黑料不打烊 Insights: Your source for healthcare news, ideas and analysis.
黑料不打烊 Insights 鈥� including our new podcast 鈥� puts the vast depth of 黑料不打烊鈥檚 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.
While legal experts assess the recent U.S. Supreme Court rulings, federal and state agency leaders face significant questions about how their agencies and their responsibilities will be impacted. This webinar featured insightful discussions with former federal and state agency leaders exploring the known and yet-to-be determined impacts of recent rulings on federal regulations, rulemaking and actions, and agency deference, and also explored the impact on state agencies implementing federal rules. The webinar addressed the impact of the pivotal and decisions. Together these decisions聽overturned the longstanding Chevron deference doctrine, are pushing Congress to craft more specific legislation, and are directing courts to interpret ambiguous statutes. The discussion also explored the most appropriate responses of agency leaders, anticipated the ways that these decisions impact federal and state agency decision-making, and identified areas of growing uncertainty.
Learning Objectives:
Understand what we know about the impact of these decisions on agency rulemaking and decision making, consider the impact on federal agency discretion, and understand the shift in power towards Congress and judicial interpretation
Analyze the likely impact on agency rulemaking processes
Explore state governance issues, both as a partner to federal agencies and as an implementer of federal policy and funds
Identify the most important questions yet to be answered
This week, 黑料不打烊 (黑料不打烊) shifts In Focus from a newsworthy development to commemorate a seminal event in the expansion and strengthening of healthcare access in the United States. On July 30, 1965, Medicaid and Medicare were signed into law under Title XVIII and Title XIX of the Social Security Act. Today we celebrate the 59th anniversary of this pivotal moment in America鈥檚 healthcare journey.
Medicaid: A Critical Safety Net that Remains Strong
All states, the District of Columbia, and the U.S. territories have Medicaid programs designed to provide health insurance coverage for low-income individuals. As of March 20241, 82,751,338 people, including eligible low-income adults, children, pregnant women, older adults, and people with disabilities are covered under their state鈥檚 Medicaid program in accordance with federal requirements. The COVID-19 pandemic underscored just how important this safety net program is for American families, as it continued to deliver vital services during unprecedented times.
Beyond its traditional role, Medicaid also drives significant innovations in care for people with complex conditions and challenges. States have implemented various programs and initiatives to improve healthcare quality and outcomes. These include:
Managed Care Expansion: Many states have expanded Medicaid managed care programs to enhance care coordination and improve health outcomes.
Value-Based Care Models: Innovations in value-based care are being tested, aiming to link reimbursement to quality of care and patient outcomes rather than volume of services.
Integration of Behavioral Health: Several states are integrating behavioral health services into Medicaid to address mental health and substance use disorders more effectively.
Telehealth: The pandemic accelerated the adoption of telehealth services in Medicaid, expanding access to care and reducing barriers for patients.
Medicare: Leading in Innovation and Coverage
Medicare provides coverage to more than 60 million seniors and people with disabilities. In addition to being a lifeline for so many Americans, Medicare is a force for innovation in health policy, piloting changes to payment and care delivery through the Innovation Center and through Medicare Advantage plan design. Key innovations include:
Alternative Payment Models: The Innovation Center has been at the center of piloting various alternative payment models to improve quality and reduce costs.
Medicare Advantage Enhancements: Medicare Advantage plans continue to evolve, offering more comprehensive benefits that include mental health and substance use disorder services and integrating additional services such as dental, vision, and wellness programs.
Chronic Care Management: Medicare is expanding its focus on chronic care management, providing additional resources and support for individuals with chronic conditions.
黑料不打烊鈥檚 Commitment to Medicaid and Medicare
Since 黑料不打烊鈥檚 founding, our experts have helped states, plans, providers, and other stakeholders deliver the full spectrum of Medicaid and Children鈥檚 Health Insurance Program (CHIP) services. As 黑料不打烊 has evolved, we have built a leading-edge Medicare team that includes former agency officials, plan leaders, policy and data analysts, and actuaries. Healthcare plans, providers, and innovators call upon our colleagues to anticipate policy and regulatory change, develop and support Medicare Advantage business, transform fee-for-service programs, and support access to new technologies and treatments that can both improve quality patient outcomes and reduce costs of care.
