Tom Cochran, partner at 720 Strategies, is a renowned expert in digital communication and healthcare public relations. Tom reflects on the broader impact of digital tools, acknowledging both their potential to connect us and their unintended consequences, such as cognitive overload and societal fragmentation. The conversation highlights practical strategies for navigating transitions in leadership鈥攚hether in politics or healthcare鈥攁nd emphasizes the importance of understanding, listening, and adapting communication strategies to fit the moment. Tom leaves us with a reminder of the irreplaceable value of face-to-face interaction in an increasingly digital world.
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The Medicaid Section 1115 demonstration landscape: past trends and anticipated shifts
This week’s聽In Focus聽section summarizes states’ Medicaid Section 1115 demonstration priorities over the last four years and highlights predicted changes coming with a new presidential administration. In the waning days of any presidency, regardless of party, reviewing and approving pending Section 1115 applications that reflect the current administration鈥檚 key policy initiatives is a priority for officials at the Centers for Medicare & Medicaid Services (CMS).聽
Each administration has discretion over which Section 1115 demonstrations to encourage and approve. Though specific Medicaid priorities under the upcoming Trump Administration are still nascent, 黑料不打烊, Inc. (黑料不打烊), federal, and state experts are monitoring these developments. This article describes a subset of the signature initiatives the Biden Administration permitted states to pursue in their Medicaid Section 1115 demonstrations and how the new administration could focus on different priorities, rescind existing guidance, or potentially withdraw already approved waivers.
Overview of Biden-Era Section 1115 Demonstration Initiatives
CMS-approved Section 1115 demonstrations permit alternative methods to improve the accessibility, coverage, financing, and delivery of healthcare services under joint federal-state funded programs, specifically Medicaid and the Children鈥檚 Health Insurance Program (CHIP).
Addressing health disparities and promoting integrated care in Medicaid became a primary focus of the Biden Administration. In November 2023, CMS introduced a , giving state Medicaid agencies the opportunity to address the broader social determinants of health (SDOH) that affect their enrollees, leading to better health outcomes. The new initiatives were not intended to replace other federal, state, and local social service programs, but rather to coordinate with those efforts. HRSN demonstration approvals to date include coverage of rent/temporary housing and utilities for up to six months and nutrition support (up to three meals per day), departing from longstanding prohibitions on payment of room and board in Medicaid.
During the present administration, CMS also has provided novel opportunities for states to adopt strategies that promote continuity of Medicaid coverage, mainly through bolstering Section 1115 demonstrations to provide 鈥痜or children. In addition, CMS released鈥痠n April 2023 so states could apply for a new Section 1115 demonstration opportunity to test transition-related strategies that support community鈥痳eentry鈥痜or incarcerated people who would otherwise be eligible for Medicaid or CHIP.
The table and map below show the types of demonstrations approved and pending to date. We anticipate that incoming administration officials will closely examine the four demonstration initiatives outlined as they determine their own Medicaid policy agenda and priorities. Under President Biden鈥檚 Administration, nine states received federal approval for HRSN demonstrations under the new framework. Another 10 states have applications pending.
Rescissions and renewals. Incoming Trump Administration officials technically could attempt to rescind some of the Section 1115 demonstrations approved during the Biden Administration. The Biden Administration unsuccessfully pursued with, a similar strategy for certain 1115 demonstration components approved during President-Elect Trump鈥檚 first term. Like the Biden Administration, the incoming Trump officials may choose not to renew demonstrations, even if the courts prevent them from rescinding approvals.
Any signature Section 1115 policy is unlikely to emerge until the new administration鈥檚 policy officials are in place. There are, however, important insights to consider based on the first Trump Administration鈥檚 priorities and areas of common ground across the Biden and first Trump administrations.
