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Future-ready: is your MCO equipped for change?

Government Funded Programs and Readiness

As a local or regional managed care organization (LRMCO), being “ready” means proactively addressing all the areas where your organization can get tripped up, or worse, lose your contract with a state Medicaid agency. LRMCOs are heavily reliant upon government funded programs. These include Medicaid, Medicare, and Marketplace business. Most LRMCOs are not as heavily involved in the commercial market, either on a fully insured or self-insured basis, and even when they are, these areas comprise smaller parts of their overall product offerings. National MCOs have looked to Medicaid managed care to fuel growth, strengthen relationships with government partners, and leverage infrastructure.

In any government program, “readiness” is a critical capability that often gets overlooked due to the daily pressures of running the organization. It’s often said that “you should always be audit ready.” The meaning of this is that you and your organization should always be prepared to undergo an outside audit from your regulator, financial auditor, or other entity such as the National Committee for Quality Assurance. Having a well-run organization allows you to not only be ready to respond to regulators or auditors but also to be able to demonstrate stable financial, operational, and compliance performance. Having this stable base of performance allows for more meaningful strategic planning, innovation, and state and federal partnership.

In Medicaid and other government programs, where public purchasers follow stringent purchasing rules, perhaps another way to think of your MCO’s operations is to always be “procurement ready.” But what does it mean to be “procurement ready” for your MCO? Today, managed care is the primary Medicaid delivery system vehicle for most states across the country. While some states procure all Medicaid managed care services in single, comprehensive contracts, many states procure for services via specific programs. Managed long-term services and supports, behavioral health, dental, and other programs are examples of specific programs that states procure alongside those that states have procured historically including low-income children and their parents, pregnant women, people with disabilities, people aged 65 and older, and, with advent of the Affordable Care Act, low-income adults without dependent children. State Medicaid managed care contracts are typically three to five years in duration, often with single or multiple year optional extensions. What this means is that in any given year there are approximately 10 Medicaid managed care program procurements. Moreover, these procurements are now among the largest contracts awarded by states, often exceeding billions of dollars per year. As a result, the importance of being ready for these events has grown substantially over the years.

Being “Ready” Means Being Prepared and Planning in Advance

A critical element of being “procurement ready” is not to rely upon fixing issues when a Medicaid request for proposal (RFP) appears likely; it is to be on top of requirements on an ongoing basis, address issues quickly, and capture success stories as they happen. Too often, LRMCOs don’t look to begin this process until it is too late—a small issue has become a big problem and remediation is expensive, time-consuming, and painful. Even the best proposal will struggle to win in the face of a record of real or perceived suboptimal performance.

The reality is that states are asking for MCO results (Healthcare Effectiveness Data and Information Set scores, state audit findings, Health Insurance Portability and Accountability Act breaches, etc.) as part of RFPs. These data points are hard to hide even with great writing and presentation. States are also more frequently including member or case “scenarios” in RFPs, which are specific in nature and are designed to have the MCO describe exact steps, processes, and outcomes. It is therefore important to monitor and measure for performance year-round.

For incumbent LRMCOs, the best way to maximize your chances of winning a renewal is to deliver effectively—and to be seen as delivering effectively—on your existing contract. A well performing incumbent LRMCO has tremendous advantages because:

Switching vendors is risky and painful for states, even under the best of circumstances.
Competitors are less likely to bid when they know the incumbent is well-regarded by the state.
The key to delivering effectively is continuous assessment and adjustment, so LRMCOs identify potential issues early and can address them before they mushroom into bigger problems.

The time to begin preparing for your next procurement is while you begin to deliver under the existing procurement, not three months before a new procurement.

Best practice is to begin RFP planning 18 months to 24 months in advance of the anticipated issuance date. That planning should include developing “win strategies,” competitive assessments, and proposal logistics. Putting remediation initiatives on top of these areas adds unnecessary stress and strain on the LRMCO and the teams responsible for delivering a winning proposal. Therefore, being “procurement ready” is an important and often critical element in ultimately preparing winning proposals.

States look for “partners” not just contractors. LRMCOs can serve as invaluable thought partners to help inform how states can meet their stated policy aims. This not only puts LRMCOs in good standing with state leaders, but it also means they are well informed about state thinking so they won’t be caught by surprise if new requirements appear in the next RFP.

States frequently provide vague guidance on when RFPs will be released (“early next year,” “in the second quarter”, etc.) Some states have published concrete schedules for their multiple RFPs, but this is the exception. The implication for LRMCOs is that it is very difficult to “time” when to get your operations optimally ready for a forthcoming RFP. A wiser approach is to always be ready for an RFP to drop (again, like being audit ready). Some operational, performance, or compliance issues can be addressed in fairly short time frames. Other areas, such as quality reporting, require about a two-year lead time to fix any problems, gather the data, and exhibit optimal performance due to data/reporting lag. Other areas that require longer lead times are claims, encounter data reporting, risk adjustment, delegation oversight, and many others. Due to the lead times required, to be always “procurement ready,” LRMCOs need to have robust operational readiness and monitoring programs established as part of daily operations.

Strategies for Achieving and Maintaining Audit Readiness and Contract Compliance

As noted earlier, strong performance on audits and a consistent record of impressive compliance is an advantage when participating in RFP processes. States prefer to contract with MCOs that have a robust track record of compliance and can persuasively demonstrate their ability to consistently meet the needs of members. Strategies that LRMCOs can employ to develop such a track record include:

Develop Robust Compliance Programs: LRMCOs should establish comprehensive compliance programs that include policies and procedures, training, monitoring, and auditing. These programs should address all aspects of contract compliance and the specific requirements of the state’s program.
Internal Controls and Documentation: LRMCOs should implement internal controls to monitor and measure contract compliance regularly. In addition, organizations should maintain thorough documentation of all activities, decisions, and communication. This documentation serves as evidence during audits and demonstrates a commitment to compliance.
Regular Audits and Self-Assessments: LRMCOs should conduct regular self-assessments and internal audits to identify and rectify potential compliance issues before external audits occur. This proactive approach helps mitigate risks and ensures continuous improvement.
Data Management and Reporting: LRMCOs should develop robust data management systems to collect, store, and report the necessary data. Accurate and timely reporting is essential for demonstrating compliance with performance measures and outcomes.
Staff Training and Awareness: LRMCOs should ensure that staff members are well-trained and aware of their roles in maintaining contract compliance. Regular training sessions can keep employees updated on changing regulations and requirements.
External Auditors and Consultants: LRMCOs should consider engaging external auditors and consultants with expertise in compliance to conduct independent reviews and provide recommendations for improvement.
Continuous Quality Improvement: LRMCOs should implement continuous quality improvement processes to enhance the quality of care delivered to members. This demonstrates a commitment to improving health outcomes and can positively influence contract awards.

The Value of a Proactive Approach

To be continuously “procurement ready,” LRMCOs must be forward-thinking and adaptive. Embracing change, data-driven decision making, quality improvement, building strong provider networks, investing in technology, engaging stakeholders, and maintaining financial stability are all essential steps to ensure the sustainability and success of these organizations in the intervening years between state-issued RFPs. By taking a proactive approach to addressing these needs, LRMCOs can position themselves as leaders in providing high-quality health care services for the members they serve.

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If you have questions about how HMA can support your efforts to be ready, please contact our experts below.

HMA and partner organizations release brief to improve coordination of services for children in foster care and those with behavioral health needs

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This week, our In Focus section highlights the efforts of Health Management Associates (HMA) and partner organizations to better coordinate services for children in foster care and for children with behavioral health needs.

First, HMA released an issue brief on November 6, 2023, as part of a partnership between HMA and the National Association of State Mental Health Program Directors (NASMHPD) Technical Assistance Coalition. Together HMA and NASMHPD experts wrote a series of five briefs on children’s behavioral health.