Our growing team of includes 10 former state Medicaid directors and many more former state agency leaders, hospital and health plan executives, senior officials from the Centers for Medicare & Medicaid Services (CMS), and public health leaders.
黑料不打烊 Colleagues Who Are Former Medicaid Directors Looking Ahead
As Medicaid and Medicare near their seventh decade, the programs will continue to evolve and change to better support covered individuals and meet the demands of policymakers and taxpayers. 黑料不打烊 experts are committed in service of this important mission, and we are excited about building their future together with our clients to create more innovative, high-quality care that improves health outcomes for all.
This week, our鈥�In Focus鈥痵ection reviews the notice of funding opportunity (NOFO) for the鈥�, which the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) announced on December 15, 2023. States interested in participating in this model must submit an application to CMS during the competitive application process.
As described in a December 2023 In Focus, pregnancy-related deaths have more than鈥�痵ince 1987 to 17.6 deaths per 100,000 live births, with鈥�痮nly worsening outcomes for different racial and ethnic groups. For example, the pregnancy-related mortality rates for Black and Native American and Alaska Native people are approximately two to three times higher than the rate for White people. In recent years,鈥�痟ave extended postpartum coverage, and鈥�痭ow offer doula coverage for Medicaid enrollees. This initiative accelerates the focus on maternal outcomes and, with Medicaid paying for nearly鈥�痮f births, has the potential to affect health across generations.
This model is designed exclusively to improve maternal healthcare for people enrolled in Medicaid and the Children鈥檚 Health Insurance Program (CHIP). The TMaH model takes a whole-person approach to pregnancy, childbirth, and postpartum care, addressing the physical, mental health, and social needs people experience during pregnancy.
Model Overview
Up to 15 participating state Medicaid agencies (SMAs) will receive as much as $17 million over the 10-year period to develop a value-based alternative payment model for maternity care services, with the intention of improving quality and health outcomes and promoting the long-term sustainability of services. TMaH will focus on three pillars:
Access to care, infrastructure, and workforce capacity
Quality improvement and safety
Whole-person care delivery
The TMaH model is designed to support birthing persons along their鈥�, expanding continuity, and improving outcomes.
During the model鈥檚 first three years, states will receive targeted technical assistance to achieve pre-implementation milestones. The table below highlights the key activities in the pre-implementation phase.
Following pre-implementation, participants will enter a seven-year implementation period during which the SMAs will implement the program with partners, such as managed care organizations (MCOs), perinatal quality collaboratives, hospitals, birth centers, health centers and rural health clinics, maternity care providers, and community-based organizations.
In year four, states will offer partnering providers and care delivery sites upside-only performance payments from state funds (no cooperative funds may be used). In year five, states will transition partner provider and partner care delivery locations to a new value-based payment model. CMS will lead the development of the value-based model, and it will be finalized during the pre-implementation period.
The model also requires a health equity plan, which has been a consistent requirement across models from the Innovation Center. Awardees must develop a plan that addresses disparities among underserved populations, such as racial and ethnic groups and people living in rural areas, who are at higher risk for poor maternal outcomes.
State Medicaid Agency Requirements
For states considering TMaH, the NOFO outlines the requirements for participating SMAs, which include:
States must include CHIP if pregnant people receive services through CHIP
States that have managed care plans must contract with at least MCO for implementation
Collaborate with partner providers (e.g., OBs, midwives, doulas), care delivery location (e.g., hospitals, birth centers, federally qualified health centers), and partner organizations
Collaborate in the process to create cost and quality benchmarks with CMS
Be actively involved in technical assistance activities, including attending regularly scheduled calls, providing input and working on portions of documents as appropriate
Execute the data-sharing agreements necessary to support the exchange of data and information related to the TA activities and completion of milestones
Provide CMS and contractors the necessary information and data to support the development of documents to help reach milestones
States must demonstrate their ability to meet these requirements as part of the NOFO process, and CMS will evaluate their responses as part of the selection process
TMaH Opportunities and Considerations
The model offers states resources and technical assistance to develop value-based alternative payment models to support whole-person pregnancy, birth, and postpartum care and improved outcomes. Many SMAs already are working on programs to innovate care and payment, and the TMaH is an opportunity to expand and accelerate those programs.