Signature 1115 initiatives. During President Trump鈥檚 first term, one signature鈥�痑llowed states to apply work requirements to some eligibility groups. CMS officials at that time also approved 鈥痜or certain components of a state鈥檚 Medicaid program. Some states might consider revisiting these options with incoming administration officials. Two other key policy areas to watch following the transition include:
- The first Trump Administration聽鈥痑 pilot program to test interventions addressing HRSNs in 鈥�疢edicaid 1115 demonstration program. Though the approved HRSNs were less expansive than the HRSN 1115 interventions later announced by the Biden Administration, this could be an area of common ground where the policy evolves and can be incorporated into discussions on other nascent initiatives.聽
- Multiple administrations, including the first Trump Administration, have prioritized Medicaid policies and demonstration initiatives to address substance use disorders (SUD) and, separately, reentry. The intersection of these issues can provide another area of common ground and opportunity to continue work on state reentry initiatives, though likely with new and modified parameters.聽
Implementation Considerations
Federal approval of Medicaid Section 1115 demonstration proposals is a critical milestone for states. Demonstration implementation also requires significant and ongoing leadership, resources, and collaboration between states and CMS and states and their partners.
The type of state demonstration activity is expected to shift dramatically over the course of the new administration. For example, proposals may shift from expansions in coverage and benefits to reflect the new administration鈥檚 other priorities. States, too, may consider alternative approaches to Section 1115 demonstrations, such as state plan authorities like in lieu of services (ILOS), to pursue certain innovative approaches that they might otherwise have implemented with demonstration authority.
Connect with Us
黑料不打烊 empowers states, providers, and other stakeholders to thrive in an ever-changing healthcare landscape. With deep expertise at every level, 黑料不打烊 teams support state Medicaid programs and stakeholder partners nationally to address a range of operational challenges, including designing innovative healthcare approaches to address urgent healthcare challenges, expanding coverage opportunities, and optimizing integration to address program efficiencies and improved 鈥渨hole person鈥� care.
We have expertise in all of the components critical to developing Section 1115 programs鈥攆rom the policy knowledge, to actuarial/budgeting talent, to communications and project management skills, as well as the necessary IT infrastructure.
Contact鈥痮ur featured experts below聽to learn more about 黑料不打烊鈥檚 capabilities and expertise.聽
Passion with Purpose: Solving Healthcare鈥檚 Biggest Challenges, Together
In this season of gratitude and joy, we reflect on a year filled with purpose and partnership. At 黑料不打烊, we鈥檙e honored to support our clients and partners working to improve the health of individuals, families, and communities nationwide.
Watch our video聽to find out what fuels our passion to create a positive impact in all the work we do, from addressing health equity and improving maternal outcomes to advancing healthcare policy and helping organizations deliver the highest quality care.
All of us at 黑料不打烊 are wishing you a joyous holiday season and new year filled with continued success.聽
MyCare Ohio: The Next Generation鈥檚 impact on the Ohio Medicare & Medicaid landscape
The transition of MyCare Ohio to the Next Generation of its program on January 1, 2026, marks a significant evolution in the way Ohio provides healthcare services to its dual-eligible population 鈥� those who qualify for both Medicaid and Medicare services.聽This evolution moves Ohio to a Fully Integrated Dual Eligible Special Needs Plan model (FIDE SNP) that aims to achieve several key goals through a population health approach, designed to address inequities and disparities in care for dual-eligible individuals.聽These goals include:
- Improved Care Coordination. Strengthening integration between Medicare and Medicaid services to provide seamless, holistic care for individuals, reducing fragmentation and ensuring comprehensive management of medical, behavioral, and social needs.
- Personalized Care. Utilizing data analytics and technology to create more tailored care plans, with a focus on proactive care to address the unique health needs of each individual, especially those with chronic conditions.
- Expanded Access to Services. Increasing accessibility, particularly through telehealth and digital tools, to reach underserved populations and improve convenience for patients, particularly those in rural or remote areas.