The brief released last month, “The Role of Specialized Managed Care,” written by HMA experts Heidi Arthur and Angela Bergefurd, with input from Caitlin Thomas-Henkel and Uma Ahluwalia, centered on the intersection of child welfare reform and behavioral health transformation. More specifically, it described how specialized Medicaid managed care plans can ensure better alignment between child welfare and behavioral healthcare services.

The paper emphasizes the role of state-level special needs plans (SNPs) in the delivery of coordinated care and examines the opportunities afforded to states seeking to leverage specialty managed care plans.

Specialized managed care plans can help fill the void by incentivizing the provision of services for children in foster care and specialty services for children with behavioral health needs. Plans in three states — Washington, Arizona, and Ohio — are highlighted, and can serve as examples of how state Medicaid SNPs can be implemented.

Link to Issue Brief

This paper is part of a larger effort that HMA and several partner organizations are supporting. Stakeholders include:

NASMHPD
The Annie E. Casey Foundation
Casey Family Programs
MITRE
National Association of Medicaid Directors (NAMD)
Child Welfare League of America (CWLA)
Administration for Children and Families
Substance Abuse and Mental Health Services Administration

The goal of these collaborations is to foster dialog between state agencies and stakeholders working to improve the well-being of children and youth with complex needs.

Most recently, HMA hosted a webinar on December 12, 2023, titled “Collaborating to improve children’s behavioral health – a comprehensive playbook to fostering wellbeing in children”. The webinar featured speakers from the partner organizations to discuss insights from a federal meeting that took place in November. Webinar speakers also informed participants about plans for a multistate policy lab scheduled for February 2024, where representatives of up to eight state child welfare agencies will participate in a two-day workshop on improving the children’s behavioral health continuum of care in their states. The webinar focused on the overall effort and provided a forum for states to hear from this partnership on the importance of collaborating to strengthen the children’s behavioral health system.

For questions about the brief, the webinar, or the larger effort, please contact our experts below.

Massachusetts releases RFR for One Care and Senior Care Options

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This week, our In Focus section reviews the request for responses (RFR) for the Massachusetts One Care and Senior Care Options (SCO) programs, released by the Massachusetts Executive Office of Health and Human Services (EOHHS) on November 30, 2023. The programs provide physical, behavioral, long-term services and supports (LTSS), and other community services to Medicare and Medicaid dual-eligible beneficiaries. Implementation is set to begin January 1, 2026.

One Care

One Care launched in 2013 as a Section 1115 Medicare-Medicaid Plan (MMP) program dual demonstration waiver. It operates under a financial alignment initiative (FAI) capitated model. The program provides integrated care to dual eligible adults ages 21 to 64. Individuals may remain enrolled in One Care when they turn 65 years old as long as they continue to meet all other requirements. Members can also access an independent LTSS coordinator.

As the Centers for Medicare & Medicaid Services (CMS) sunsets the FAI dual demonstrations, One Care will shift to a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) beginning in 2026, pending federal approval of the Section 1115 amendment request. Members will have exclusively aligned enrollment with the same plan for both Medicare and Medicaid coverage.

SCO

SCO launched in 2004 and is currently a FIDE SNP with exclusively aligned enrollment. Medicaid enrollees ages 65 and older with or without Medicare are eligible. Enrollment in this managed care program is voluntary. Individuals on the Frail Elder Waiver can only join SCO.

RFR

Massachusetts will award separate contracts for One Care and SCO but may prefer bids from plans seeking to operate both; however, plans may submit bids to operate one type of plan. The state seeks to offer both One Care and SCO coverage for eligible individuals in as many counties as possible, and ideally statewide. Plans must propose to cover people in at least six counties for each type of plan.

To be selected, plans will need to have a contract with CMS to operate a FIDE SNP in Massachusetts in 2026. Applications must be submitted to CMS by February 2025.

Timeline

Letters of intent are due February 15, 2024, and the deadline for responses is March 22, 2024. Plans will be selected by November 1, 2024. Implementation is set to begin January 1, 2026. Contracts will run an initial five-year term through December 31, 2030. Contracts may be renewed for up to five years in any increment.

Current Market

Commonwealth Care Alliance, Tufts, and UnitedHealthcare serve 43,000 One Care members.

SCO incumbents WellSense Senior Care Options (formerly BMC Healthnet), Commonwealth Care Alliance, Fallon Health, Molina/Senior Whole Health, Tufts, and UnitedHealthcare serve 77,000 members.

Link to RFP

Proposed rule changes for mental health parity requirements and their impact on local and regional MCOs

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Previously, Wakely Consulting Group, an HMA company, reviewed aspects of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requirements proposed rule published by the Internal Revenue Service (IRS), Employee Benefits Security Administration (EBSA), and Centers for Medicare & Medicaid Services (CMS) on August 3, 2023. The agencies accepted comments on the proposed rule through October 17, 2023. Because the proposed rule, if finalized as put forward, will have a significant impact on the compliance obligations of managed care organizations (MCOs) related to mental health parity requirements for the 2025 plan year in the group market and 2026 plan year in the individual market, MCOs will need to ensure, as they enter 2024, that they are in a position undertake any necessary steps to meet such obligations. This blog post outlines three specific requirements in the proposed the rule related to non-quantitative treatment limitations (NQTL) and their implications for a subset of MCOs: regional and local MCOs.

No More Restrictive Requirement

In the proposed rule, the IRS, EBSA, and CMS restate that MCOs may not apply any NQTL to mental health/substance use disorder (MH/SUD) benefits in any classification that is more restrictive, in policy or practice, than the predominant NQTL that applies to substantially all medical/surgical benefits in the same classification. To ensure compliance with this requirement, the proposed rule specifies exactly how an MCO must determine if the requirement is met.

First, the proposed rule outlines in detail how an MCO must complete a quantitative calculation to determine whether an NQTL applies to substantially all medical/surgical benefits in the classification at issue. If the NQTL does apply to substantially all medical/surgical benefits in the classification, the proposed rule then outlines exactly how the MCO must determine what version of the NQTL counts as the predominant one within the classification as well. Finally, once the predominant variation of the NQTL is established for an NQTL that applies to substantially all medical/surgical benefits in the classification, an MCO would have to use the proposed rule’s definition of “restrictive” (i.e., “imposes conditions, terms, or requirements that limit access to benefits under the terms of the plan,”) to determine if the NQTL applied to the relevant MH/SUD benefit is no more restrictive than the applicable medical/surgical benefit NQTL.

For local and regional MCOs, while the no more restrictive standard is not new, the steps required to ensure compliance likely represent—at the very least—an area where materially more intensive and sophisticated capabilities will need to be brought to bear. Completing the steps outlined above will require a cross-functional approach that leverages such areas as actuarial, behavioral health, clinical, compliance, financial analytics, and legal. The necessary people and processes will need to be deployed not only to accomplish the work effort but to do so in a way that is intelligible to federal and state regulators.

Design Requirement

In the proposed rule, the IRS, EBSA, and CMS seek to make explicit a requirement which mandates that MCOs cannot impose an NQTL on MH/SUD benefits in any classification unless the factors used in designing and applying the NQTL to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than, the factors used in designing and applying the NQTL to medical/surgical benefits in the classification. The agencies note that the regulatory revisions offered only seek to codify what has been a longstanding position of the agencies on this issue.

The most notable and innovative provision put forward by the agencies for purposes of determining comparability is one that would prohibit MCOs from relying on any factor in the design or application of an NQTL if the information on which the factor is based discriminates against MH/SUD benefits when compared to medical/surgical benefits. In this context, the proposed rule makes clear that discriminating against MH/SUD benefits means being biased or not objective, in a manner that results in less favorable treatment of MH/SUD benefits, based on all the relevant facts and circumstances.