The model offers an opportunity for states that have yet to expand postpartum coverage or added doula benefits to adopt these policies with the funding and technical assistance they may need to support their efforts.
SMAs interested in this opportunity should evaluate their application readiness and pre-plan for the application.
What鈥檚 Next?
States interested in TMaH should submit a letter of intent by August 8, 2024. Applications are due by September 20, 2024, and the model is expected to start January 2025.
The 黑料不打烊 team will continue to evaluate the TMaH model as more information becomes available. For more information, contact our featured experts below.
黑料不打烊 is hosting its 2024 Fall Conference October 7鈭�9 in Chicago, IL. promises to enhance your ability to navigate and shape healthcare programs and systems, focusing on improving health and well-being.
In a landscape dominated by endless video meetings, the offers a refreshing change. Join us for an enriching experience featuring:
Engagement with healthcare experts and thought leaders who are actively collaborating with stakeholders
Participation in face-to-face discussions to exchange ideas and receive valuable feedback
Opportunities to connect with peers who are committed to strengthening public programs and enhancing health outcomes
Keynote Address and Sessions
, from the Advanced Research Projects Agency for Health (ARPA-H), will deliver the Keynote Address. He and other speakers will inspire attendees to explore innovative healthcare programs and their potential impacts on healthcare delivery, reimbursement, and health outcomes.
The conference will feature a diverse array of speakers and participants, including C-suite executives from national, regional, and local health plans. Federal and state leaders joining panels will include:
State Medicaid directors from New York, Iowa, New Mexico and Alabama
State insurance commissioners
Behavioral health agency officials
State housing agencies
Leaders from the US Interagency Council on Homelessness
The conference will include a revamped pre-conference workshop on October 7, featuring hands-on exercises and interactive sessions led by 黑料不打烊 leaders. Sessions will include a value-based care contracting exercise, a value-based purchasing assessment discussion for providers, tips and tricks on navigating Medicaid section 1115 demonstrations, AI applications in healthcare, and more.
View the , including speakers confirmed to date.
Registration
Early bird registration聽is open until July 31. Don鈥檛 miss this opportunity to gain actionable knowledge, forge valuable connections, and discover fresh insights and best practices.聽Register now聽to secure your spot at the forefront of healthcare innovation.聽
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the 鈥渄ually eligible鈥�). Dually eligible individuals residing in rural areas represent about 5 percent of all rural residents. They reside at the intersection of a public health crisis and a fragmented Medicaid and Medicare care delivery system. , this small population is at risk of falling through the cracks of this crisis and suffering a steep rural mortality penalty.
With support from Arnold Ventures, 黑料不打烊 prepared 鈥淭he Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit: Raising Rural Voices from New Mexico, North Dakota, and Tennessee to Create Action. The toolkit contains eight actionable solutions for federal and state policymakers to use and tailor to states鈥� needs. Ellen Breslin, Samantha Di Paola, and Susan McGeehan authored the toolkit, with research contributions from Rebecca Kellenberg and Andrea Maresca.
In 2022, 黑料不打烊 convened stakeholder roundtables in three states 鈥� including New Mexico, North Dakota, and Tennessee to identify the challenges facing dually eligible individuals living in rural areas and to propose solutions to these challenges. Informed by this process, 黑料不打烊 developed the Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit.
The toolkit is structured around three domains used to organize eight solutions. For each solution, 黑料不打烊 provides a description of the rural access challenge, the proposed solution, and the proposed tool. Each tool is powered by some type of lever available to the federal and state government. We anticipate that policymakers will build upon this toolkit through continued dialogue with rural communities. The toolkit鈥檚 framework, goals, and actionable solutions are summarized in the figure below.
