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The Medicaid Section 1115 demonstration landscape: past trends and anticipated shifts

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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, 量子资源网, Inc. (量子资源网), 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 

量子资源网 empowers states, providers, and other stakeholders to thrive in an ever-changing healthcare landscape. With deep expertise at every level, 量子资源网 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 量子资源网鈥檚 capabilities and expertise.聽

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MyCare Ohio: The Next Generation鈥檚 impact on the Ohio Medicare & Medicaid landscape

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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. 量子资源网 (量子资源网) 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 量子资源网鈥檚 many experts for more details on how to navigate this evolution in health care.

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Major changes to Medicare Advantage and Part D proposed by CMS for 2026

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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 量子资源网 (量子资源网) 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, 量子资源网 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

量子资源网鈥檚 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. 量子资源网鈥檚 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.

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量子资源网 webinars offer insights into big changes expected after the 2024 election

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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.  量子资源网 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 量子资源网 and from Wakely and Leavitt Partners, both 量子资源网 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 量子资源网 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 量子资源网, 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.

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Insights into federal approval of Medicaid-covered traditional healing to improve culturally relevant care for AI/AN populations

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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, 量子资源网, Inc. (量子资源网), 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) 

Source: 量子资源网 analysis of 2022 T-MSIS (Transformed Medicaid Statistical Information System)

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. 

量子资源网 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 

量子资源网 has learned the value and importance of working with Native American and Alaska Native populations and respecting their unique approaches to improving healthcare. 量子资源网 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 量子资源网鈥檚 work to support Native American and Alaska Native communities.聽

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Health policy priorities on the table: Understanding the post-election landscape for Marketplace, Medicaid, and Medicare programs

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This week’s In Focus鈥痵ection addresses post-election implications and initial considerations for understanding President-Elect Donald J. Trump鈥檚 possible federal healthcare policy agenda. Though healthcare was not the highest priority campaign issue, the president-elect and his team have signaled the policy agenda could include changes to the Affordable Care Act (ACA), Medicaid, and the nation鈥檚 public health programs. 

Additionally, President Trump鈥檚 first term policy agenda and how these policies fared, provide critical insights into the policy direction for his second term, including policies on Medicare drug pricing, ACA marketplaces, and interoperability. Also vital to understanding and planning for a second term will be the appointees to key healthcare positions at the Department of Health and Human Services and in the White House. 

Policy officials and specific policy agendas are still nascent, and 量子资源网, Inc., federal and state experts are continuing to monitor these developments. The remainder of this article focuses on a few key considerations for the Marketplace, Medicaid, and Medicare healthcare insurance programs heading into 2025. 

ACA Marketplace Issues to Watch 

President-Elect Trump signaled he is uninterested in revisiting a legislative initiative to repeal and replace the ACA. However, one of the major defining issues facing the president-elect and the next Congress is the temporary policy providing enhanced tax credits that lower ACA premiums, which expires at the end of 2025. This and other tax policies are very likely to be on the table, particularly as budget reconciliation is an available tool in unified government. 

Key considerations for healthcare stakeholders regarding the subsidy policy and federal funding for Marketplace outreach and education programs include: 

  • The Congressional Budget Office (CBO)聽聽that extending the present enhanced subsidy policies would cost more than $300 billion over 10 years. The CBO also聽聽that ACA marketplace enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 if the subsidy policy is not renewed.聽
  • The loss of subsidies would increase the number of uninsured individuals in the United States, but the size of the increase would depend on the state-specific landscape. For example, states that have not adopted the ACA鈥檚 Medicaid expansion for adults are expected to have a higher increase relative to states that have more expansive Medicaid eligibility. One potential approach is for lawmakers to modify the enhanced subsidy policy, rather than let it expire entirely.  
  • Marketplace plans should be prepared for a change in the acuity mix of enrollees while providers should expect a change in their payer mix, with more uninsured individuals in states that have not expanded Medicaid. 

Federal and state policymakers may pursue a combination of alternatives to fill gaps in access to healthcare coverage and services. For example, the president-elect and incoming congressional leaders may focus on alternative coverage options and other state-driven reforms to Marketplace programs. Alternatives that could become part of the regulatory policy agenda include: 

  • Supporting association health plans (AHPs) and high-risk pools 
  • Reverting to a federal regulatory environment that supports short-term limited-duration healthcare insurance (STLDI) plans 
  • Approving Section 1332 waivers to allow state-designed programs 

Medicaid Policy Outlook 

During Mr. Trump鈥檚 first term, one of his administration鈥檚 signature  was approving Section 1115 demonstrations that allowed states to apply work requirements to certain populations, including adult expansion populations. The first Trump Administration also revised the demonstration parameters for Section 1115 Institutions for Mental Disease (IMD), allowed coverage lockout for beneficiary noncompliance with premium payments, and  a pilot program to test interventions addressing health-related social needs (HRSNs). 