For local and regional MCOs, it is advisable, given both the prudence of mitigating forthcoming potential compliance risks and likely limitations on the resources that can be devoted to compliance efforts in a discrete time period, to begin to evaluate upon entering 2024, whether NQTLs imposed on MH/SUD benefits have been designed and applied in a way that comports with this proposal by the agencies. For example, an MCO should evaluate whether factors currently employed rely on historical data or other historical information from a time when coverage was not subject to MHPAEA or was in violation of MHPAEA’s requirements where the use of such data results in less favorable treatment of MH/SUD benefits, as this would be prohibited. To this point, the agencies specifically note that MCOs would not be permitted to calculate reimbursement rates based on historical data on total spending for each specialty that is divided between MH/SUD providers and medical/surgical providers, when the total spending was based on a time period when coverage was not subject to MHPAEA or was in violation of MHPAEA, if the data results in less favorable treatment of MH/SUD benefits.

Outcomes Data Use Requirement

In the proposed rule, the IRS, EBSA, and CMS note that substantially disparate results are often a red flag that an MCO may be imposing an NQTL in a manner that does not comply with MHPAEA and so the agencies have included a proposal to add a requirement that, when designing and applying an NQTL, an MCO must collect and evaluate relevant outcome data in a manner reasonably designed to assess the impact of the NQTL on access to MH/SUD benefits and medical/surgical benefits as well as consider the impact as part of the MCO’s analysis of whether such NQTL complies with MHPAEA.

At minimum, MCOs would have to collect and evaluate data for all NQTLs that includes, but is not limited to, the number and percentage of relevant claims denials, as well as any other data relevant to the NQTLs as required by state law or private accreditation standards. Furthermore, due a specific concern of the agencies about network composition, the proposed rule would mandate that MCOs also collect additional applicable data for NQTLs that relate to network composition such as in-network and out-of-network utilization rates, network adequacy metrics (i.e., time and distance data and data on providers accepting new patients), and provider reimbursement rates. To the extent that data collected and analyzed demonstrates significant differences in access to MH/SUD benefits when compared to medical/surgical benefits, the MCO would be required to take reasonable action to address these differences in access as necessary to ensure compliance with MHPAEA.

For local and regional MCOs, beginning in 2024 to inventory readily available data sources that would be able to be leveraged to comply with this proposal is an important step in order to be prepared to comply during the 2025 plan year in the group market and 2026 plan year in the individual market. Additionally, assessing analytic capabilities to determine the level of readiness to be able to complete the evaluation based on the data collected is also an important component of preparing for this proposed new compliance obligation.

For More Information

If you have questions about how HMA can support your efforts related to the proposed rule’s implications for local and regional MCOs, please contact our experts below.

HMA Fall Conference: Highlights and Takeaways

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As we look back at our 2023 Fall Conference on publicly sponsored healthcare held in October, we wanted to highlight a few key takeaways from the event:

Behavioral Health Pre-Conference workshop: An impactful pre-conference session convened influential leaders in behavioral health to deliberate on the urgent need for a purposeful disruption of mental health accessibility across multiple sectors. Participants were actively challenged to reimagine strategies that could effectively disrupt the prevailing status quo in behavioral health, focusing on three key components essential for constructing a comprehensive system of care: population health and prevention, quality, and network.

The discourse highlighted pervasive issues such as silos that contribute to a lack of accountability within the system. There was a unanimous recognition of the imperative to eliminate barriers to access, accompanied by a resounding call for a pivotal transformation in payer models. Throughout the session, a prevailing theme underscored the critical need for fostering collaborative efforts across different sectors, emphasizing the creation of opportunities for cross-sector groups to work together.

Participants echoed a shared sentiment regarding the urgency of dismantling the current lacking system and replacing it with a more inclusive, patient-centered approach. The session served as a platform for thought-provoking discussions, inspiring innovative solutions to address the challenges in behavioral health, paving the way for a more effective and accessible system.

The three main conference themes – Equitable Access, Digital Innovation, and Value-based Care – were touched upon in many of the panels and plenary sessions.

Equitable Access: Several panels and speakers talked about health equity as a moral imperative as well as an organizational priority. Payers and providers understand that the Centers for Medicare and Medicaid Services (CMS) is developing metrics and measures to incorporate equity into accreditation and reimbursement and are anxious to get down to the details of the specific items that will be included. There was also robust discussion about how to incorporate community-based organizations and social services into Medicaid managed care plans to ensure that health-related social needs are being addressed in a more holistic way. There are opportunities to ensure contracting parameters and quality metrics work as intended to enable payers and providers to improve outcomes and reduce inequities of all types.
Digital Innovation: In addition to a “shark tank” style presentation of innovative technology vendors, the HMA conference featured a panel of experts in data liquidity and interoperability. They discussed the opportunity to embrace application programming interfaces (APIs) and digital health as a strategic imperative instead of a compliance issue. The new electronic prior authorization requirements are already starting to produce big results by expediting approvals, which is good for patients, but also reducing workload to allow staff to be redeployed to other areas of need. The panel also discussed the real need to improve digital access for rural health clinics (RHCs) and federally qualified health centers (FQHCs) that serve rural communities, where fee-for-service payment creates barriers to greater data coordination. And finally, the panel discussed the need to improve Medicaid procurement, so it does not impose barriers to digital innovation for vulnerable populations.
Lessons of Value-Based Care: This session featured a lively conversation about how value-based care is more important than ever, and frankly, that it is the right thing to do for mission-driven organizations to improve the health of patients. The organizations represented discussed how it has not been easy to learn new approaches to care coordination and managing financial risk, but they can do what is best for the patient by investing in the right things up front. Value-based care approaches are proliferating, including FQHCs where the providers’ motivation to serve vulnerable families is now supported by the right financial incentives.

HMA is committed to bringing together experts from across the healthcare spectrum, and advancing the conversation about ways to improve access, equity, and innovation in healthcare. In early March 2024, we will be offering an HMA Spring Workshop on value-based care in Chicago. Registration will open soon; to receive the invitation, please be sure you are subscribed to the HMA News and Events list.

Proposed changes to opioid treatment: implications for providers, payers, and regulators

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After more than two decades, SAMHSA and its Center for Substance Abuse Treatment (CSAT) is revisiting regulations governing opioid treatment programs (OTPs), as required by the 2023 Consolidated Appropriations Act passed by Congress. These new federal rules around treatment will change how medications are delivered to persons with opioid use disorder (OUD), offering opioid treatment centers a unique opportunity to advance person-centered care, and can build on the lessons learned from the flexibilities offered during the public health emergency.

This is a real opportunity to change how care is delivered. It will increase access to lifesaving medications, including:

A change in take-home schedules, which will allow for additional take-home medications sooner in the treatment process to reduce the burden of coming to the program daily, alleviating transportation challenges and the disruption of work and family routines.
Emphasizing and codifying the importance of harm reduction.
Clarifying diagnoses required for admission to be active moderate-to-severe OUD, OUD in remission, or at high risk for recurrence or overdose.
Removing access barriers for persons under 18; expanding use of telehealth; and finally, expanding interim maintenance dosing up to 180 days in a 12-month period.

These new changes will help alleviate admission barriers caused by workforce shortages and allow patients better access to medication and treatment. The increase in use of telehealth combined with medications for opioid use disorder (MOUD) will remove time and travel barriers for treatment, allowing persons treated with methadone and buprenorphine, including new persons, to be treated remotely.

What does this mean for the field?

OTPs have historically been reimbursed based on volume, with daily attendance as a steady source of revenue and a “captive” audience for counseling services. For persons with OUD to feel the full benefits of the new rule, changes will need to be made at all levels:

OTPs will need to rethink their clinical models to develop a service mix driven by a person’s need as opposed to regulations. Engagement will drive attendance, outcomes and thus revenue. Additionally, there will be a need to:
- Retrain staff.
- Work with medical team to develop new clinical protocols.
- Structure revenue cycle management processes and business models of service delivery.
Regulators will need to adapt state licensing rules and re-train licensing staff.
Payers have an opportunity to move Value-Based Payment (VBP) more steadily into the OUD treatment space and will need to realign payment structures to incentivize providers to provide care according to a person’s need.