黑料不打烊 Principal Ellen Breslin, Consultant Samantha Di Paola, and Senior Consultant Susan McGeehan authored the toolkit, with research contributions from 黑料不打烊 Principals Rebecca Kellenberg and Andrea Maresca. Download the toolkit.
On February 2, 2023, 黑料不打烊 will hosted a webinar on the HEARD toolkit. During this webinar, 黑料不打烊 experts and panelists including Dr. Kevin Bennett (USC-SOM Columbia, SC CRPH), Dennis Heaphy (DPC), Pam Parker (SNP Alliance), and Tallie Tolen (New Mexico Medicaid) will summarized and discussed the toolkit鈥檚 actionable solutions for improving rural dually eligible individuals鈥� health and social outcomes.
This week, our In Focus section highlights the Health Affairs article, Advancing Health Equity and Integrated Care for Rural Dual Eligibles, authored by聽Ellen Breslin, Samantha Di Paola, Susan McGeehan, Rebecca Kellenberg, and Andrea Maresca, 黑料不打烊.
A public health crisis is growing more acute in rural America, disproportionately impacting individuals with both Medicaid and Medicare (the 鈥渄ually eligible鈥�). The rural health crisis is a health equity concern that affects all rural residents, including dually eligible individuals. There are 47 to 60 million people residing in rural areas. Twenty-one percent of dually eligible individuals live in rural areas鈥攖hat鈥檚 about 2.6 million people. Based on these numbers, the authors calculate that the dual eligible population residing in rural communities accounts for about 5 percent of the total rural population. Dually eligible individuals living in rural areas are at risk of falling through the cracks.
Dually eligible individuals lack access to adequate medical, behavioral health, home-and community-based services (HCBS) and other social services; those living in rural areas face even steeper challenges. Since dually eligible individuals are among the poorest of all individuals covered under Medicare, they are at significant risk of paying a steep rural mortality penalty.
With these challenges there are opportunities for innovation for the dually eligible population living in rural communities. The US can reverse the mortality-disparity rate trajectory. Public and private entities are interested in revitalizing rural America, confronting the rural health crisis, and harnessing the power of rural communities. Investment in the rural health care sector is essential given it is a major economic driver of rural communities.
黑料不打烊 is creating a toolkit with actionable solutions to improve access to services and integrated care and health equity for individuals dually eligible for Medicare and Medicaid who live in rural areas across the country. 鈥婽his project is a follow-on project to a previous 黑料不打烊 project supported by Arnold Ventures. 鈥婭n 2021, 黑料不打烊 prepared a brief, Medicare-Medicaid Integration: Essential Elements for Integrated Care Programs for Dually Eligible Individuals, to increase and promote enrollment in integrated care programs (ICPs) meeting dually eligible individuals鈥� needs and preferences. Interviewees including dually eligible individuals helped 黑料不打烊 to identify 鈥渁ccess to needed services in rural areas鈥� as an essential element of ICPs. In response, 黑料不打烊 started a new project to create a toolkit with actionable strategies to improve access to needed services and improve integrated care opportunities, specific to dually eligible rural residents鈥� needs.
黑料不打烊 designed the toolkit around four values: 1) rural health equity is an imperative for dually eligible individuals, 2) actionable solutions and innovations must come from the community, 3) there is no single pathway to integration, and 4) Medicare and Medicaid flexibilities are critical to inspiring innovations to advance health equity, access, and integration. The toolkit will provide actionable solutions for states with and without integrated care programs for dually eligible individuals to increase access to needed supports and services, care coordination, and integrated care programs. We expect that states and rural communities will use the toolkit as a foundation for mapping a holistic plan to advance access to care coordination and integrated programs for dually eligible individuals residing in rural communities. Other states may employ contractual tools listed in the toolkit to expand access to providers and new services; strengthen partnerships among entities serving the community such as community-based organizations, providers, and health plans; and increase community-wide accountability for meeting dually eligible individuals鈥� whole person-centered needs. The toolkit is scheduled for an early 2023 release.