- Enhanced Quality of Care. Shifting focus from service volume to outcomes, encouraging providers to deliver high-quality care and improve patient satisfaction, while incentivizing preventive care to reduce hospital admissions and other high-cost interventions.
- Technology Integration. Leveraging advanced technologies like mobile apps, predictive analytics, and telemedicine to monitor patient health, improve communication between patients and providers, and enable more efficient care delivery.
The current MyCare program is offered in 29 counties across Ohio but will transition to a statewide program as a part of the Next Generation changes. Additionally, Coordination Only Dual Eligible Special Needs Plans (CO DSNP) will no longer be permitted.
After the Ohio Department of Medicaid (ODM) publicly released the request for applications (RFA) and evaluated submitted proposals, they selected four Managed Care Organization (MCOs) that will become the Next Generation MyCare plans. The ODM awarded the following MCOs to serve MyCare members beginning in January 2026: Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina HealthCare of Ohio.
The shift to the FIDE SNP model and selection of four participating health plans will have a considerable impact on the competitive landscape for Medicare and Medicaid managed care in Ohio. The resulting changes can affect both selected and non-selected participants in different ways, including:
- Increased competition among chosen MyCare MCOs. MCOs will need to focus on enhancing their care coordination systems, adopting new technologies, and developing personalized care plans to compete not just on the volume of services provided but also on the quality and effectiveness of care. Those who can best integrate services, offer proactive care management, and improve patient outcomes through value-based care and advanced technology initiatives will gain the competitive advantage, potentially attracting more beneficiaries.
- Strategic responses of nonparticipating MCOs to counter potential membership and financial losses. MCOs that lose membership by not being selected, or are unable to offer CO DSNPs moving forward, will likely strategize how to gain membership through other product lines or benefit design to offset losses. Strategies may vary but could include tactics such as enhancing benefits or decreasing member cost shares to entice member movement across carriers for non-DSNP plans; finding innovative ways to further reach different segments within the Medicare population, such as Value Based Insurance Design (VBID) packages or Chronic SNP plays; or shifting focus to product lines outside of Medicare Advantage and Medicaid.
Ohio is one of many states transitioning to a FIDE model beginning January 2026. 黑料不打烊 (黑料不打烊) has successfully supported participating and non-participating carriers throughout the transition process and continues to be a dedicated partner to organizations navigating Medicare and Medicaid changes across the country. Contact one of 黑料不打烊鈥檚 many experts for more details on how to navigate this evolution in health care.
Major changes to Medicare Advantage and Part D proposed by CMS for 2026
This week’s In Focus聽section examines a comprehensive proposed rule that the Centers for Medicare & Medicaid Services (CMS)聽聽on November 26, 2024. These highly anticipated regulations鈥攚hich represent the last major Medicare regulations from the Biden Administration鈥攊nclude several significant and聽聽designed to strengthen plan oversight and enhance beneficiary protections for millions of Medicare beneficiaries who have coverage through Medicare Advantage and Medicare Part D plans beginning in contract year 2026. The rule also comprises proposals with fiscal and policy implications for state Medicaid programs.
Comments on the proposed rule are due by January 27, 2025, and the incoming Trump Administration could make significant changes before finalization. New administration officials may choose to delay certain provisions, scale back, or eliminate certain proposed policy changes when they finalize the regulations next year.
This article explains several of the proposed policies, considerations for healthcare stakeholders, and developments that 黑料不打烊 (黑料不打烊) experts will be tracking in the coming weeks.
Coverage of Anti-Obesity Medications Under Medicare Part D and Medicaid
In the proposed regulations, CMS seeks to expand coverage of anti-obesity medications (AOMs) under the Medicare Part D and Medicaid programs. Under current Medicare Part D coverage rules, medications used exclusively for weight loss are excluded from the definition of a Part D covered drug. Through the proposed change, CMS is seeking to align Medicare and Medicaid coverage policy with the prevailing medical consensus that recognizes obesity as a chronic disease.