Key considerations for healthcare stakeholders regarding Medicaid flexibilities and funding include: 

  • Officials in the first Trump Administration approved  Medicaid 1115 demonstration program to address HRSNs. President Biden鈥檚 Administration expanded these policies and approved demonstrations in more than 10 states, with additional state applications pending. Incoming officials may maintain the overall policy direction  with regard to HRSNs. However, they could pivot to narrow the scope of future state HRSN proposals. Another approach could include directing states to use in lieu of services (ILOS) authority in managed care delivery systems to address HRSN.  
  • During President-Elect Trump鈥檚 first term, Centers for Medicare & Medicaid Services (CMS) officials prioritized work requirements and  for certain components of a state鈥檚 Medicaid program. Some states might consider revisiting these options, with modifications. If this policy direction is refreshed, federal and state officials would benefit from the foundational work conducted during the first term. 
  • New CMS officials could prioritize work on transparency in Medicaid financing and reimbursement to providers. Federal officials, regardless of political affiliation, historically have sought to improve their understanding of the flow of Medicaid funding. Incoming officials could prioritize this issue again, which would have a varied effect on health plans and providers. 

Medicare Priorities: 

Relative to Marketplace and Medicaid, first term Trump Medicare policies were advanced with less conflict. Notable policy initiatives included a focus on healthcare-related challenges in , improving , and reducing  鈥攁ll of which were also cross-cutting issues that encompassed policy work beyond Medicare and could continue to be central to the next Medicare policy agenda.  

Key considerations for healthcare stakeholders regarding Medicare policy are as follows: 

  • The president-elect鈥檚 first term  to Medicare Advantage (MA) plans sought to maximize enrollment in MA and encourage . It鈥檚 reasonable to expect second term CMS officials to maintain an overall favorable approach to MA too. Incoming officials could narrow their scrutiny of MA plans to bipartisan concerns, for example MA plans鈥� prior authorization policies. 
  • While improving outcomes for dually eligibles beneficiaries generally is a bipartisan issue, state agencies, MA and Medicaid managed care plans, and other interested stakeholders should monitor the incoming Administration鈥檚 policy agenda for dually enrolled beneficiaries in Medicare and Medicaid. During the Biden Administration, CMS issued  for Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) to improve integration for the Medicare-Medicaid dually eligible population., Incoming Trump officials could revisit the approach, including the breadth of requirements and compliance timelines.  
  • During his first term, President Trump was highly engaged in elevating concerns about  and HHS and CMS announced models and policies to  for patients. In his second term, however, the President could seek to rein in certain aspects of the Inflation Reduction Act (IRA), while revisiting some of his prior proposals. 

What to Watch 

The incoming Administration and its transition team are moving expeditiously to nominate new Cabinet Secretaries and to identify key staffers. The individuals appointed to departmental, agency, and advisory leadership positions will have significant leeway in shaping the federal and state healthcare policy landscapes 鈥� determining which existing policies to review and potentially revise, new policies to develop, and the approach to working with state and local officials and stakeholders. This includes the Secretary of Health and Human Services, CMS Administrator, Director of the Centers for Disease Control and Prevention, Food and Drug Administration Commissioner, and Director of the National Institutes of Health, all of which require Senate confirmation. Additionally, healthcare stakeholders should continue to monitor the leadership races for the House and Senate and the primary congressional committees with jurisdiction over healthcare programs. These leaders will be key to a second term Trump legislative policy agenda. 

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This article focuses in on a subset of issues within Marketplace, Medicaid, and Medicare and in the overall healthcare sector. Our  features our experts discussing these and other insights on the election results. They provided an overview of what to expect from Congress and the Administration, focusing on key legislative priorities and executive actions.  

Join us for our next two webinars in the series exploring the election results:  

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Comprehensive 50-state survey explores Medicaid policy landscape for FY 2025

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This week, our In Focus highlights the 24th annual Medicaid Budget Survey conducted by the Kaiser Family Foundation (KFF) and 量子资源网, Inc. (量子资源网), in collaboration with the National Association of Medicaid Directors (NAMD). Survey results were released on October 23, 2024, in two new reports:  and . 

The sections below review results and share key takeaways. On November 12, during NAMD鈥檚 2024 Fall Conference, KFF experts and state Medicaid directors will delve into survey findings on policies in place or planned for fiscal year (FY) 2024 and FY 2025, including state experiences with reduced state revenues and the unwinding of the pandemic-related continuous enrollment provision.  