If you want to learn more about the changes ahead, HMA hosted a 3-part webinar series on the effect of proposed regulations on delivery of opioid treatment services. The series New Rules in Treatment of Opioid Addiction was aimed at helping stakeholders prepare for and adapt to these changes to ensure a successful transition for the people they serve. Our series focuses on three areas where changes can help those managing OUD:

How do OTPs deliver services to better support persons with OUD?
How do payers create the right financial incentives to help providers deliver better behavioral health solutions for OUD?
How do state regulators make changes to rules and laws to promote a treatment system that prioritizes a person’s health and recovery?

Watch here:

Part 1 Opioid Treatment Providers

Part 2 Opioid State Payers – Aligning Incentives for Treatment

Part 3 Opportunities for State Regulators to Shape Policy and Regulation of Treatment

If you are ready to explore these changes in your organization, HMA can help. We have experience in:

Developing clinical workflows
Aligning revenue cycle and clinical operations
Developing and implementing state OUD code
Supporting health plans and providers in moving into VBP
Supporting health plans in adapting to new clinical models

Advancing Life Sciences with expertise across healthcare

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Your organization’s success relies on understanding evolving market dynamics and navigating a complex statutory and regulatory environment. Drug, device, and diagnostic firms, from established to start-up, come to HMA when they want experienced partners who can help with regulatory strategy, coding, coverage, and payment solutions, investment strategy, navigating the complexities of federal and state law, or even creating new policy. HMA, working with our partner companies, provides consulting with depth and breadth throughout the life sciences sector and the broader healthcare industry.

We work with drug, device, and diagnostic companies and their trade associations, pharmacies, physician specialty societies, hospitals, health systems, and community health centers, as well as investment firms and their portfolio companies.

Before joining HMA, our team spent years as senior officials in Medicare and Medicaid; cabinet-level health secretaries; and policy advisors to governors and other elected officials. They also served as directors of large nonprofit and social services organizations, top-level advisors, and C-level executives. Our team is expert in federal and state policy, reimbursement, actuarial consulting, medical coding support, public affairs, and corporate development.

Our Life Sciences team, comprised of experts across our firm, can help with:

We help you navigate the complexities of FDA regulation to help with product development and marketing authorization strategies and regulation throughout the product lifecycle.

Regulatory policy counseling

Product development and target product profile

FDA authorization strategy

Post-approval compliance

Contact our FDA Experts:

Clay Alspach, Principal, Leavitt Partners
Ralph Hall, Senior Advisor, Leavitt Partners
Eric Marshall, Principal, Leavitt Partners
Amy Rick, Principal, Leavitt Partners
Vince Ventimiglia, CEO, Leavitt Partners Collaborative Advocates

We help your organization understand the commercial market for life sciences products and develop strategies to support patient access, product launches and growth, and value.

Market intelligence, including market, customer, and stakeholder analysis

Strategic planning, considering risk-based contracting, value-based care, and population health

Business development and strategy

Formulary and market access insights

Go-to-market and launch strategies

Contact our Commercial Experts:

David Kulick, Managing Director, HMA
Spencer Morrison, Associate Principal, Leavitt Partners
Rebecca Nielsen, Managing Director, Leavitt Partners
Alex Rich, Managing Director, HMA

Experts in Medicare, Medicaid, and the commercial market, we help you understand and navigate the complexities of coding, coverage, and payment for approved products and develop and execute strategies to support product access and value.

Code assessment and recommendation

Coverage mapping and guidance

Payment strategy across settings

CMS engagement

Emerging technology strategies

Alternative payment model (APM) development

Payment change impact modeling

Contact our Reimbursement Experts:

Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, HMA
Zach Gaumer, Principal, HMA
Kevin Kirby, Managing Director, HMA
Rachel Kramer, Principal, HMA
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, HMA

We help you understand how evolving Federal policy impacts your business and develop strategies for creating and advancing Federal policy that advances value and your business.

Congressional and Administration intelligence and strategy

Policy development and strategy

Multi-sector alliances to create and advance new policy

Policy modeling and CBO scoring projections

Contact our Federal Experts:

Clay Alspach, Principal, Leavitt Partners
Amy Bassano, Managing Director, Medicare, HMA
Mark Desmarais, Principal, HMA
Zach Gaumer, Principal, HMA
Ralph Hall, Senior Advisor, Leavitt Partners
Kevin Kirby, Managing Director, HMA
Rachel Kramer, Principal, HMA
Anne Marie Lauterbach, Principal, Leavitt Partners
Clare Mamerow, Principal, HMA
Eric Marshall, Principal, Leavitt Partners
Sara Singleton, Principal, Leavitt Partners
Josh Trent, Managing Principal, Leavitt Partners
Vince Ventimiglia, C EO, Leavitt Partners Collaborative Advocates
Liz Wroe, Principal, Leavitt Partners

We help you understand how evolving State policy impacts your business and develop strategies to support product access and value in Medicaid programs.

State-related access issues

State policy impact modeling

State research support

Contact our State Experts:

Clay Alspach, Principal, Leavitt Partners
Anne Marie Lauterbach, Principal, Leavitt Partners
Stephen Palmer, Managing Principal, HMA
Matt Powers, Managing Director, HMA
Josh Trent, Managing Principal, Leavitt Partners

We work with investment firms and their portfolio companies to provide insight that helps you invest wisely in the rapidly evolving healthcare marketplace.

Comprehensive due diligence studies

In-depth research projects

Billing and compliance reviews

Identification, analysis, and outlook on federal, state, and local reimbursement/regulatory issues

Contact our Investment Strategy Experts:

David Kulick, Managing Director, HMA
Alex Rich, Managing Director, HMA

Project Spotlight

Pipeline research and policy recommendations to address new innovative therapies

A large national pharmaceutical manufacturer hired HMA, The Moran Company, and Leavitt Partners, both HMA subsidiaries, to assess the current pipeline of innovative therapies, examine current reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process.

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

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This week, our In Focus section reviews a wide-ranging proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) on November 6, 2023. The rule would update various policies governing Medicare Advantage (MA, or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly. These proposed policy reforms would implement changes related to Star Ratings, marketing and communications, agent/broker compensation, health equity, dual eligible special needs plans (D-SNPs), utilization management, network adequacy, and other programmatic areas. The proposals reflect the agency’s continuing focus on increasing program transparency, improving health equity, reducing the cost of care for Medicare beneficiaries, and expanding access to behavioral health services.

MA and Part D stakeholders are encouraged to provide CMS with feedback and analysis regarding the potential impact of these changes. Comments on the proposed rule are due by January 5, 2024. The final rule would take effect in contract year 2025.

Improving Access to Behavioral Health Care Providers

CMS proposes regulatory changes intended to improve access to behavioral healthcare by adding certain provider specialties to the MA network adequacy standards as follows.

CMS proposes to add a new facility-specialty type to the existing list of facility-specialty types evaluated as part of its plan network adequacy reviews. The new facility-specialty type, outpatient behavioral health, would be included in network adequacy evaluations, including marriage and family therapists (MFTs), mental health counselors (MHCs), opioid treatment programs, community mental health centers, and/or other behavioral health and addiction medicine specialists and facilities.
MFTs and MHCs will be eligible to enroll in Medicare and start billing for services beginning January 1, 2024, because of the new statutory benefit category established in the Consolidated Appropriations Act (CAA) of 2023. CMS proposes to make corresponding changes to its network adequacy requirements for MA organizations.
For purposes of the network adequacy requirements, the new facility-specialty type would be evaluated using time and distance and minimum number standards in the proposed regulation.