Under the proposed reinterpretation, CMS would expand eligibility for Part D coverage of AOMs for Medicare beneficiaries with obesity. AOMs used for weight loss or chronic weight management would continue to be excluded from Part D coverage under the proposed regulation.
As it relates to Medicaid, CMS鈥檚 proposed reinterpretation would require Medicaid coverage for anti-obesity medications when used for weight loss or chronic weight management for the treatment of obesity. State Medicaid programs would continue to have discretion to use preferred drug lists and prior authorization (PA) to establish certain limitations on the coverage of these drugs, consistent with existing statutory requirements.
CMS estimates the proposal would increase federal costs by $24.8 billion as the result of expanded Part D coverage and $14.8 billion because of expanded Medicaid coverage over a 10-year period.
Key considerations: Though expanded access to innovative medications may improve access and outcomes for obese patients, these considerations may need to be balanced against the proposal鈥檚 considerable fiscal costs. In addition, key health nominees put forth by President-Elect Donald J. Trump have different views about how best to prevent and treat chronic disease, creating additional uncertainty about whether this proposed expansion will go forward.
Strengthening Prior Authorization and Utilization Management Guardrails
The proposed rule includes a series of recommendations for reforming Medicare Advantage PA, utilization management (UM), and coverage decisions, which include:
- Defining the meaning of internal coverage criteria to clarify when MA plans may apply UM
- Ensuring MA plans鈥� internal coverage policies are transparent and readily available to the public
- Requiring plans to inform beneficiaries of their appeal rights
- Revising the current metrics for the annual health equity analysis on the use of PA to require more detailed and granular reporting to allow CMS to determine whether MA plans disproportionately deny certain services
Key considerations: Continued scrutiny of MA plans鈥� PA practices and strong bipartisan support for reforms increase the likelihood that certain changes will be made to these policies within the next year.
Enhancing Medicare Plan Finder to Include Information on Plan Provider Directories
Another notable proposal would require MA plans to make provider directory data available to CMS for inclusion in Medicare Plan Finder (MPF), the online tool that allows beneficiaries to compare coverage options, including Medicare Advantage and Part D plans. At present, provider directories must be accessible on MA plans websites.
CMS seeks to enhance MPF with searchable provider information for all MA plans while requiring plans to attest to the accuracy of the provider directory data, including updating data within 30 days of receiving notification that provider information has changed. CMS would ensure compliance with this expectation by requiring plans to meet data compliance and quality checks, which will be detailed in upcoming technical guidance.
Improving Access to Behavioral Health Care
The proposed rule furthers federal policymakers鈥� initiatives to address the nation鈥檚 behavioral health crisis. CMS proposes to establish the following three standards to ensure that beneficiary cost sharing in Medicare Advantage is no greater than in Traditional Medicare:
- A 20 percent coinsurance or an actuarially equivalent copayment rate for mental health specialty services, psychiatric services, partial hospitalization, and outpatient substance abuse services
- No cost sharing for opioid treatment programs
- All (100 percent) of the estimated Traditional Medicare cost sharing for inpatient psychiatric services
Improve Oversight and Administration of Supplemental Benefits
MA plans may offer a variety of supplemental benefits such as vision, dental, and gym memberships, which have come under increasing scrutiny by CMS. CMS proposed several actions to reduce misuse of these benefits, including:
- Outlining proper usage by MA organizations and enrollees
- Adding disclosure rules for transparency
- Ensuring enrollees can access covered services through alternative methods
- Requiring real-time electronic links between debit cards and covered services
- Defining acceptable over-the-counter products.
Key Considerations: CMS officials in President-Elect Trump鈥檚 first administration expanded flexibility for plans to offer supplemental benefits. Incoming policy officials may seek an opportunity to fully review the Biden Administration鈥檚 proposals. Data and experience-informed comments from MA plans and stakeholders can support such discussions.