Several of 量子资源网鈥檚 former Medicaid directors and Medicaid experts will be in attendance at the NAMD meeting to provide additional context and address questions about FY2025 Medicaid policies in the post-election landscape. Visit our Medicaid team at our exhibit hall booth, where we will have executive summaries on hand.

Medicaid Enrollment and Spending Growth 

During the COVID-19 pandemic, Medicaid enrollment reached record highs as a result of the Families First Coronavirus Response Act, which authorized a 6.2 percentage point increase in the federal match rate, also known as the or Federal Medical Assistance Percentage until the public health emergency ended, provided that states did not disenroll people with Medicaid coverage. During this time, Medicaid and Children鈥檚 Health Insurance Program (CHIP) enrollment rose to 94 million in April 2023 from 71 million in February 2020. In FY 2024 and into FY 2025, states are concluding their Medicaid unwinding eligibility redeterminations. 

Medicaid enrollment declined by 7.5 percent year over year in FY 2024 and is expected to further decline by 4.4 percent in FY 2025. However,鈥痭et Medicaid enrollment remained above pre-pandemic levels. Total Medicaid spending growth slowed to 5.5 percent in FY 2024 and is expected to slow further to 3.9 percent in FY 2025. State shares of spending, however, rose by 19.2 percent in FY 2024 and is estimated to slow to 7 percent in FY 2025. According to FY 2025 enacted budgets, most states anticipate revenue growth will continue to flatten and expect state general fund spending growth to slow. More than half of responding states anticipated a state revenue shortfall to some degree (see Figure 1). 

Figure 1. Percent Change in Medicaid Spending and Enrollment, FY 1998鈭�2025 

Source: FY 2024鈭�2025 spending data and FY 2025 enrollment data are derived from the annual KFF survey of state Medicaid officials conducted by 量子资源网, October 2024. All 50 states submitted survey responses by October 2024; state response rates varied across questions. FY 2025 projections based on enacted budgets. Historic data reflects growth across all 50 states and DC and comes from various sources.

Managed Care and Provider Rates 

Capitated managed care remains the predominant delivery system for Medicaid in most states. Specifically: 

  • A total of 46 states operated some form of Medicaid managed care (managed care organizations [MCOs] and/or primary care case management [PCCM]). 
  • 42 states contracted with risk-based MCOs. 

States use a variety of鈥痳isk mitigation tools鈥痶o ensure appropriate payment levels for MCOs, including risk-sharing arrangements, risk and acuity adjustments, medical loss ratios, or incentive and withhold arrangements (see Figure 2). 

  • Of the 41 responding MCO states, 25 reported seeking approval from the Centers for Medicare & Medicaid Services (CMS) for a capitation rate amendment to address shifts in the average risk profile of MCO members in FY 2024 and/or FY 2025 because of the unwinding.  
  • Separate from the KFF report, 量子资源网 tracks state Medicaid managed care rate certifications. In addition, Wakely, an 量子资源网 Company,  a paper summarizing approaches taken by actuaries in 27 states, and considerations for how they relate to the biggest enrollment shift in Medicaid since the implementation of the Affordable Care Act. 

Figure 2. States Seeking Capitation Rate Amendments to Address Acuity Shifts Resulting from the Unwinding for the Rating Periods Beginning in FY 2024 and/or FY 2025 

Source: Annual KFF survey of state Medicaid officials conducted by 量子资源网, October 2024

States also are implementing a range of fee-for-service (FFS) rate increases across provider types. More than half of states reported increasing both inpatient and outpatient hospital FFS base rates in FY 2024. States reported rate increases for nursing facilities and home and community-based service providers more often than for other provider categories, reflecting ongoing staffing challenges for long-term services and supports (LTSS).鈥疢ost states also reported rate increases for outpatient behavioral health providers, primary care professionals, and dentists. 

Social Determinants of Health and Reducing Health Disparities 

States are increasingly addressing social determinants of health (SDOH) and associated health-related social needs (HRSN) using several types of Medicaid authorities. For example: 

  • A total of 39 states reported leveraging Medicaid MCO contracts to promote at least one strategy to address SDOH, including screening enrollees for behavioral health or social needs, providing referrals to social services, partnering with community-based organizations, and requiring providers to capture SDOH data and employ community health workers. See Figure 3 for details. 

Figure 3. MCO Contract Requirements Related to SDOH, FY 2024鈭�25 

Source:鈥疉nnual KFF survey of state Medicaid officials conducted by 量子资源网, October 2024
  • Nearly all states also had least one specified MCO requirement related to reducing racial and ethnic health disparities in FY 2025. 量子资源网 one-third of states reported at least one MCO financial incentive tied to reducing racial/ethnic disparities in place in FY 2024, most commonly linking capitation withholds or pay for performance incentives to improving health disparities. 
  • Medicaid Section 1115 demonstrations are also being used to expand flexibilities by adding HRSN services and supports, including coverage of rent/temporary housing, utilities, and meal support. CMS has approved ten states under the new HRSN Section 1115 framework. 