Increased Transparency for Special Supplemental Benefits for the Chronically Ill

In 2018, Congress enacted new authorities pertaining to supplemental benefits for MA members with chronic health conditions. CMS refers to this category of benefits as Special Supplemental Benefits for the Chronically Ill (SSBCI). These services are available only to enrollees with ongoing conditions and who meet certain criteria established in the statute. In contrast to the general policy that MA benefits should be offered uniformly to all plan members, MA plans may offer SSBCI tailored to a qualifying individual’s specific medical diagnosis and needs.

Supplemental benefits, including SSBCI, are generally funded with MA plan rebate dollars. CMS notes that the number of MA plans that offer SSBCI—and the number and scope of SSBCI that individual plans provide—has increased since their introduction in 2019.

Under the proposed rule:

MA organizations would be required to demonstrate, through relevant and acceptable evidence, that an item or service offered as SSBCI has a reasonable likelihood of improving or maintaining the health or overall function of chronically ill beneficiaries. MA plans also must, by the date on which they submit a bid to CMS, include a bibliography of evidence supporting this position. According to CMS, this expectation would shift the burden of proof from the agency to MA organizations, requiring plans to demonstrate compliance with this standard and that SSBCI items and services are evidence-based.
MA plans must follow their written policies based on objective criteria for determining enrollee eligibility for SSBCI when making determinations.
Require that MA plans document denials of SSBCI eligibility rather than its approvals.
CMS would codify its authority to review and deny approval of an MA organization’s bid if the plan cannot demonstrate, through relevant and acceptable evidence, that its proposed SSBCI has a reasonable expectation of improving or maintaining the health or overall function of a chronically ill enrollee.
CMS also would codify its authority to review SSBCI offerings annually for compliance and in light of the available evidence.

According to CMS, these proposals, if implemented, would better ensure that the benefits offered as SSBCI are reasonably expected to positively affect the health and well-being of chronically ill beneficiaries and guard against the use of MA rebate dollars for SSBCI that unsubstantiated.

In addition, CMS is proposing new policies to improve transparency regarding SSBCI so that beneficiaries are aware that SSBCI are only available to enrollees who meet the eligibility criteria. More specifically, CMS proposes to:

Modify the current requirements for the SSBCI disclaimer that MA organizations must use whenever SSBCI are mentioned. The SSBCI disclaimer would have to list the relevant chronic condition(s) that qualify for the benefits that MA organizations offer.
Establish specific font and reading pace parameters for the SSBCI disclaimer in print, television, online, social media, radio, other voice-based ads, and outdoor advertising, including billboards. Finally, it would clarify that MA organizations must include the disclaimer in all marketing and communications materials that mention SSBCI.

Requiring Mid-Year Enrollee Notification of Available Supplemental Benefits

As noted previously, over the past several years, the number of MA plans offering supplemental benefits has increased. The benefits offered are broader in scope and variety, and an increasing amount of MA rebate dollars are being directed toward these benefits. At the same time, plans have reported that the number of enrollees who use many of these benefits is low.

CMS proposes requiring MA plans to notify enrollees mid-year of the unused supplemental benefits available to them. The notice would list any supplemental benefits that a beneficiary does not use during the first six months of the year (January 1−June 30).
At present, MA plans are not required to send any communication specific to an enrollee’s usage of supplemental benefits. This policy is intended to educate enrollees on their access to supplemental benefits and encourage greater use of these benefits.

Enhancing “Guardrails” for Agent and Broker Compensation

For many years, CMS has set upper limits on the compensation that agents and brokers can receive for enrolling Medicare beneficiaries in MA and Part D plans. CMS believes that many MA and prescription drug payment plans, as well as third-party entities with which they contract, make structured payments to agents and brokers that circumvent these compensation caps.

In this regulation, CMS proposes to generally prohibit contract terms between MA organizations and agents, brokers, or other third party marketing organizations (TPMOs) that may interfere with the agent’s or broker’s ability to objectively assess and recommend the plan that best-suited to a beneficiary’s healthcare needs; to set a single reimbursement rate for all plans; to revise the scope of items and services included within agent and broker compensation; and to eliminate the regulatory framework that currently allows for separate payment to agents and brokers for administrative services.
The agency would make conforming changes to the Part D agent broker compensation rules.

Requiring an Annual Health Equity Analysis of Utilization Management Policies and Procedures

CMS proposes several regulatory changes to the composition and responsibilities of an MA organization’s utilization management (UM) committee.

The new rules would require that a member of the UM committee have expertise in health equity and that the UM committee conduct an annual health equity analysis of the use of prior authorization.
The proposed analysis would examine the impact of prior authorization on enrollees with one or both of the following social risk factors (SRFs): receipt of the low-income subsidy, dual eligibility for Medicare and Medicaid (LIS/DE), or a disability.
The proposed analysis must compare metrics related to the use of prior authorization for enrollees with the specified SRFs with enrollees without the specified SRFs. The results of the analysis must be made publicly available on the MA organization’s website in an easily accessed manner.

Enhancing Enrollees’ Right to Appeal an MA Plan’s Decision to Terminate Coverage for Non-Hospital Provider Services

Beneficiaries enrolled in traditional Medicare and MA plans have the right to a fast-track appeal by an independent review entity (IRE) when their covered skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. At present, quality improvement organizations (QIOs) function as IREs and conduct these reviews.

Furthermore, MA enrollees do not have the same access to QIO review of a fast-track appeal as traditional Medicare beneficiaries.

CMS proposes to:

Require that QIOs, instead of MA plans, review untimely fast-track appeals of an MA plan’s decision to terminate HHA, CORF, or SNF services
Fully eliminate the provision requiring the forfeiture of an enrollee’s right to appeal a termination of services decision when they leave the facility

According to CMS, these proposals would align MA regulations with the parallel reviews available to beneficiaries in traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.

Increasing the Percentage of Dually Eligible Managed Care Enrollees Who Receive Medicare and Medicaid Services from the Same Organization

In the proposed rule, CMS expresses concern that a significant number of dually eligible enrollees receive Medicare services through one managed care entity and Medicaid services through another (misaligned enrollment), rather than from one organization (aligned enrollment. The proposed rule states that in the long run, “for dually eligible individuals who are in Medicare and Medicaid managed care, we believe that we should continue to drive toward increasing aligned enrollment until it is the normative, if not only, managed care enrollment scenario…. For dually eligible individuals that elect MA plans, we are focused on increasing enrollment in integrated D-SNPs: fully integrated dual eligible special needs plans (FIDE SNPs), highly integrated dual eligible special needs plans (HIDE SNPs), and applicable integrated plans (AIPs) [pages 286-287].”

To move in this direction, CMS offers several interconnected proposals as follows:

Replace the current quarterly special enrollment period (SEP) with a monthly SEP for dually eligible individuals and others enrolled in the Part D low-income subsidy program to elect a standalone PDP
Create a new integrated care SEP to allow dually eligible individuals to elect an integrated D-SNP on a monthly basis
Limit enrollment in certain D-SNPs to individuals who are also enrolled in an affiliated Medicaid managed care organization (MCO)
Limit the number of D-SNP plan benefit packages an MA organization, its parent organization, or an entity that shares a parent company with the MA organization, can offer in the same service area as an affiliated Medicaid MCO

According to CMS, these initiatives would increase the percentage of dually eligible MA enrollees who are in plans that are also contracted to cover Medicaid benefits, thereby expanding access to integrated materials, unified appeal processes across Medicare and Medicaid, and continued Medicare services during an appeal.

Impose New Contracting Standards for Dual Eligible Special Needs Plan (D-SNP) Look-Alikes

Under existing regulations, CMS does not contract with and will not renew the contract of a D-SNP look-alike; that is, an MA plan that is not a SNP but in which dually eligible enrollees account for 80 percent or more of total enrollment. CMS proposes to lower the D-SNP look-alike threshold from 80 percent to 70 percent in 2025 and to 60 percent in 2026. CMS states that this proposal is intended to help address the continued proliferation of MA plans that serve high percentages of dually eligible individuals without meeting D-SNP requirements.

