areas reside at the intersection of a major public health crisis and a fragmented Medicaid and Medicare delivery system. They experience poor access to services and to integrated care programs (ICPs) to address their whole person needs.
HMA designed this Toolkit to help policymakers address access issue dually eligible individuals in rural areas have to navigate every day. For example, addressing access must encompass getting to a comprehensive Medicaid and Medicare services continuum that includes home- and community-based services (HBCS), as well as ICPs. A primary focus on equity can help states, local communities, payers, and providers begin to address issues of access for these very vulnerable individuals in rural communities. The Toolkit provides examples and ideas for rural providers and communities to address equity and improve services and supports for dually eligible individuals.
For example, HMA can assist rural communities and the organizations that support their needs with:
Rural-specific workforce solutions
Programs addressing Social Determinants of Health/Health-related Social Needs
Payment system reforms
Development of integrated care programs for Dual Eligibles
Substance Use Disorder/Opioid Use Disorder prevention, treatment, and recovery services
Behavioral health services and supports
Justice-involved carceral healthcare and transitions
Long-term services and supports and home and community-based services
HMA understands the multilevel challenges for delivery of quality health care and social services to rural populations. From workforce and care access issues to transportation difficulties and technology barriers, to socio-economic differences, we can help rural providers and organizations overcome challenges and achieve their goals to serve and support their communities’ needs.
Other Rural Health Project Examples:
HMA is supporting review and reform of the primary care payment environment in New Mexico working under a contract with Mercer. New Mexico’s Medicaid program had identified multiple challenges the primary care providers faced across the state, including rural sustainability and fiscal soundness. HMA’s approach includes coupling data analysis with stakeholder engagement. Our work to date includes designing, testing, and evaluating new primary care alternative payment models (APMs); fiscal, policy, and/or programmatic implementation recommendations related to the multi-payor roll-out of a primary care APM; and supporting primary care practitioners related to NM Medicaid APM implementation. Additional project work will include more provider specific analysis, recruitment for pilot testing and provide education, analysis and training for providers, health plans and state regulators.
HMA is working with the Colorado Department of Health Care Policy and Financing (HCPF) to perform a dynamic heat mapping as the first phase of a three-phase project that includes an environmental scan of home and community-based services (HCBS)/Medicaid. HMA is creating a tool that HCPF can leverage to update and track progress to close provider gaps. In subsequent work HMA will identify potential geographic regions which would benefit from reimbursement structure changes, including geographic adjustment factors to apply to preexisting fee-for-service rates or other mechanisms to effectively address identified care gaps. Based on these results, HMA will recommend strategies and best practices to expand the provider network in rural areas to avoid care deserts and assure access to services for all Medicaid members.
Over the past six years, HMA has supported tribal communities in Montana with an array of data and evaluation expertise specific to behavioral health system assessments and evaluation activities. To date, we have conducted feasibility assessments for tribes considering options to 638 their behavioral health services, evaluated high-fidelity wraparound services in tribal communities through the Montana Systems of Care program, supported efforts to discern a concept design for a joint tribally operated Substance Use Disorder (SUD) Continuum of Care, and assisted tribally operated clinics in best practices in opioid prescribing and addiction treatment.
The Georgia Health Policy Center provides technical assistance for grantees of HRSA’s Rural Health Programs. HMA created a primer and additional tools, including a webinar, designed to inform and support rural provider leadership on Value-Based Care. The primer serves as a self-paced guide helping organizations consider national trends and experiences, assess their current state and readiness, understand benefits and barriers of Value-Based Care. The primer and tools are used by the technical assistance team and rural health grantees.
HMA has worked with HSHS for over 10 years, providing a wide range of services including:
Grant surveillance related to strategic plans, project management, grant program development, and narrative writing for multiple state and federal grants including USDA, HRSA, and SAMHSA.
Expanding access to medication assisted treatment (MAT) in emergency departments by activating a team of HMA experts to implement a global assessment of readiness to adopt MAT, create a comprehensive training curriculum, assist with development of policies, workflows and standardized orders; and provide technical assistance required to address stigma and implement change. HMA also aided in writing the successful proposal for state funding for this project.
Stakeholder engagement for a hub-and-spoke model of telehealth network, assessed strategic priorities across multiple diverse stakeholders, and developed a strategic plan for HSHS’ Wisconsin rural healthcare provider telehealth network.
Development of the Illinois Telehealth network composed of 21 rural healthcare providers across Illinois. HMA provided technical expertise on the adoption of telehealth services and the development of clinical protocols and led strategic planning efforts. The network now functions to support the members in disseminating best practices, implementing telehealth service lines, sharing clinical protocols, removing barriers, and promoting evaluation.
HMA is currently assisting HSHS’ rural behavioral health team in devising new models of community-based withdrawal management processes consistent with recent changes in Wisconsin’s regulations. HMA experts on residential substance use disorder and integrated care provide technical assistance, training, and evidence-based policy development.
