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HMA Insights – including our new podcast – puts the vast depth of HMA’s expertise at your fingertips, helping you stay informed about the latest healthcare trends and topics. Below, you can easily search based on your topic of interest to find useful information from our podcast, blogs, webinars, case studies, reports and more.

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HMA Weekly Roundup

June 29, 2022

Early Bird Registration Discount Expires July 11 for HMA Conference on The Future of Publicly Sponsored Healthcare, October 10-11 in Chicago

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Blog

Staying ahead of the star rating curve: insights from HMA and Wakely’s Medicare Summit

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This week, our In Focus section highlights a presentation from HMA and Wakely, an HMA company, titled “Staying Ahead of the Star Rating Curve – A Case Study,” which was given at the 12th Medicare Stars, HEDIS, Quality Assurance, & Risk Adjustment Summit on June 15, 2022.

The presentation provided an overview of major changes in the Medicare stars program, which will result in both higher ratings and significantly higher revenues for many Medicare Advantage plans in 2023.  However, the presentation indicated the higher ratings reflect temporary changes and not necessarily improvements in quality, adding that Medicare Advantage plans should be cautious about enhancing future benefits based on additional 2023 revenues.

Click here to view the presentation.

For questions, please contact our experts below.

Blog

Quality standards in addiction care

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Across the healthcare landscape, quality standards are in place to ensure patients are receiving safe, appropriate, evidence-based, and standardized care that is tailored to their individual needs and symptomology.   

A significant gap has long existed in the treatment of substance use disorders (SUD), as there was no standardized method to provide treatment based on an individual’s needs at that moment, meaning people seeking treatment often received care that was either too intense or not intense enough, preventing them from attaining sustained recovery.

To create standardized treatment protocols and build additional credibility around programs, the American Society of Addiction Medicine (ASAM) developed criteria based on a holistic, multidimensional assessment[1] to determine what level of care (LOC) an individual needs. This development was revolutionary as it was the first time the field agreed on established criteria. After 35 years of improvement and refinement, the ASAM Criteria has become the national standard.

Learn More about ASAM Level of Care Certification

While many providers have adopted the ASAM criteria, and most regulators and payers require its use to determine the LOC a person may need, a significant gap still persists in ensuring services are delivered with fidelity to the criteria. As a result, those seeking treatment for themselves or a loved one continue to face challenges identifying a setting that provides evidence-based treatment focused on their specific needs. 

To close this gap, ASAM partnered with CARF International, the leading accreditor of behavioral health services, to develop criteria that demonstrates providers are, in fact, delivering the LOC for which they are admitting persons. Programs that are providing levels of residential care can be certified for three levels including: 3.7- Medically Monitored Intensive Inpatient Services, 3.5- Clinically Managed High Intensity Residential Services, and 3.1- Clinically Managed Low Intensity Residential Services.

By achieving the ASAM LOC certification, residential treatment programs can establish themselves as high quality SUD providers and ensure future program licensing as well as future funding from states, and private and public payors. This certification demonstrates that facilities are delivering the appropriate care to the appropriate person at the appropriate time. 

Preparing for certification is different from preparing for licensure in that a program must take an in-depth look at their clinical practice to ensure alignment with the ASAM criteria.

Because of our long and proven track record of helping clients prepare for, and secure, NCQA, AAAHC and URAC accreditation as well as deep expertise in SUD programs and treatment, HMA was selected by ASAM as a preferred partner to provide technical assistance and usher programs through the certification process as well as help address shortfalls and gaps in programs and care.

Our team has the right mix of clinical and operational knowledge, training, and frontline experience to guide clients through the certification process and help build better systems of care and accountability from the ground up.

HMA has the depth and breadth of services across the healthcare spectrum, and we are uniquely positioned to help organizations address gaps identified in the certification process and improve care by ensuring services are delivered in fidelity to the LOC at which a person presents.

HMA is able to provide a full complement of services and support to residential providers including ASAM LOC clinical expertise, developing policies and procedures, building and operationalizing clinical programs, and improving revenue cycle, operations, and as well as payor contracting strategies.

Certification is really step number one. Utilizing HMA’s “Survey Ready Model,” we will identify ways to build quality into everyday practice allowing programs to stay on top of – and ahead of – requirements. 

For more information, contact our expert below.

[1] https://www.asam.org/asam-criteria/about-the-asam-criteria

Blog

CMS revitalizes Medicaid HCBS investment opportunities

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On June 3, 2022, the Centers for Medicare & Medicaid Services (CMS) notified states that they will have an additional year, until March 31, 2025, to use funding from the American Rescue Plan Act (ARPA) to strengthen their Medicaid home and community-based services (HCBS). CMS’ update extends important flexibility to ensure state Medicaid programs and stakeholders, including beneficiaries, realize maximum benefit from federal investments in expanding and enhancing HCBS services.