Dually eligible individuals covered under Medicare and Medicaid living in rural areas struggle to access the services, care coordination, and integrated care programs they need. To address these needs, 黑料不打烊 conducted multi-state roundtable discussions with diverse stakeholders to create The Health Equity & Access for Rural Dually Eligible Individuals (HEARD) Toolkit. During this webinar, our experts summarized and discussed the toolkit鈥檚 actionable solutions for improving health and social outcomes for rural dually eligible individuals.
Learning Objectives:
Understand why the voices of rural dually eligible individuals must drive planning efforts to generate innovations and prioritize investments to advance independent living and recovery goals.
Learn how experiences shared from New Mexico, North Dakota, and Tennessee can offer lessons.
Explore eight actionable solutions for improving health and social outcomes among rural dually eligible individuals as outlined in the HEARD toolkit.
Understand why community engagement and investment in rural capacity are essential to improving access to services and integrated care programs for rural dually eligible individuals.
Speakers
Arielle Mir, Vice President, Health Care, Arnold Ventures
Expert Panelists
Dr. Kevin Bennett, Professor of Family Medicine, University of South Carolina School of Medicine, Director of the Research Center for Transforming Health, and Director of the South Carolina Center for Rural and Primary Care Dennis Heaphy, Health Justice Advocate and Researcher, Massachusetts Disability Policy Consortium, Co-Chair, One Care Implementation Council, a One Care member, and MACPAC Commissioner Pamela J. Parker, Medicare-Medicaid Integration Consultant, SNP Alliance Tallie Tolen, Long-Term Services and Supports Bureau Chief, Medicaid, New Mexico Human Services Department
The Nevada Division of Health Care Financing and Policy (DHCFP) engaged 黑料不打烊 to evaluate Nevada鈥檚 Medical Assistance for the Aged, Blind, and Disabled (MAABD) program and the needs of its participants. A targeted focus of the evaluation was on home and community-based services (HCBS) within the Nevada MAABD population, including Nevada鈥檚 Frail Elderly (FE) and Physically Disabled (PD) waiver.
The project included:
Data analyses of Nevada鈥檚 population and long term services and supports (LTSS) landscape, the state鈥檚 ongoing efforts to rebalance LTSS dollars from institutional to HCBS services and demographic and other information about the MAABD population
Stakeholder engagement, including three focus groups that engaged 55 stakeholders and individual interviews, to provide stakeholders a greater voice in the MAABD improvement process
Evaluation of the MAABD structure and administration
Program recommendations to help inform and guide DHCFP鈥檚 considerations for better serving the FE and PD MAABD populations throughout the state
The report made recommendations to enroll the MAABD population aged 65 and older into a combination MLTSS/FIDE-SNP (managed long-term services and supports/fully integrated dual eligible special needs plan) program, implement Program of All-Inclusive Care for the Elderly (PACE) as a targeted nursing home diversion strategy and strengthen Nevada鈥檚 Medicaid quality framework to better deliver and ensure improved quality of care for the MAABD population.
Over the past decade, the U.S. has seen significant federal and state policy initiatives to improve and expand assistance for the millions of family members who help care for older adults, and those who support people with intellectual and developmental disabilities (I/DD) across the lifespan. The pandemic, combined with workforce shortages, accelerated these efforts. In this webinar with national family caregiving experts, we discussed policy and practice advances and their potential impact on enabling more Americans to live at home and in the community.
Learning Objectives:
Review evidence that supporting family members improves outcomes for older adults and people with I/DD.
An overview of current federal and state implementation of the 2022 National Strategy to Support Family Caregivers and the 2022 National Agenda for Supporting Families with a Member with I/DD.
Share evolving opportunities for improving policy and practice in family caregiving initiatives.
This week鈥檚 In Focus section delves into the Next Generation MyCare Ohio managed care program, spotlighting the request for applications (RFA) that the Ohio Department of Medicaid (ODM) released on May 31, 2024. The MyCare Ohio Program, which serves people who are dually eligible for both Medicaid and Medicare, is undergoing a substantial transformation. Transitioning from the financial alignment initiative (FAI) demonstration model used in 29 counties, it is evolving into a statewide, fully integrated dual eligible special needs plan (FIDE-SNP) model. This shift is more than procedural; it signifies a pivotal moment of transition to new federal D-SNP requirements.