Improve Care Experience for Dual Eligibles
CMS proposed the following two new federal requirements for Dual Eligible Special Needs Plans (D-SNPs) that are applicable integrated plans (AIPs):
- AIP D-SNPs will need to have integrated member ID cards for their Medicare and Medicaid plans.
- D-SNPs will be required to conduct an integrated health risk assessment for Medicare and Medicaid, rather than separate ones for each program.
Key Considerations: These proposals further CMS鈥檚 multi-year work to advance integrated care by applying Medicare-Medicaid Plan features into D-SNP requirements. States and MA and Medicaid plans should plan for operational and policy changes if the proposals are finalized.
Formulary Inclusion and Placement of Generics and Biosimilars
CMS proposes to require Part D formularies to provide beneficiaries with broad access to generic, biosimilar, and other low-cost drugs while also ensuring that tier placement and UM practices do not limit access to these drugs as compared with more expensive brand name and reference products.
Key considerations: If finalized, the proposal would require MA-PD and Part D plans to update their approach and considerations for plan formulary development. Consumer groups and other stakeholders should consider the possibility that the proposal will improve access to lower cost products.
Other Topics in the Proposed Rule
In addition, the proposed rule calls for the following:
- Guardrails for artificial intelligence to protect access to health services, such as requiring that MA plans ensure services are provided equitably, regardless of delivery method or origin (i.e., human or automated systems)
- Changes to MA and Part D medical loss ratio (MLR) reporting to improve the meaningfulness and comparability of MLR across plan contracts
- Expanded Part D medication therapy management eligibility criteria
- Adding and updating measures addressed in this proposed rule, beginning with the 2028 Star Ratings
- Promoting community-based services and enhancing transparency of in-home service providers, including new definitions and standards for community-based organizations
- Codifying existing guidance related to implementation of the Medicare Prescription Payment Plan, which is part of the Inflation Reduction Act (IRA)
What to Watch
During the lame duck session, Congress could advance legislation related to some proposals in this rule. Specifically, PA has been an area of significant bipartisan interest, along with access to and cost of GLP-1 products. CMS will need to ensure the final MA and Part D policy and technical rule for contract year 2026 reflects approved statutory changes.
In addition, 黑料不打烊 is watching key appointments within the US Department of Health and Human Services, including individuals selected to lead CMS鈥� Medicare and Medicaid centers. These appointments will provide valuable insights on the emerging policy agenda of the incoming administration.
Connect with Us
黑料不打烊鈥檚 Medicare and Medicaid experts will continue to assess and analyze the policy and political landscape, which will determine the final policies in the MA and Part D policy and technical rule for contract year 2026. 黑料不打烊鈥檚 experts have the depth of knowledge, experience, and subject matter expertise to assist organizations that engage in the rulemaking process and to support implementation of final policies, including policy development, tailored analysis, and modeling capabilities, as well as quality improvement initiatives and plan benefit design.
For further analysis of the MA and Part D proposed rule and potential impact on MA and Part D plans, Medicaid programs, providers, and beneficiaries, contact聽our featured experts below.
Has Medicare鈥檚 Drug Policy Struck the Right Balance Between Access and Cost?聽
Kevin Kirby, managing director at 黑料不打烊, gives a closer look at the evolution of Medicare鈥檚 drug coverage and the policies that have transformed patient access and affordability. From Clinton era ideas, to the launch of the Medicare Modernization Act and then the Affordable Care Act, Kevin has advised clients as these significant milestones have shaped and reshaped Medicare鈥檚 drug benefits. He discusses the implications of the Inflation Reduction Act, raising important questions about sustainability and cost control. The episode will explore how these pivotal policies will impact access to treatment and the sustainability of Medicare in a rapidly changing healthcare landscape.聽
Strategic Expenditure Planning: Empowering County Government Agencies to Optimize Opioid Settlement Funds
THE CLIENT
The Lake County Behavioral Health Services Department and the residents of Lake County, California.