HMA supported the Texas Department of Agriculture, State Office of Rural Health (SORH) by leading SORH’s three-year strategic plan and design future programs. For the needs assessment, HMA conducted a systematic assessment that included an environmental scan of rural health key issues and trends, online survey of rural Critical Access Hospitals (CAHs) and prospective payment systems (PPS) hospitals in Texas identify needs and gaps, and an analysis of publicly available data to identify health needs and differences between rural and urban residents. Informed by this assessment and close collaboration with SORH staff, HMA developed a strategic plan to guide the next three years of SORH’s programming, as well as created work and evaluation plans for the SORH and Flex grant programs. Other tasks included assessment of Texas rural hospital telemedicine readiness, recommendations for value-based payment models for rural hospitals, and opportunities to support rural hospitals in reducing health disparities.
Contact our experts:
Ellen Breslin
Principal
Rebecca Kellenberg
Principal
Jill Kemper
Associate Principal
CMS takes major step forward in Medicare drug price negotiation program
This week’s In Focus centers on the U.S. Department of Health and Human Services (HHS) August 29, 2023, announcement of the first 10 prescription medications that will be subject to price negotiation for Medicare coverage. This week, Health Management Association (HMA) experts offer their perspective on what this change means and what to expect next.
Background
Medicare was granted the authority to negotiate prescription drug prices through the Inflation Reduction Act (IRA), which the president signed into law on August 16, 2022. HHS, acting through the Centers for Medicare & Medicaid Services (CMS), will lead negotiations and enter into agreements with manufacturers for these products, negotiating a maximum fair price (MFP) for each selected drug in the Medicare program. HHS is required to negotiate on a certain number of drugs each year: 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and subsequent years. Up to 60 drugs could be negotiated by 2029. Manufacturers that are noncompliant will face an excise tax that could far exceed the cost of drugs sold over time and civil monetary penalties.
Medicare Drug Negotiations: The Latest Development
Since passage of the IRA, CMS has been working to establish the regulatory infrastructure and policies to support implementation of Medicare’s new drug price negotiation authority on an expedited timeline. Guidance on the approach the agency will take in negotiating MFPs, along with other provisions of the act, has been issued.
With this week’s action, CMS will begin the first round of negotiations. Table 1 lists the drugs CMS has identified for the first round of negotiations. Products selected for negotiation (with prices effective in 2026) are medications that represent the highest spending in the Part D drug benefit, excluding products with generic or biosimilar competition as well as certain orphan drugs and other products that qualify for a small biotechnology exemption.
Alongside CMS’s announcement, HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) released its analysis of prescription drug use and out-of-pocket spending for each of the 10 drugs for all Part D enrollees and separately by whether an enrollee receives the low-income subsidy (LIS). The report also examines demographic information about enrollees who use the selected products.
Takeaways
The products selected were largely in line with initial modeling that Moran Company analysts and others performed, but with some surprises. Variation from earlier projections could be expected for a number of reasons, including:
- The June 2022−May 2023 data CMS used were not generally available to outside analysts, and it is clear that several products had spending increases (whether because of volume or price increases) relative to prior years that moved them up the list.
- Some higher spending products have seen generic or biosimilar competitors launch, making them ineligible for selection for negotiation.
- For the top 30 products identified in previous dashboard data, at least 10 have evidence of generic or biosimilar competition.
- CMS’s decision to treat multiple products together for purposes of negotiations also affected the products included on the list.
- For a few other products, it is still unclear how CMS decisions were made.
What to Expect Next
The drug negotiation policy is highly controversial and is the subject of litigation that could delay the process. If litigation does not affect the timeline for implementation, manufacturers of selected drugs have until October 1 to agree to negotiate and provide initial information to CMS. If a manufacturer opts out of the negotiations, the company must pay either an excise tax or withdraw all its products from the Medicare and Medicaid programs. CMS and participating companies will then meet to discuss manufacturer submissions, and CMS will receive information from other stakeholders. Several listening sessions will take place.
CMS will make initial price offers by February 1, 2024. After a counteroffer process, negotiations may continue into the summer of 2024, but final determinations will be made by August 1, 2024. CMS plans to publish any agreed-upon negotiated prices for the selected drugs by September 1, 2024. Those prices take effect starting January 1, 2026.
In addition to the short-term impact on prices for specific drugs, several questions about the potential effects of the policy are worth monitoring over the long-term:
- How will research and development of new products and trends in the type of products prioritized change as a result of these policies?
- How will the policies affect pricing for competitor products and the launch prices of products in the future?
- Beyond the Medicare population, for whom the prices are directly applicable, how will MFPs affect negotiations on costs and supplemental rebates for other payers. including state Medicaid programs, state employee programs, drug purchasing pools, and commercial insurers?
- Will negotiations affect the design of standalone Prescription Drug Plans (PDPs) and Medicare Advantage PDPs.
The IRA included several other changes to the Medicare program, which we discussed in a previous In Focus.