叠别苍别蹿颈迟蝉听

In all, 41 states reported new or enhanced benefits in FY 2024, and 38 states reported plans to add or enhance benefits in FY 2025. Benefit enhancements continue to outpace benefit cuts. 

  • States especially continue to expand behavioral health benefits, particularly for mental health and substance use disorder services. 
  • A total of 11 states reported benefit actions related to the addition or expansion of crisis services, including mobile crisis responses and crisis services for youth. 

Prescription Drugs 

Rising prescription drug鈥痗osts鈥痑re an ongoing concern for states and nearly three-quarters of states reported at least one new or expanded initiative to contain prescription drug costs in FY 2024 or FY 2025. 

  • Efforts to implement or expand value-based arrangements with pharmaceutical manufacturers were the most frequently mentioned cost-containment initiative across states. 
  • Weight-loss prescription drugs also are a hot topic in the states; 13 states now cover GLP-1s (glucagon-like peptide-1s) prescribed to treat obesity. Most state Medicaid programs reported that cost was a key factor contributing to their decisions. 

Key Opportunities, Challenges, and Priorities in FY 2025 and Beyond 

Medicaid directors are focused on behavioral health, LTSS, and key initiatives related to SDOH or reentry services for justice-involved populations in FY 2025 and beyond. In addition, state-reported priorities included鈥痬aternal and child health, rural initiatives, school-based services, continuous coverage for children, value-based payment and quality initiatives, and network monitoring and oversight. 

Budget pressures and workforce shortages are among the main challenges for Medicaid. States noted adequate staffing and systems are obstacles for compliance with recently promulgated federal regulations, particularly the access and managed care rules, which present new reporting, oversight, and beneficiary protection responsibilities for states. Many states also reported a notable increase in per enrollee costs due to the greater healthcare needs of enrollees who retained coverage during the unwinding, adding pressure to budgets. 

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The KFF Medicaid budget report provides important policy insights for federal and state government decisionmakers and Medicaid stakeholders. 量子资源网鈥檚 Medicaid experts know the impact and planning needed to navigate these policies and to inform new decisions in 2025 and beyond. For more information about the key takeaways from the KFF report and 量子资源网鈥檚 Medicaid solutions, contact our experts below.

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How satisfaction impacts Medicare Advantage plans Star ratings聽

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Medicare Advantage (MA) Star ratings are more than a quality score鈥攖hey shape the financial and operational success of MA plans. These ratings hinge on factors that every plan can impact by developing continuous improvement processes. The Consumer Assessment of Healthcare and Provider Systems (CAHPS) survey, Healthcare Effectiveness Data and Information Sets (HEDIS) ratings, and the Member Retention rate are all significant levers affecting Star ratings.  

The importance of member retention rate 

Member retention rate is a measure of member satisfaction but also impacts plan scale. One Medicare Advantage (MA) plan typically reports 0% voluntary disenrollment each year. Another plan is reporting 60% voluntary disenrollment. The voluntary disenrollment threshold is currently set at 18% for a 4-star rating and 10% for a 5-star rating on the measure.  The average MA plan is losing more than $60 million in Medicare premium annually due to voluntary disenrollments. The voluntary disenrollment measure excludes members moving out of the service area or sponsor-initiated contractions of the service area.

CAHPS survey impact on Star ratings 

CAHPS metrics are an important factor in the Centers for Medicaid and Medicare Services (CMS) Star rating system. MA plans need to develop strong companywide focused member experience processes to help them navigate the healthcare delivery system and community resources available. Evaluating the entire member experience from enrollment through access to care, messaging, outreach, customer service, to disenrollment, involves mapping out every member touchpoint, from a population health approach, to ensure the plan has a caring, approachable, supportive, and balanced experience with the member. Opportunities to eliminate frustrative process steps include identifying health related social needs and disparities that provide easier and time-sensitive access to care and services that are essential to increasing member satisfaction and engagement.

Health plans need a process to identify members who are most likely to be dissatisfied due to events and contact these members to understand the needs and resolve issues quickly. A dissatisfying process issue will repeat if not addressed. Understanding what data the health plan should be continually monitoring and the steps to effectively address any issues is essential to increasing trust with members. It is imperative that members get the opportunity to express their concerns to the health plan with the opportunity to resolve issues satisfactorily before they receive a CAHPS survey.