BACKGROUND
In 2021, opioid manufacturer Janssen Pharmaceuticals along with three opioid distributors, McKesson, Amerisource Bergen, and Cardinal Health (collectively known as The Distributors) reached settlements for their roles in the opioid epidemic that amount to $26 billion. These settlements will be distributed to states that participated in the joint lawsuits. It is estimated that California will receive approximately $2.05 billion over 18 years to focus on opioid abatement activities within the state. As a participating subdivision, Lake County is set to receive a portion of California鈥檚 Abatement Fund and began receiving payments on November 15, 2022. The County will receive approximately $18 million over the course of eighteen years.
黑料不打烊 was tasked with creating an expenditure plan for the opioid abatement settlement funds distributed to the Lake County Behavioral Health Services Department and the residents of Lake County. 黑料不打烊 facilitated community engagement to gather stakeholder feedback and align community priorities with the High Impact Abatement Activities (HIAA) and goals as defined by the California Department of Healthcare Services.
APPROACH
黑料不打烊 works with state, county, and local government entities across the U.S. in collaboration with community members, engaged stakeholders, and policymakers to develop funding priorities that are designed to facilitate improvements in the quality of life of those experiencing opioid use disorder (OUD) and to prevent overdose deaths. The 黑料不打烊 team has worked closely with organizations in counties across the U.S. to help develop plans for OUD programs using opioid settlement funds, and does so through partnering with clients and communities, community advisory councils/boards and with local community-based organizations to co-create community engagement strategies, tools, and plans and to engage communities in the decision-making process.
For this project, 黑料不打烊 organized and conducted four, 4-hour, collaborative meetings with a variety of partners in Lake County, as well as analyzed the capacity, available resources, and demographic trends of the OUD population. This comprehensive data collection culminated in a final report which provides an analysis of persistent challenges, proposed actions, and desired outcomes, including identifying current efforts and best practices that are most effective in addressing OUD needs across the continuum of care (prevention, intervention, and treatment).
TESTIMONIAL
鈥淚t has been an absolute pleasure working with 黑料不打烊 on the Opioid Settlement Funds project. You guided us deftly through a methodical and intentional process with a clear focus on results. You have a unique ability to both diffuse and validate the tensions that typically arise whenever you bring a community together to make decisions about a big pot of money. I must admit, there was a point during the stakeholder engagement process where I was worried we might not be able to land on shared ground. At the finish line of this project I am excited and energized with a clear plan to move forward.鈥�
Elise Jones, Director, Lake County Behavioral Health Services
RESULTS
As the final deliverable, 黑料不打烊 developed a dynamic and actionable expenditure plan for the opioid settlement funds. Lake County was adamant that the voice of community members including, persons with lived experience, health service providers, and local partners were elevated to inform the funding priorities. The expenditure plan highlights the engagement process and input received, including the invaluable perspectives of tribal partners, older adults, children and families, and people with lived experience. The culmination of the engagement process resulted in community-wide consensus of 26 prioritized strategies, categorized into f ive themes: structural, prevention & education, treatment, aftercare & community, and social determinants of health (SDOH). The expenditure plan will serve as a manual for the use of opioid settlement funds informed not only by the state鈥檚 requirements but also by Lake County community members.
Opioid Abatement Settlement Funding Workgroup-Community Conversations Prioritized Strategies for Funding Recommendations
*The Title IV-E Stipend Program is the nation鈥檚 largest consortium of schools of social work and public service agencies providing support for the delivery of a specialized public child welfare curriculum and support for students committed to service in public child welfare.
**The Pathways Hub is a hub for community-based service providers to ensure the coordination of care.
***The city of Lakeport is working on creating a navigation center that will provide a variety of resources to the community, largely focusing on the unhoused population and will likely be funded through Lakeport鈥檚 opioid settlement dollars. This navigation center is still in the conceptual phase, but the intention is to serve as a hub for providers offering SUD services, housing coordination, operating mobile health clinics, and more.