November is National Adoption Month

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When Love is Not Enough to Preserve a Forever Family for a Child

Families formed by adoption face unique challenges in their lifelong journey as adoptees, parents, and siblings. Adoption-competent mental health is a necessary resource for adoptive families. This November, we are honoring adoption as a vital permanency strategy and the importance of forever families in the lives of children and youth who need this sense of permanency, security, and wellbeing.

The Children’s Bureau, part of the U.S. Department of Health and Human Services Office of the Administration for Children and Families (ACF) created National Adoption month to increase national awareness of adoption issues, encourage the development of permanent relationships, and bring attention to the need for adoptive families to provide placement for teens in the U.S. foster care system. The theme for 2023, “Empowering Youth: Finding Points of Connection,” focuses on ways to provide opportunities and services that connect youth to their identity—including culture, background, interests, and ambitions – to support meaningful permanent relationships with adults.

Adoption Statistics

The following are key data from the fiscal year 2021 report for the Adoption and Foster Care Analysis and Reporting System.

In the U.S., as of September 30, 2021, there were 114,000 children and youth waiting to be adopted who were at risk of aging out of foster care without permanent family connections.

More than one in five children waiting for adoption were 13–17 years old.
The average age of all children waiting to be adopted was 7.5 years old.
The average time in care for all children waiting to be adopted was 33.7 months.
The average time in care for children waiting to be adopted after termination of parental rights was 19 months.

The National Council for Adoption reports an 18 percent decrease in adoptions from FY19-FY21, with over 19,000 children who aged out of foster care without a permanent family. There has been a 24 percent decrease in domestic adoptions from 2019-2020 and 93 percent decline in intercountry adoptions since peaking in 2004.^[1] . These data points reflect the urgency of revitalizing adoption as an important tool for the wellbeing of children who need permanent loving families.

Recognizing that adoption is just the beginning of the family’s journey and the fact that adoptive families need special attention, especially when the children who have been adopted have suffered the trauma of entering the child welfare system, mental health treatment and resources are critical to the wellbeing of these families and the children in them.

Importance of Identity

Research has shown that strong cultural identity can contribute to mental health resilience, higher levels of social well-being, and improved coping skills, greater self-esteem, higher education levels, better psychological adjustment, and improved coping abilities.^[2] But many youth in foster care often have lower cultural identity strength than those who did not experience foster care. This can lead to higher levels of loneliness and depression, lower self-esteem, and difficult psychological adjustments that in turn affect coping skills and learning.^[3]

In her book You Should be Grateful, Angela Tucker offers many practical insights and tools aimed at nurturing identity and helping transracial families and adoptees to center around the cultural norms and experiences of the adoptees themselves.^[4]

A Changing Landscape

Many states now have safe-haven laws where parents can drop off their babies without penalty at hospitals, fire stations or police department if they are not able to care for them knowing their babies will be cared for and placed in families through the child welfare system. At the same time there are many children and youth who languish in foster care waiting for a ‘forever family’ to adopt them. Thousands of teens in foster care are looking for the love, support, and encouragement that families provide throughout their lives—not just until they turn 18. Youth who were adopted from the foster care system when they are 16 or older may be able to access Education and Training Vouchers (ETV) of up to $5,000 per year. Those who were adopted from foster care when they are 13 or older are more likely to qualify for federal financial student aid because they do not have to count family income when applying.^[5]

When it comes to medical and mental health benefits, qualifying families may receive federally funded monthly maintenance payments, and other support, often until a child turns 18 or 21, depending on the state where they live, and medical assistance until age 26 if they were in foster care at a certain age depending on the state. Recognizing the need for adoption competent mental health, the Federal Administration for Children and Families has awarded the Center for Adoption Support and Education the grant to build a national Center to Support Mental Health Services in the Child Welfare System.^[6]

The recent Biden-Harris regulations strengthen services and supports for children and families in the child welfare system. These regulations require additional support for kinship families, and protections for LGBTQI+ youth and expansion of access to legal services for children and families entering the child welfare system. Congress could use the momentum from these regulations to make the Adoption Tax Credit fully refundable and extend it to legal guardians to assist with the financial resources of raising children.

The recent Supreme Court Dobbs decision will likely impact adoption trends, but that trend is still evolving and will need to be monitored before conclusions can be drawn.

How HMA Can Help

HMA assists organizations working in child welfare and adoption, and grounds our work in human-centered design, lived expertise, and change management and leadership principles in state and county program development. We can help support organizations working with children and youth in foster care or with adoption agencies by:

Providing technical assistance to state and local government, and community-based organizations
Developing system redesign and strategic planning
Facilitating stakeholder engagement
Implementing workforce and leadership development strategies

Visit the ACF website to learn more about National Adoption Month and find tools and resources to educate yourself and your community about how we can achieve better outcomes for youth in foster care.

If you have questions on how HMA can support your efforts in Child and Family Wellbeing, please contact our experts below.

[1] Adoption by the Numbers – National Council for Adoption (adoptioncouncil.org)

[2] Anderson, M., & L.O. Linares. “The Role of Cultural Dissimilarity Factors on Child Adjustment Following Foster Placement.” Children and Youth Services Review 34(4), 2012, 597-601.

[3] Children on AdoptUSKids – AdoptUSKids

[4] “You Should Be Grateful” Stories of Race, Identity and Transracial Adoption — Angela Tucker

[5] Teens need families – AdoptUSKids

[6] Adoption Support Center & Services | C.A.S.E

Preventing Type 2 Diabetes in correctional settings

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Today is World Diabetes Day, a day created to keep the importance of diabetes prevention and management in the public and political spotlight. One in every four U.S. healthcare dollars is spent on individuals diagnosed with diabetes, and more than half of that expenditure is directly attributable to diabetes. An estimated 37 million people in the U.S. have type 2 diabetes, and another 96 million (more than one out of every three people) have prediabetes, meaning they are at risk of developing type 2 diabetes.^[i]

The urgency of preventing and managing type 2 diabetes is as applicable in correctional facilities as it is in populations in the community. Especially as there is an overrepresentation of populations that have a higher burden of prediabetes and type 2 diabetes in correctional facilities including individuals who:

are older,
have serious mental illness,
have poorer physical and mental health than counterparts in the community,
are above recommended body weight,
have reduced access to health insurance, and
are from racial and ethnic minority groups.

Administrators of correctional facilities are responsible for the healthcare costs for individuals in their custody who have type 2 diabetes, and the cost of managing this condition in these settings is particularly high.

Fortunately, type 2 diabetes is preventable. One evidence-based and effective strategy for preventing type 2 diabetes is the National Diabetes Prevention Program (National DPP) lifestyle change program. This program is a year-long evidence-based program delivered over 22 sessions using a CDC-approved curriculum. Program participants are expected to lose 5−7 percent of their weight and engage in physical activity for 150 minutes each week.^[ii]The National DPP lifestyle change program can be offered in person, online, through distance learning, or a combined approach and is led by a trained lifestyle coach.^[iii]The program has been proven to reduce the risk of individuals with prediabetes developing type 2 diabetes by 58 percent (71 percent for people older than age 60).^[iv] Projections in other settings that compare the cost of the National DPP lifestyle change program to the costs of treating type 2 diabetes show that the program is cost-effective.^[v]

HMA recently published a white paper, “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings,” describing how the National DPP lifestyle change program can be used to achieve cost savings and better health for people at risk of developing type 2 diabetes in correctional settings. There have been two successful implementations of the National DPP lifestyle change program to date. The first is described in the study “Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting,” where 47 people from a federal correctional facility participated in a modified version of the National DPP lifestyle change program. Participants who completed the program demonstrated significant reductions in their body mass index and A1C levels. Weight loss in the study was similar to what participants of the National DPP lifestyle change program in the community typically achieve.^[vi]

The second successful implementation is with the Wisconsin Department of Corrections (DOC), which has successfully offered the National DPP lifestyle change program in three correctional facilities. To date, 19 Wisconsin DOC staff have trained as lifestyle coaches and 131 individuals across the three facilities have participated in the program. The Wisconsin National DPP state quality specialist shared the following cohort data in 2018−2019:

16 percent of the participants were Black and 84 percent were White
100 percent of participants were male, with an average age of 45.6 years
58 percent of participants were eligible for the program based on a blood test
100 percent of participants attended 14 or more sessions in months one through six (typically, 16 sessions take place in the first six months)
71 percent of participants attended six or more sessions in months 7−12 (typically, six sessions take place in the second six months)

Overall average weight loss was 8.3 percent during the year-long cohort, well above the National DPP lifestyle change program goal of 5−7 percent weight loss. The response from program participants was positive. Wisconsin DOC plans to scale the National DPP lifestyle change program to all appropriate facilities in the future.