HEDIS and Star ratings 

MA plans need to develop focused processes to proactively monitor HEDIS metrics and drive improvement interventions to keep up with the competition. Having a holistic approach to monitoring, understanding the status and what gaps persist, and a year-round strategy for addressing these gaps is essential to being able to focus efforts on improvement.

As the National Committee for Quality Assurance (NCQA) is moving from a hybrid sampled process to an administrative whole population calculation system, it’s essential that MA plans are addressing each measure in its entirety throughout the year. Digital measurement and Electronic Clinical Data Sets (ECDS) measures are increasing with CMS having a goal of interoperability and implementation of digital quality measures by 2030. Changes with CMS Star metric weightings has increased the total percentage that HEDIS impacts the overall calculation.

Partnering with Pharmacy Benefit Manager to improve Stars 

Medicare Part D measures are among the most highly weighted measures in the CMS Stars performance program. Having a strong Pharmacy Benefit Manager (PBM) p artner is a necessity for success. Measures include medication adherence for high blood pressure, cholesterol, and diabetes. Successful plans ensure that members have sufficient prescription fills and re-fills to cover 80% of the days during the year. Measures are scored based on the percentage of members in the denominator who are compliant by the end of the measurement year. Member satisfaction with the plan鈥檚 pharmacy program is a key determinant in plan rating by the member and plan retention, impacting other parts of the CMS Stars program, whether Part D is measured alone or as part of an MA-PD plan.

Accelerating Star Rating Performance 

The 量子资源网 Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple 鈥渨hat-if鈥� scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year.

The Accelerator approach includes 鈥渁ll-hands-on-deck鈥� 鈥� care coordination, customer service, network development, marketing, analytics, and others. Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest. These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.

量子资源网 Accelerator plans experience a reduction in members choosing to leave, attributed more to prevailing cultural changes over time than to enhanced benefits or member rewards. This program is a cultural transformation designed to strengthen star performance. Click here to learn more about the 量子资源网 Stars Accelerator Solution鈥檚 capabilities, where you can request a copy of the 量子资源网 Stars Accelerator Playbook. Let鈥檚 have a conversation about how your plan can improve member retention for increased star rating and increased enrollment scale.

Watch a replay of Mastering Star Performance: Strategies from the 量子资源网 Stars Accelerator Program.

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In behavioral health, parity is essential, but not enough

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Today鈥檚 post is by Linda Rosenberg, who has recently joined 量子资源网 as a Senior Advisor. In this blog she offers her perspective on parity rules for behavioral health from her many years of experience in the field, most recently as the President and CEO of the National Council for Mental Wellbeing until her retirement in 2019 and as part-time faculty member at the Columbia University Department of Psychiatry.

Attending the 2024 Alignment for Progress conference and experiencing the collective commitment to the 90/90/90 goals, I was once again struck by the groundbreaking nature of the Mental Health Parity and Addiction Equity Act of 2008. The legislation was the critical step in ensuring mental health and substance use is treated on equal footing with physical health. Patrick Kennedy, both as the driver of the Act and in his ongoing advocacy helped us to reshape national conversations and policies.

The new regulations released by the Biden administration add much-needed teeth to the Mental Health Parity and Addiction Equity Act.  The regulations take on one of the biggest ongoing challenges: the lack of adequate provider networks. Behavioral health clinicians are far harder to find in-network compared to medical providers, with many leaving networks due to low reimbursement rates. Under the new regulations, insurers must maintain adequate networks, regardless of the challenges, which will likely come with significant costs to entice clinicians back.

Implementation of the regulations won鈥檛 be simple. The insurance industry is sorting out what compliance will mean to their operations and bottom line. The federal government is struggling to fund and build a monitoring infrastructure.  State governments need to understand their roles and responsibilities. And patients and the people who love them need to learn about their expanded rights and how to exercise those rights. Everyone has a job to do.

The intent of the parity law was about ensuring that mental health and addiction services are treated with the same urgency, seriousness, and respect as any other form of medical treatment. And yet parity has remained a promise unfulfilled for too many. The new regulations are a welcome and necessary step forward, but they cannot address all that needs to be done. Parity is essential, but it鈥檚 not enough. 

Early on in my tenure and long before I retired from the National Council for Mental Wellbeing, a very special member and mentor Carl Clark MD, CEO of WellPower in Denver shared a secret with me.  There are 鈥渨icked鈥� problems, and wicked problems don鈥檛 have a single solution. A wicked problem is complex and interconnected 鈥� and has no stopping rule, rather wicked problems are opportunities for progress.