黑料不打烊 webinars offer insights into big changes expected after the 2024 election
Following the 2024 election, incoming federal officials have begun to lay the groundwork for significant changes in the federal policy landscape and agency operations. In 2025, Republicans will control the executive branch and both chambers of Congress, a trifecta of power that affords more opportunity for advancing their federal healthcare agenda over the next two years. 黑料不打烊 consultants are available to help organizations understand, inform, and plan for future federal policy initiatives and the impact for publicly funded programs and the healthcare sector.
Experts from 黑料不打烊 and from Wakely and Leavitt Partners, both 黑料不打烊 companies, collaborated to host three webinars that examine key issues and considerations for different parts of the healthcare sector.
This webinar explored insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Panelists from 黑料不打烊 and Leavitt Partners provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions, and shared their prediction for what to watch over the first 100 days.
With a Republican majority in Congress and presidency, healthcare priorities are expected to include revisiting ACA tax subsidies, addressing Medicaid allotments, and reexamining Medicare鈥檚 system for reimbursing providers. Powerful tools like budget reconciliation could drive major changes in tax and healthcare entitlement programs, however, this tool can be limited by parameters of the Senate鈥檚 procedural rules, known as the Byrd Rule.
Panelists also addressed the regulatory policy landscape which could include reinstating Trump-era policies like the 1332 waivers, allowing non-ACA plans, and altering Medicare and Medicaid policies to emphasize transparency and fiscal responsibility.
The Future of Medicare Advantage: How the Election Results Impact the Program
With Medicare Advantage (MA) a key area of focus for incoming federal agency leaders, experts from 黑料不打烊, Leavitt Partners, and Wakely discussed how the election results will impact what policy changes could be considered in the coming year.
As the MA program expands, conversations about its future reveal a mix of partisan priorities and bipartisan opportunities. Partisan changes are likely to include moderation of regulatory oversight, and the possibility of easing the audit process and restrictions on payment models. Other strategies and policies may shift the emphasis away from health equity initiatives and revise the federal approach to competitive prescription drug pricing negotiations.
There are, however, certain reforms that are likely to garner bipartisan support, such as the expansion of telehealth services and increased access to behavioral healthcare. Ongoing discussions about health plans鈥� approaches to prior authorization and management of prescription drug will likely remain a bipartisan priority.
Electoral Consequences: Impact on the ACA Marketplace
The 2024 elections may lead to significant changes in the ACA Marketplace. Enhanced ACA subsidies available during the COVID-19 pandemic are set to expire in 2025, and the new CMS administrator will shape policy and regulatory components that affect marketplace and consumer dynamics.
Key insights highlight anticipated changes to the Meaningful Difference Rules for non-standard plans, an increase in Marketplace user fees, and a proposal to codify silver loading into regulation. Additionally, it鈥檚 important to monitor policy areas focused on improving compliance among agents and brokers in the Marketplace the unveiling of a new Risk Adjustment model and coefficients to reflect costs that are not related to active medical conditions.
Our consultants are ready to meet with you to discuss any projects or ideas to help you navigate the evolving landscape in 2025.
Insights into federal approval of Medicaid-covered traditional healing to improve culturally relevant care for AI/AN populations
This week’s In Focus聽section reviews new state initiatives to cover traditional healing services through Medicaid for American Indian/Alaska Native (AI/AN) individuals and communities.聽
Overview
In October 2024, The Centers for Medicare & Medicaid Services (CMS) Medicaid Section 1115 demonstration amendments for , , , and , allowing Medicaid and Children鈥檚 Health Insurance Program (CHIP) coverage of traditional healing services delivered at or through Indian Health Service facilities, Tribal facilities, and urban Indian organizations (I/T/U facilities).
This demonstration approval enables state Medicaid agencies to acknowledge traditional healthcare practices as important components of the wellness continuum of care for Native American populations. Medicaid funding will help strengthen and expand access to these services and support integration of these services into primary care, substance use disorder (SUD) treatment, and other behavioral health care in a way that I/T/U providers have designed and developed to meet the unique needs of their community.