For over a decade, the Medicaid program has been leading transformations of state long-term services and supports systems (LTSS), including physical and behavioral health services and health-related social needs. These efforts primarily focus on broadening eligibility, making more significant Medicaid investments in HCBS, and improving beneficiaries’ access to HCBS programs. The COVID-19 pandemic heightened attention to beneficiaries’ disparate experiences with accessing HCBS and exacerbated pre-COVID challenges faced by the LTSS workforce.

Section 9817 of ARPA provides an increase for Medicaid-funded HCBS by offering states the option to claim an additional 10 percentage point increase in federal match (FMAP) for the one-year period from April 1, 2021, to March 31, 2022. To receive the higher federal funding, states cannot make changes to the amount, duration, and scope of covered HCBS; they cannot reduce HCBS provider payment rates; and they cannot make eligibility standards for HCBS programs or services stricter until all additional funds are expended. CMS also requires states to submit a spending plan and narrative that describes planned enhancement activities.

Notably, a state must reinvest the higher federal funding in Medicaid HCBS while maintaining the spending levels they had in place on April 1, 2021. According to CMS’s new guidance, states can now use the funds until March 31, 2025, rather than March 31, 2024, under the previous guidance.

Actions Stakeholders Can Take to Maximize the Extra Time

The updated spending deadline is grounded in a better understanding of the level of effort and time necessary for states to identify, build consensus, and implement specific actions to include in a state’s HCBS spending plan. HMA works with states, providers, health plans, and other stakeholders, including consumers, who will benefit from the additional time to make investments. Our work includes supporting states as they align the multitude of needs and priorities with the available funds and supporting robust stakeholder engagement efforts to inform the plans.

The following are some of the most impactful “next steps” that states and stakeholders can pursue to best utilize the additional time to reinvest in Medicaid HCBS programs:

  • States can communicate with stakeholders, including health plans, providers, community organizations, consumers, and others, to share how the extension impacts the state’s spending plan.
  • States and stakeholders can renew their engagement to consider potential changes to the spending plan activities, timelines, or both. Stakeholders may have additional opportunities to offer input to refine further and prioritize the design and delivery of augmented or new services, systems, and related initiatives.
  • State Medicaid, aging, and various other programs and providers have more time to strengthen their collaboration to meet the needs of individuals of all ages who are living with disabilities.
  • States, vendors, health plans, and providers can evaluate through evidence, analysis and stakeholder feedback, if the projects they are pursuing are effective and/or should be modified. For example, it may be beneficial to provide more flexibility in the deadlines for case management and referral systems builds and implementation of the training for workers on these new systems.
  • States and their stakeholder partners can refocus on workforce issues, including examining eligible provider types and scopes, evaluating provider network issues, considering the role of virtual services, conducting provider and managed care rate setting studies, and other changes to support the HCBS direct care workforce.
  • States can develop reasonable timeframes to strengthen existing efforts or pursue new initiatives to develop and implement managed long-term services and supports for certain groups of Medicaid beneficiaries.

Looking ahead, states and all stakeholders need to assess the impact of these investments. ARPA funds are a significant investment in strengthening Medicaid LTSS programs, but these transformative efforts require sustained commitment. There is continued uncertainty around additional federal Medicaid funding over the long term that are necessary to address ongoing needs and make further progress towards high-quality, accessible HCBS services. Understanding the extent to which the funds are achieving the desired structural transformations and the impact on Medicaid beneficiaries can guide future areas of federal and state focus and investments.

For more information, please contact our experts below.

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Blog

Low-cost carriers in ACA: insights from the 2018-2021 market experience

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This week, our In Focus highlights a white paper from Wakely, an HMA Company, exploring the potential design elements and expected effects of a public option or a low-cost plan being newly introduced in the Affordable Care Act (ACA) individual market.

1332 state innovation waivers have been in place for a number of years and allow states to implement programs that increase access to and the affordability of healthcare coverage, subject to approval by the Department of Health and Human Services (HHS) and Department of Treasury (Treasury). Nearly all waiver programs in effect in 2021 employ a reinsurance program aimed at reducing the overall claim costs and premiums for members by reimbursing issuers for a portion of claim costs over a specified threshold.

A number of states have been exploring other ways to structure a waiver program, including introducing a public option plan into ACA markets (individual and small group plans subject to the ACA market reforms). The definition of a “public option plan” has evolved over time and can vary, but more commonly refers to a privately funded health plan with some level of government oversight or additional requirements established to improve consumer value and facilitate cost containment.