For too long I鈥檝e listened to too many talks and read too many reports about 鈥渇ixing鈥� or 鈥渃reating鈥� a behavioral health system, but the reality is far more complex, far more 鈥渨icked鈥�. Fragmentation is endemic to all of healthcare in the USA, we have no single healthcare system and no unified behavioral health system either. We have thousands of systems鈥攑ublic, private, nonprofit, hospital-based, and government-run – each serving different populations and communities with varying levels of resources and approaches and each dependent on a bottom line.

The fight for parity was never just about changing laws鈥攊t鈥檚 about changing hearts, minds, and systems, reshaping the way we understand and deliver care across all these thousands of systems we鈥檝e created and continue to create.

Well intentioned programs with layered initiatives focused on whole health, social determinants of health, and other efforts are adding complexity to a system that鈥檚 already overwhelming for the very people these systems are supposed to serve.

What we need is a financing model that ties all the pieces together – Certified Community Behavioral Health Centers (CCBHCs) are a promising start – a financing model that pays for the continuum of services, inpatient and community, rather than the current fragmented approach that pays for pieces separately. At the same time, we need to leverage technology to alleviate pain points, establish desperately needed standards of care, and provide decision support for both clinicians and patients. With technology, we can measure and benchmark care across systems, creating transparency and accountability at every level.

By aligning financing with the full spectrum of services and using technology to drive transparency and accountability, we can finally begin to address the wicked problems that prevent effective mental health and addiction care. As I help non-profits, health technology companies, and venture firms build growth strategies that result in consumer and economic benefits, I understand that the new regulations give us a foundation to build on鈥攖he rest is up to us.

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Nevada releases Medicaid managed care RFP: State will expand managed care statewide into rural areas

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This week, our In Focus section highlights the State of Nevada鈥檚 October 21, 2024  (RFP), which will expand Medicaid managed care to cover nearly all populations in all counties. The Department of Health and Human Services鈥� Division of Health Care Financing and Policy (DHCFP) estimates that the expansion statewide will cover 75,000 additional individuals who live in rural areas, including children, parents, and adults without children. The expansion to rural areas in all counties presents new opportunities and critical issues for managed care plans, ensuring that they meet the needs of rural populations effectively. 

Background 

In 2024, Nevada covers 788,000 Medicaid members, with risk-based capitated Medicaid managed care making up about 75 percent of the total Medicaid population. Managed care covers traditional Medicaid and expansion, the Children鈥檚 Health Insurance Program (CHIP) known as Nevada Check Up, and children who have aged out of foster care. Enrollment in an MCO is mandatory for these populations. Currently, Medicaid managed care is only offered in the urban Washoe and Clark counties, which include cities such as Reno and Las Vegas.  

Nevada has four MCOs that were procured in 2021: Centene/SilverSummit HealthPlan, Elevance/Anthem, Molina, and UnitedHealthcare/Health Plan of Nevada. These MCOs serve approximately 588,000 beneficiaries in Urban Washoe and Urban Clark counties as of August 2024. 

United and Elevance make up the majority of market share by enrollment, with 34.4 percent and 33 percent respectively.  

Individuals who receive Medicaid through fee-for-service (FFS) are Medicaid-enrolled children in foster care, juvenile justice, and child welfare systems; individuals with disabilities; seniors; and individuals receiving services through one of the three 1915 home and community-based waiver programs. These individuals will continue to receive services through FFS. 

RFP Highlights  

The RFP describes the state鈥檚 three managed care service areas (SA): Urban Washoe, Urban Clark, and Rural. The Rural SA will include all other counties in Nevada in addition to the rural areas of Washoe and Clark counties. 

MCOs must bid on all service areas. DHCFP anticipates selecting four plans. The two awarded vendors with the highest rural care score will operate in all three SAs. The remaining awarded vendors will operate in Urban Clark and Urban Washoe SAs. The state has the option to award a fifth contract to an MCO to operate in the Urban Clark SA only.  

The RFP focuses on rural care and policies designed to improve outcomes and access to care, reduce burdens for providers to participate, and simplify administrative tasks for the state. MCOs will need to show their understanding of the unique challenges facing rural providers. They will describe their approach for provider outreach, contracting, and provider training strategies in rural areas, with a focus on primary care, maternal and child health, and behavioral health. Due to the geographic limitations, telehealth will also play a strong role. MCOs will need to address limitations such as access to internet and provide an approach to help members access telehealth. Additionally, MCOs will need to provide their experience in managing non-emergency medical transportation (NEMT) in rural areas and describe an approach for establishing and maintaining a network of transportation providers in these remote areas.  

MCOs also will be required to offer at least one Silver and one Gold Qualified Health Plan (QHP) on Nevada Health Link Marketplace by the 2026 coverage year. The state expects this contractual requirement will help reduce churning and improve continuity of care for individuals and families who have a change in eligibility status. 