Background
The MyCare Ohio Program launched in May 2014 as a Centers for Medicare & Medicaid Services (CMS) FAI demonstration. MyCare Ohio integrates Medicare and Medicaid benefits for dually eligible members enrolled in competitively selected MyCare Ohio managed care plans, providing one care coordinator and streamlined communication and services. It serves 150,000 individuals in 29 counties.
CMS is sunsetting all FAI demonstration programs on December 31, 2025, prompting ODM to convert to the FIDE-SNP model.
Next Generation RFA
The MyCare Ohio Program will convert to the Next Generation MyCare Ohio Program in January 2026. ODM is modeling portions of the program after the state鈥檚 Next Generation Medicaid managed care program. The Next Generation MyCare Ohio Program initially will be implemented in the 29 currently participating counties and then expand statewide, covering a total of 250,000 eligible individuals. Medicaid managed care organizations (MCOs) that serve the program will need to become CMS-approved FIDE-SNPs. MCOs awarded a Next Generation MyCare Ohio contract will need to notify CMS of their intent to establish a statewide FIDE-SNP in Ohio by fall 2024 to begin operations in January 2026.
ODM anticipates selecting up to four Next Generation MyCare Ohio MCOs to serve enrollees statewide, though a decision on the number of plans will be finalized as awards are made and based on what is most advantageous to the state.
MCOs will need to develop a member-focused strategy with care coordination as a priority. MCOs will also increase focus on behavioral health coordination. According to ODM, goals for the Next Generation program include:
Focusing on the individual
Improving individual and population wellness and health outcomes
Creating a personalized care experience
Supporting providers in continuously improving care
Improving care for people with complex needs to promote independence in the community
Increasing program transparency and accountability
Next Generation MyCare will advance these goals through a population health approach, designed to address inequities and disparities in care.
The program will enroll dually eligible individuals ages 21 and older. This is a change from the current program, which enrolls dual eligibles who are 18 years old and older. The eligible age increase is being made to align with the Medicaid early and periodic screening, diagnostic, and treatment (EPSDT) benefit.
The new program also will continue to offer all the same services available through Ohio鈥檚 home care, PASSPORT (long-term services and supports), and assisted living waivers.
Evaluation
Applications initially will be reviewed to confirm the applicant meets the mandatory requirements. Applicants who meet the mandatory requirements will proceed to review and evaluation of responses to application questions that fall into seven topic areas, with a total of 1,000 available points (see Table 1). Of note, if an applicant is not currently serving as either a Next Generation MCO or a MyCare Ohio MCO, the applicant will receive zero points for qualifications and experience. Organizations that have yet to participate in at least one of these programs should consider the effect on their total score.
Table 1
Current Market
Five MCOs鈥擟VS/Aetna, CareSource, Centene/Buckeye, Molina, and United鈥攑articipate in the current MCOP, with two or three of them participating in each of the seven regions.
Timeline
MCOs should submit a notice of intent to apply by June 21. Proposals are due August 2, and awards will be issued October 8. Implementation is scheduled for January 1, 2026.
Connect With Us
Ohio is one of several states transitioning from a FAI demonstration at the end of December 2025. Additionally, the 2025 Medicare Advantage Final Rule includes new policies affecting D-SNPs that could reshape the integrated care plan landscape in many states.
黑料不打烊 (黑料不打烊) will host a webinar on June 20, 2024 titled “D-SNP growth and integration: key implications of the 2025 CMS final rule” to review the current landscape and federal changes that will affect D-SNPs in 2025 and beyond. The session will feature an analysis of the new regulations and a discussion of the critical strategic and product impacts on Medicare organizations that offer D-SNPs or are considering offering D-SNPs. Attendees also will have the opportunity to engage with the panelists during a Q&A session.聽Watch the replay now.
Contact our experts below聽for details about the nationwide D-SNP rules and landscape.聽聽
On May 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published the Medicaid and Children鈥檚 Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F).