For additional information, consult the white paper “Implementing the National Diabetes Prevention Program Lifestyle Change Program in Correctional Settings.”

If you would like to learn more about how HMA can help your organization implement a DPP program, contact our experts below.

[i] Centers for Disease Control and Prevention. The Facts, Stats, and Impacts of Diabetes. Available at: https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed April 18, 2023.

[ii] Centers for Disease Control and Prevention. Research Behind the National DPP. Available at: https://www.cdc.gov/diabetes/prevention/research-behind-ndpp.htm. Accessed on June 15, 2023.

[iii] National DPP Coverage Toolkit. National DPP Coverage Toolkit: Delivery Options. Available at: https://coveragetoolkit.org/medicaid-agencies/medicaid-agencies-delivery/program-delivery-options/. Accessed January 18, 2023.

[iv]Centers for Disease Control and Prevention. National Diabetes Prevention Program. Available at: https://www.cdc.gov/diabetes/prevention/index.html. Accessed December 19, 2022.

[v]National DPP Coverage Toolkit. Cost & Value. Available at: https://coveragetoolkit.org/cost-value-elements/. Accessed June 15, 2023.

[vi]Fine A, Gallaway SM, Dukate A. Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting. Diabetes Spectrum. 2019;32(4):331-337.

CMS issues final 2024 provider payment rules

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This week, our In Focus section reviews several calendar year (CY) 2024 Medicare payment final rules that the Centers for Medicare & Medicaid Services (CMS) issued in recent weeks, including those pertaining to:

The Physician Fee Schedule and Other Changes to Medicare Part B Policies
The Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) reimbursement
The Home Health Prospective Payment System Rate Update, Quality Reporting Program Requirements, and Value-Based Purchasing Expanded Model Requirements
The End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)

CMS also announced the OPPS Rule for 340B-Acquired Drug Payment Policy in response to court-invalidated payment rates and on November 6, 2023, released the 2025 Contract Year Policy and Technical Changes to Medicare Advantage. The latter regulation addresses guardrails for brokers, behavioral health expansions, and several dual eligible-related policies. We will analyze these provisions in next week’s In Focus.

These final rules set the payment rates and other Medicare payment policies for services that applicable providers provide under the fee-for-service Medicare program and take effect January 1, 2024. Additionally, the final rules, particularly the Physician Fee Schedule, are expected to further inform Congress’ discussions and, ultimately, any action on healthcare policies in a possible year-end legislative package.

For example, the Senate Finance Committee has released draft language that would mitigate the projected physician payment reduction, among other policy changes. Provider organizations and interested stakeholders will want to analyze the impact of the final policies across the rules, including new codes, payment rates, and opportunities to participate in accountable care organizations (ACOs).

Overall, Health Management Associates (HMA) notes several trends across these three Medicare payment regulations:

Health equity remains a significant focus of CMS under the Biden Administration.
The agency continues to expand its coverage of behavioral health services under Medicare and enhance payment for and access to these services.
Medicare is moving toward incrementally supporting care delivered in accordance with beneficiaries’ preferences, such as moving away from reimbursing largely for in-person services and toward supporting telehealth services.
CMS is creating pathways for reimbursement for a broader range of clinicians and caregivers who are addressing Medicare beneficiaries’ needs.
CMS continues its efforts to improve hospital price transparency with policies aimed at encouraging providers to publicly report data.

2024 Medicare Physician Fee Schedule and Other Part B Payment Policies Final Rule

On November 2, 2023, CMS released the final rule for the Medicare Physician Fee Schedule (MPFS) for CY 2024. CMS finalized an overall 1.25 percent decrease in MPFS payment rates from 2023 to 2024. The final 2024 PFS conversion factor remains largely unchanged ($32.74) from the proposed rule ($32.75) but will result in a 3 percent decrease from the CY 2023 conversion factor ($33.89). Among the most important policy changes in the final rule is the establishment of a new add-on code (G2211) for complex care provided in the primary care setting.

In addition, CMS will begin allowing additional behavioral health providers to participate in Medicare (described further below) and make numerous telehealth policy changes mandated in the Consolidated Appropriations Act of 2023. CMS also finalized changes to the Medicare Shared Savings Program (MSSP), which CMS estimates will increase ACO participation in MSSP by roughly 10−20 percent.

CMS finalized several policies to address health equity, including coding and payment changes focused on providing access to new services and addressing Medicare beneficiaries’ unmet health-related social needs (HRSNs). The final changes affect mental health and substance use disorder (SUD) treatment providers, address payment accuracy for primary care in the context of whole-person care, and expand access to dental care for cancer patients. The changes for 2024 include:

Caregiver training: Medicare will now pay practitioners who train caregivers to support patients with certain diseases (e.g., dementia) in carrying out a treatment plan. Services must be furnished by a physician or a non-physician practitioner or therapist.
Community health integration (CHI) services: The final rule includes separate coding and payment for CHI services, including person-centered planning, health system coordination, and facilitating access to community-based resources to address unmet social needs that interfere with a practitioner’s diagnosis and treatment plan.
Principal illness navigation (PIN) services: The final coding and payment rules for PIN services describe care navigation services for individuals with high-risk conditions. CMS included a subset of PIN services to support individuals with severe mental illness and SUD through use of auxiliary personnel (i.e., peer support specialists). The definition of a serious, high-risk condition is dependent on clinical judgment. CMS will monitor utilization across beneficiaries and specialties to ascertain how PIN services are best used going forward.
Social determinants of health risk assessments: This evaluation can be provided and billed as an add-on service to an annual wellness visit or with an evaluation and management or behavioral health visit.
Marriage and family therapists and mental health counselors, including eligible addiction, alcohol, or drug counselors who meet qualification requirements for mental health counselors: These types of providers may now enroll in Medicare and bill for their services starting January 1, 2024. The rule expands coverage and increases payment for crisis care (including mobile units), SUD treatment, and psychotherapy as well as psychotherapy performed in conjunction with an office visit and for health behavior assessment and intervention services.

2024 Hospital OPPS and ASC Final Rule

On November 2, 2023, CMS released a final rule for hospital OPPS and ASCs. The following policies are included in the final rule:

A 3.1 percent increase in payment rates for hospitals and ASCs that meet certain quality reporting requirements. This amount is based on the projected 3.3 percent increase in the hospital market basket and is consistent with the 2024 payment increase for inpatient services.
No services will be removed from the inpatient-only (IPO) list, but 10 procedures will be added to the IPO.
The list of ASC-covered surgical procedures will be updated to include 37 additional surgical procedures.
Drugs and biologicals acquired through the 340B program will have the same payment rate as those not acquired under the 340B program—the average sales price plus 6 percent.
CMS will pay for intensive outpatient program services. The final rule includes the scope of benefits, physician certification requirements, coding and billing, and payment rates.