A public option plan aims to further increase access to coverage and affordability by offering a new qualified health plan, typically with a lower premium relative to existing premiums in the market. A public option plan specifically aims to extend a more affordable coverage to individuals who are currently not eligible for ACA subsidies (e.g., family glitch, non-citizens, and those with higher incomes). The plan could be structured in a variety of ways such as a state-sponsored product, state employee health plan buy-in, Medicaid plan buy-in, or a private plan offered by existing issuers. Colorado and Washington will require health plans to offer public option plans with a target premium reduction relative to other plans in the market, with constrained rate increases over time, giving health plans the opportunity to arrive at the lower premiums through their own means, for the 2023 plan year. Lower premiums would likely be achieved through a combination of lower provider reimbursement and lower risk margins.

Given the nature of premium subsidization in the individual ACA market, where premium subsidies are tied to the second lowest cost silver (SLCS) plan in the market, the introduction of a lower cost public option plan has a mixed impact on market growth and the types of member segments that benefit. Since Washington State is the only Exchange that currently offers a public option plan, there is minimal experience available to understand the impact a public option plan may have on the market. As a result, our goal was to look at states where a new issuer has entered a market as a low-cost plan over the last four years, to better understand plan enrollment migration (how many members switch to the low-cost carrier), competitors’ reactions, and the reduction in premium needed to incentivize members to take up coverage. This market dynamic potentially closely mimics a public option plan that offers lower premiums being introduced in a market. Over the last four years (2018-2021), we identified 51 instances of new issuers entering an individual on-Exchange market. Of those 51 new entrances, 25 met our criteria of a low-cost plan.

The analysis showed mixed impacts of a low-cost plan introduction in ACA markets, with minimal impact on the uninsured, but with improved affordability, particularly for the unsubsidized. The detailed observations are discussed further in this paper.

For more information, contact our expert below.

HMA News

Health Management Associates Acquires Medical Audit Resource Services, Inc.

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Today, Jay Rosen, founder, president, and co-chairman of Health Management Associates (HMA), announced the firm’s acquisition of Medical Audit Resource Services, Inc. (MARSI).

Founded in 1991, MARSI specializes in medical coding support, physician education and healthcare revenue cycle management. MARSI’s experts provide coding and auditing services for hospitals and physicians using inpatient, outpatient and risk adjusted reimbursement methodologies. Other clients include commercial fee-for-service plans as well as risk-adjusted plans.

“MARSI is recognized nationally for the expertise of its team and the results they deliver for clients. They will add enormous value to our healthcare delivery system, actuarial and revenue cycle work,” Rosen said. “I am excited to welcome such talented professionals to HMA as we continue to expand the ways in which we can meet our clients’ current and emerging needs.”

MARSI has been a pioneer in several areas that are now standard operating procedure among healthcare providers and their contracted service providers, including over-code identification, physician queries, pre-bill auditing, coder and physician training, and clinical documentation improvement.

“We are excited to join an organization that shares our commitment to integrity and excellence,” said Dr. Todd M. Husty, MARSI owner, founder, and chief medical officer. “HMA is home to an unmatched breadth and depth of experience and expertise. We look forward to the new opportunities we will have to serve our clients and extend our reach.”

MARSI will continue to operate as Medical Audit Resource Services, an HMA Company, under the leadership of Dr. Husty. Terms of the transaction were not disclosed.

Founded in 1985, HMA is an independent, national research and consulting firm specializing in publicly funded healthcare and human services policy, programs, financing, and evaluation. Clients include government, public and private providers, health systems, health plans, community-based organizations, institutional investors, foundations, and associations. With offices in more than 20 locations across the country and over 500 multidisciplinary consultants coast to coast, HMA’s expertise, services, and team are always within client reach.

MARSI: https://himexperts.com/

Blog

Oklahoma to transition to Medicaid managed care

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This week, our In Focus section reviews a new Oklahoma law to implement Medicaid managed care by October 1, 2023. The law, signed by Governor Kevin Stitt on May 26, 2022, requires the state to issue a request for proposals and to award at least three Medicaid managed care contracts to health plans or provider-led entities like accountable care organizations.

Provider-led entities would receive preferential treatment, with at least one targeted to receive a contract. However, if no provider-led entity submits a response, the state will not be required to contract with one.

Goals of the legislation 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; and
  • Ensure a sustainable delivery system that is a provider-led effort and that is operated and managed by providers to the maximum extent possible.

Plans would provide physical health, behavioral health, and prescription drug services. Covered beneficiaries would include traditional Medicaid members and the state’s voter-approved expansion population, but not the aged, blind, and disabled population eligible for SoonerCare.

Plans will need to contract with at least one local Oklahoma provider organization for a model of care containing care coordination, care management, utilization management, disease management, network management, or another model of care as approved by OHCA.

Oklahoma will also issue separate RFPs for a Medicaid dental benefit manager plan and a Children’s Specialty plan.

Background

Oklahoma currently does not have a fully capitated, risk-based Medicaid managed care program. The majority of the state’s more than 1.2 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 Specialty Children’s Health Plan program, covering foster children, juvenile justice-involved individuals, and children either in foster care or receiving adoption assistance.

Link to Senate Bill 1337