CMS created a which concisely reviews the final rule鈥檚 key provisions, as well as an , which serves as a reference guide to the various applicability dates for different provisions in the final rule. The creates new flexibilities and requirements aimed at enhancing accountability for improving access and quality in Medicaid and CHIP by principally addressing these topic areas:
ILOSs are defined as substitute services or settings for a service or setting covered under the state plan and can be leveraged by Managed Care Organizations (MCOs) to address unmet health-related social needs (HRSNs).
They must be offered to all members and must be voluntary as well as documented in MCO contracts.
ILOSs cannot exceed 5% of total capitation.
If ILOS costs exceed 1.5% of total capitation, states must provide additional documentation to CMS to demonstrate medical appropriateness and cost-effectiveness.
When an ILOS is terminated, states must develop a transition plan to arrange for state plan services and settings to be provided in a timely manner.
States must make available online a “one-stop-shop” where members can learn about and compare MCOs based on quality and other variables.
Mandatory quality measures are established.
The methodology for calculating the quality ratings displayed on each state鈥檚 MAC QRS is also established.
Although guidelines exist, states can submit their own version of a MAC QRS to CMS for approval.
Provider incentive payments must be tied to clearly defined, objectively measurable, and well-documented clinical or quality improvement standards to be classified as incurred claims (in alignment with private market MLR regulations).
Prohibits the inclusion of indirect administrative costs that are not directly related to improving quality as QIAs as incurred claims in the numerator (in alignment with private market MLR regulations).
Imposes additional expense allocation methodology requirements (in alignment with private market MLR regulations).
Requires SDPs to be included as both incurred claims (for payments made by MCOs to providers) and premium revenue (for payments made by states to MCOs).
Sets maximum appointment wait time standards of no more than 15 business days for routine primary care (adult and pediatric) and obstetric/gynecological services and 10 business days for mental health and substance use disorder services (adult and pediatric).
Enforces these standards using secret shopper surveys and requires states to contract for the secret shopper surveys.
Requires states to post the appointment wait time standards as well secret shopper survey results.
A remedy plan must be implemented for any MCO that fails to meet these required standards for access.
States must also conduct an annual enrollee experience survey for each MCO.
Codifies ACR payment ceiling, which applies to hospitals, practitioner services at academic medical, and nursing facility services.
Requires “hold harmless” attestation.
Allows for SDPs at 100% of Medicare without prior written approval.
Removes network provider requirement to receive payment.
Prohibits use of interim payments based on prior period data even if ultimately reconciled.
Prohibits use of separate payment term where SDPs are paid separate from capitation rates.
Explicitly states that SDPs must result in “stated goals and objectives.鈥�
Requires states to submit detailed, provider level SDP data to the Transformed Medicaid Statistical Information System.
Implications for States
The final rule creates opportunities for states to leverage new flexibilities to further policy goals but also creates new administrative burdens. MCOs and providers will look to states to comprehensively understand final rule鈥檚 requirements and be prepared to manage the steps necessary to achieve compliance over a multiyear implementation process.
Implications for MCOs
As states move to comply with the final rule, MCOs will be immediately downstream from the steps taken by states to do so and MCOs need to prepare accordingly. Proactive actions by MCOs to not only engage with states early but also to prepare financially and operationally for the different provisions of the final rule over time will put them in the best position possible.
Implications for Providers
The most significant implications for providers in the final rule are related to SDPs, where a new level of accountability will be required. All topics covered by the final rule, however, have provider implications.
Looking ahead
The provisions of the final rule range in their effective dates from as early as the final rule鈥檚 effective date, July 9, 2024, to as late as the first rating period on or after four years after July 9, 2024.
Because of these variable effective dates, states, MCOs, and providers will need to comply with the final rule immediately in some cases, while having significant lead time to do so in other areas. Sub regulatory guidance is also forthcoming and must be monitored for and digested.
黑料不打烊 stands ready to support states, MCOs, and providers in analyzing and responding to the strategic, financial, and operational impacts of the final rule鈥檚 provisions in specific markets and organizational contexts.
If you have questions or want to connect with our expert team members, e-mail [email protected].