340B Rule

Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs or biologicals from manufacturers at discounted prices. Until 2018, the Medicare payment rate for Part B-covered outpatient drugs provided in outpatient hospitals was generally the average sales price (ASP) plus 6 percent. From 2018 through September 2022, CMS paid for these drugs at ASP (22.5 percent). After extensive litigation and a Supreme Court ruling, CMS returned payment for 340B drugs to ASP plus 6 percent in late 2022, and payment has continued at that level since. Consequently, payment for other services was reduced slightly more than 3 percent in 2023 to meet statutory budget neutrality requirements.

In this rule, CMS finalizes a remedy for 2018−22 payments in light of the court rulings. The agency will provide lump sum payments to 340B hospitals to cover the difference between ASP + 6 percent and ASP – 22.5 percent. Lump sum payments to 340B hospitals will result in roughly $9 billion in payouts to these facilities, in addition to the $1.5 billion they already have received through resubmitted claims. CMS had proposed that beginning in 2025, non-drug OPPS payments would be reduced by 0.5 percent to recover the budget neutrality-based payment increases resulting from the rescinded 340B cuts. According to CMS, hospitals received approximately $7.8 billion in additional spending on non-drug items and services because of budget neutrality. Earlier this year, CMS proposed a 0.5 percent pay cut to all hospitals, which would be in place for 16 years to fully adjust for the payment changes. CMS is finalizing the budget neutrality adjustment but will defer implementing these cuts to 2026 based on public comments about hospital budgetary pressures.

CY 2024 Home Health Prospective Payment System Final Rule

On November 1, 2023, CMS issued the CY 2024 Home Health Prospective Payment System (HH PPS) Rate Update final rule, which informs Medicare payment policies and rates for home health agencies (HHAs). This rule includes routine revisions to the Medicare Home Health PPS payment rates for CY 2024 in accordance with existing statutory and regulatory requirements. According to CMS estimates, Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, or $140 million, from CY 2023.

However, CMS also finalized a permanent prospective payment adjustment to the CY 2024 home health 30-day period payment rate that reduces the update. This adjustment is intended to account for any increases or decreases in aggregate expenditures that result from the implementation of the Patient-Driven Groupings Model (PDGM) and 30-day unit of payment as required in the Bipartisan Budget Act of 2018. The finalized −2.890 percent adjustment is half the total projected adjustment of negative 5.779 percent. As a result, CMS estimates that Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, rather than the 2.2 percent decrease as initially proposed.

CMS’ decision to implement only half of the permanent prospective payment adjustment in CY 2024 was in response to concerns from public commenters about the magnitude of implementing the proposed large single-year payment reduction. However, CMS also maintains that it will have to account for the remaining permanent adjustment it chose not to apply in CY 2024 and make other potential adjustments to the base payment rate in future rulemaking.

Other Proposals

CMS also is finalizing proposals to:

Rebase and revise the home health market basket to adopt a 2021-based home health market basket, including proposed changes to the market basket cost weights and price proxies
Reduce the labor-related share of the market basket to 74.9 percent based on the 2021-based home health market basket compensation cost weight (down from 76.1 percent)
Recalibrate the PDGM case-mix weights using CY 2022 data
Update the low utilization payment adjustment thresholds, functional impairment levels, and comorbidity adjustment subgroups for CY 2024
Codify statutory requirements for disposable negative pressure wound therapy
Establish regulations to implement payment for items and services under two new benefits: lymphedema compression treatment items and home intravenous immune globulin
Establish several enrollment provisions for hospices and other provider types and create a new informal dispute resolution process for hospice programs and a special focus program to provide enhanced oversight of the poorest-performing hospices
Implement various changes to the Home Health Quality Reporting Program and Home Health Value-Based Purchasing Model

2024 End-Stage Renal Disease Prospective Payment System Final Rule

On October 27, 2023, CMS issued a final rule that updates payment rates and policies under ESRD PPS for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2024. This rule also updates the acute kidney injury (AKI) dialysis payment rate for renal dialysis services that ESRD facilities furnish in CY 2024.

For CY 2024, CMS will increase the ESRD PPS base rate to $271.02, upping total payments to ESRD facilities by approximately 2.1 percent. The CY 2024 ESRD PPS final rule also includes several changes related to ESRD PPS payment policies. First, the rule includes a payment adjustment that will increase payment for certain new renal dialysis drugs and biological products after the transitional drug add-on payment adjustment period ends. According to CMS, the increase will ensure payment is not a barrier to accessing innovative treatments for Medicare ESRD beneficiaries.

For more details about the policies described herein, contact our experts below.

Michigan releases Medicaid Managed Care RFP

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This week, our In Focus section reviews the Michigan Medicaid Managed Care Comprehensive Health Care Program (CHCP) request for proposals (RFP), which the Michigan Department of Health and Human Services released on October 30, 2023. CHCP covers 2.2 million Medicaid members and is worth approximately $15 billion.

MIHealthyLife

The rebid is part of MIHealthyLife, an initiative that the department launched in 2022 to strengthen Medicaid services through new Medicaid health plan contracts. At that time, Michigan Medicaid sought input from nearly 10,000 stakeholders in an effort to strengthen Medicaid managed care contracts and create a more equitable, coordinated, and person-centered system of care. Based on the feedback, the department designed the RFP with a focus on five strategic pillars:

• Serve the Whole Person, Coordinating Health and Health-Related Needs
• Give All Kids a Healthy Start
• Promote Health Equity and Reduce Racial and Ethnic Disparities
• Drive Innovation and Operational Excellence
• Engage Members, Families and Communities

RFP

Medicaid managed care organizations (MCOs) serve 10 regions, each consisting of multiple counties. MCOs will bid on one or more of the regions throughout the state. Each region requires at least two plans, with the exception of Region 1, a rural area that includes Michigan’s Upper Peninsula, where members are enrolled in a single plan.

As part of the MIHealthyLife initiative, the RFP will include the following changes:

• Prioritizing health equity by requiring Medicaid health plans to achieve National Committee for Quality Assurance Health Equity Accreditation
• Addressing social determinants of health through investment in and engagement with community-based organizations
• Increasing childhood immunization rates, including greater provider participation in the Vaccines for Children program
• Adopting a more person-centered approach to mental health coverage
• Ensuring access to health care providers by strengthening network requirements
• Increasing Medicaid Health Plan accountability and clarifying expectations to advance state priorities

Timeline

Proposals are due January 16, 2024, and implementation is anticipated to begin October 1, 2024. Contracts will run through September 30, 2029, with three one-year optional periods.

Current Market

Michigan currently has nine plans, which serve more than 2.2 million Medicaid and expansion members. The table below provides a breakdown of the plan market share by enrollment.

Link to RFP

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Government Funded Programs and Readiness

Being “Ready” Means Being Prepared and Planning in Advance

Strategies for Achieving and Maintaining Audit Readiness and Contract Compliance

The Value of a Proactive Approach

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One Care

SCO

RFR

Timeline

Current Market

No More Restrictive Requirement

Design Requirement

Outcomes Data Use Requirement

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Project Spotlight

Pipeline research and policy recommendations to address new innovative therapies

Improving Access to Behavioral Health Care Providers

Increased Transparency for Special Supplemental Benefits for the Chronically Ill

Requiring Mid-Year Enrollee Notification of Available Supplemental Benefits

Enhancing “Guardrails” for Agent and Broker Compensation

Requiring an Annual Health Equity Analysis of Utilization Management Policies and Procedures

Enhancing Enrollees’ Right to Appeal an MA Plan’s Decision to Terminate Coverage for Non-Hospital Provider Services

Increasing the Percentage of Dually Eligible Managed Care Enrollees Who Receive Medicare and Medicaid Services from the Same Organization

Impose New Contracting Standards for Dual Eligible Special Needs Plan (D-SNP) Look-Alikes

Other Topics in the Proposed Rule