MCOs must also contract with providers that use alternative payment methodologies (APMs), and plans will need to outline value-based purchasing (VBP) strategies within their proposals. APM contracting strategies must support priority areas such as addressing health-related social needs (HRSNs) and improving health equity, access, behavioral health, and maternal and child health outcomes. APM contracting strategies must include quality measures in the payment methodology and outline reporting and estimated financial details. Additionally, MCOs are required to develop a Population Health Program, so proposals must outline how it will leverage specific APMs to meet the program鈥檚 goals. 

Evaluation 

MCOs will require a minimum score of 945 points (out of 1,350 points) on the Technical Proposal to be eligible to win a contract. The Building Provider Networks and Access to Care technical questions is worth the most points, 450, while 300 points are available under the Rural Care and Service Area Expansion section. The table below provides a breakdown of the Technical Proposal Scoring. 

The state assigns the highest number of points to the section addressing provider networks and access to care followed by the section addressing rural care and service area expansion. 

Timeline 

Key Considerations  

量子资源网 experts identified the key considerations for MCOs, partners to MCOs, providers who will furnish services to members, and other interested stakeholders.  

  • The Building Provider Networks and Access to Care Rural Care and Service Area Expansion sections together are worth 750 points, most of the minimum needed, and more than half of the total available points. This is a strong indicator of that MCOs need to demonstrate capacity and innovation to ensure access to members using multiple strategies. Ensuring a robust network of healthcare providers in rural areas is crucial. This includes recruiting and retaining providers who are willing to serve in these regions.  
  • In this RFP, DCHFP is evolving its value-based payment (VBP) initiatives and expectations for MCOs. The VBP strategies are intended to enhance care quality, improve patient outcomes, and ensure the sustainability of the Medicaid program. MCOs will need to design these models and successfully work with providers to implement the strategies and models.  
  • Both improving maternal and child health outcomes and addressing mental health and substance use disorders are priorities for the state. These can be more challenging in rural settings due to limited access to specialized care and will require rural specific solutions. 
  • Changing the Medicaid delivery system model in some rural areas may create the need for building awareness and understanding for the changes that come with this transition. MCOs should be prepared to effectively address the issues of equity and disparities that are present in in rural communities.  

Connect with Us 

量子资源网鈥檚 experts understand the Medicaid managed care environment and specific issues presented by rural areas. We work with clients to address the multilevel challenges for delivery of quality healthcare and social services to rural populations, and the workforce concerns they create. We identify and help plan for access issues such as lack of services, transportation difficulties, and socio-economic barriers.  量子资源网 knows the difficulties that often keep rural providers and organizations from achieving their full potential to serve and support their communities鈥� need and help Medicaid clients in rural areas in states around the country to solve these difficult problems. 

Read more about the work we are engaged in with a range of healthcare industry leaders focused on rural and frontier areas.  

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Healthcare solutions unlocked: Key takeaways from the 2024 量子资源网 Conference

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The 量子资源网 Conference – Unlocking Solutions in Medicaid, Medicare, and Marketplace 鈥� was held in early October in Chicago, drawing a crowd of 350 participants hailing from all parts of the healthcare ecosystem. In the words of one attendee, what made the 量子资源网 conference unique was that 鈥渋t was very rare to have providers, CBOs, health systems, insurers, and public sector organizations in one place鈥 gained significant value by viewing similar issues from different perspectives.鈥�

Attendees participated in plenary sessions and breakouts that were grounded in Medicaid, Medicare, and Marketplace, with each session extending beyond the traditional topics for these public health insurance programs. Attendees were challenged and inspired to consider the cross-cutting work underway to address health equity, the integration of housing into healthcare, innovative strategies for behavioral health coverage for adults as well as children and families involved in the child welfare system, and the opportunities for federally qualified health clinics to engage in value-based care delivery to improve outcomes.

Signature 量子资源网 discussions with health plan leaders and Medicaid directors also provided valuable insights that will help guide the next phase of innovative programs and technologies designed and deployed to improve health. Breakout sessions offered in-depth exploration across Medicaid/Duals, Medicare/MA, and Marketplace/ACA tracks, alongside discussions on demand for innovation, advances in treating sickle cell disease, and creative workforce strategies. The conference concluded with a panel that prepared attendees for policymaking in the post-election, post-Chevron deference landscape.

The 量子资源网 event created opportunities to learn and network with potential partners against the background of the city of Chicago skyline, as one participant put it, 鈥渁way from the daily craziness.鈥� The discussions were robust and focused on new ideas that can be deployed by stakeholders all trying to improve the accessibility, quality, equity, and value of healthcare.

Listed below are conference takeaways that will be of interest and relevant to the broader healthcare ecosystem:

Systemize the little things that improve outcomes.