Demonstrations for Arizona and Oregon are approved through September 30, 2027, New Mexico鈥檚 demonstration is authorized through December 31, 2029, and California鈥檚 through December 31, 2026.
Traditional Health Services: Providing Culturally Relevant Care
AI/AN populations generally experience worse health disparities compared with non-AI/AN populations, particularly in terms of obesity, diabetes, tobacco addiction, and cancer. AI/AN populations also face higher rates of mental health disorders, SUDs, and suicide.
Using Transformed Medicaid Statistical Information System (T-MSIS) claims and demographics data, 黑料不打烊, Inc. (黑料不打烊), staff assessed the incidence of specific chronic diseases in the Native American and non-Native American population in the four states approved to cover traditional healing services through their Medicaid program. For example, in these states, the prevalence of diabetes in AI/AN populations ranged from 27 percent to 87 percent higher than among non-AI/AN groups. Figure 1 shows the percentage of three chronic conditions among these groups in the four states.
Figure 1. Percentage of AI/AN vs. Non-AI/AN Medicaid Beneficiaries Living with Chronic Conditions in AZ, CA, NM, and OR (2022)
The demonstration approval is expected to improve access to culturally appropriate healthcare to address these disparities in chronic conditions for Tribal communities. Traditional healthcare practices vary widely across the 574 federally recognized Tribes in the United States, and many see traditional healthcare practices as a fundamental element of well-being that can help patients with specific physical and behavioral health conditions. For example, commonly offered traditional practices in Native American communities include talking circles, sweat lodges, and smudging. Studies show that incorporating traditional healthcare practices may improve mental health symptoms, outcomes, and quality of life, including among individuals with SUD.
Considerations for Key Partners
AZ, CA, NM, and OR are the first states to receive federal approval and will lay the groundwork for integrating time-honored healing practices into their Medicaid systems. They also could serve as a model for other states that choose to pursue this demonstration. I/T/Us were integral to shaping the demonstration design and are poised to continue shaping the program details and implementation of traditional approaches to care into their Medicaid systems.
黑料不打烊 experts identified some key considerations for partners, such as states and Medicaid managed care organizations (MCOs), to follow as these services are incorporated into Medicaid:
- Collaborate with I/T/U facilities and communities.聽Traditional healing practices are sacred and ceremonial, so flexibility will be essential in determining how Medicaid funding can be best allocated to support providers who offer traditional practices. Communities will be critical in helping identify the specific traditional healing practices that are needed.聽
- Support operational changes needed in I/T/U facilities.聽Compliant and efficient billing practices will be essential to the success of the demonstrations. States can support I/T/U facilities to develop necessary trainings, workflows, and administrative processes. For example, the provider qualification criteria and implementation is central to meeting federal compliance and reporting requirements. Facilities also will need to meet Medicaid billing requirements to collect 100 percent of the federal medical assistance percentage (FMAP).聽
- Partner with I/T/U facilities. To facilitate proper care coordination, states, health plans, and non-I/T/U providers should partner with I/T/U facilities to ensure patients experience the best health outcomes.聽
Connect With Us
黑料不打烊 has learned the value and importance of working with Native American and Alaska Native populations and respecting their unique approaches to improving healthcare. 黑料不打烊 has expertise on healthcare issues that uniquely affect AI/AN populations and is experienced in addressing these challenges through AI/AN leadership and engagement that is culturally sensitive and respectful. Our experience working directly with Tribes encompasses extensive and applicable knowledge of healthcare operations in rural and urban settings to support infrastructure needs, including data management, IT, staffing, policies and procedures, training, and eligibility and enrollment processes.
Contact our featured expert below聽to learn more about 黑料不打烊鈥檚 work to support Native American and Alaska Native communities.聽