Keynote speaker Dr. Darshak Sanghavi from ARPA-H challenged people to focus on systematizing the 鈥渓ittle things鈥� that drive measurable improvements in outcomes as a source of meaningful innovation. His presentation focused on how ARPA-H is investing differently in private sector innovation 鈥� not just big breakthroughs, but also in data-informed approaches that produce consistent quality.

Housing is a healthcare issue.

There is increasing overlap between initiatives to address housing support in Medicare and Medicaid. Bridging diverse sectors and stakeholders is essential to address critical gaps in service delivery. 量子资源网鈥檚 new Housing Services & Supports practice group recognizes that housing is part of healthcare, but it does not have to be fully funded by healthcare entities.

Cross-payer collaboration would improve behavioral health.

Behavioral health coverage has historically relied on the Medicaid-based chassis of coverage, but the breadth of needs and federal parity requirements have created an urgent need for new approaches to coverage across all systems and all payers. Cross-payer innovation and collaboration are essential, and systems need to position themselves to scale effective solutions that allow individuals to access services when they need them. In particular, youth and family voices must be part of the transformation of children’s mental health systems to smooth their experience.

The ACA is stable, but 2025 brings uncertainty.

The stability and future success of the ACA marketplaces hinge on the decisions of the 119th Congress regarding the extension of subsidies. If these subsidies are reduced or cancelled it could disrupt what has become a robust and reliable segment of the health insurance market, potentially requiring another pivotal transformation.

Community collaboration can bridge Medicaid health gaps.

New norms are emerging in the Medicaid program. There is unprecedented policy and programmatic work underway to ensure member experiences are informing the design of Medicaid programs as well as the type and pathways for accessing health and health adjacent services. Federal and state government, managed care plans, and providers must work together to bridge the gap to ensure Medicaid programs are best able to serve their members.

Interoperability remains foundational to quality improvement.

We have many different information systems, but when data is pushed to providers to help them manage their patient panel — ED visits, medications, and other data 鈥� higher quality care is more likely to be provided to patients.

Provider networks can be structured to ensure success in value.

Medicare providers are embracing value-based care on different timelines and in varied ways. Policymakers, health plans, and other stakeholders need to think carefully about how to structure networks with those providers who are doing it well to get the best results.

Clinics need help with data and financing to drive value-based outcomes.

Poverty is the primary diagnosis for patients of federally qualified health centers (FQHCs), and payment can better recognize the connections FQHCs make to anti-poverty services and programs. As the healthcare industry moves providers along the trajectory of value-based payment, FQHCs will be positioned to deliver whole person care if their data and financing is aligned.

These 鈥� and other takeaways and partnerships 鈥� will inform strategic, policy, programmatic and operational decisions at the hundreds of organizations represented at the 量子资源网 conference. They are also key points as we shape the conversations for the 2025 event.

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Medicare Advantage Plans: It鈥檚 time for the Stars 4th quarter push

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The Medicare Stars program is a year-round endeavor for Medicare Advantage (MA) plans. That being said, all MA plans intensify their Stars campaign during the fourth quarter of each year. The most important aspect of the fourth quarter push is to know where to focus. MA Star ratings are more than a quality score鈥攖hey shape the financial and operational success of MA plans.

Some measures may no longer apply in the fourth quarter. Once the Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey has been completed, the fourth quarter becomes a time to continue the effort to enhance and improve consumer experience for next year’s CAHPS survey. For example, post discharge follow-up is time limited and going back to earlier quarters is not possible.  Adherence measures work similarly; if a member has already lost 80% of days covered, coverage cannot be made up during the fourth quarter. The message should be 鈥渇ocus only on measures where you can make a difference.鈥�

Mammograms and colorectal exams can occur any time of year. These two measures should definitely be the focus of a fourth quarter push. A constraint may be provider capacity since all MA plans are focused on the same measures. Measures with low denominators like the osteoporosis management measure may be an important element in fourth quarter strategies.

Star Ratings and Operational Excellence

Operational excellence begins with robust, accurate, and actionable data, and even using lean six sigma principles to drive process improvement. Advanced analytics platforms are needed to aggregate and analyze vast amounts of healthcare data and operational data. Accurate risk adjustments, quality measurement, and operational metrics like appeals are essential. Data discrepancies or delays result in penalties, lower Star ratings, and incorrect payments. MA plans must develop processes to validate via quality assurance process and audit data regularly against CMS requirements.

Operational excellence also relies on a well-trained engaged workforce. Training should focus on fostering a culture of continuous improvement, where every team member is aligned with the organization’s goals of improving quality and operational performance.

Star ratings are a byproduct of strategic, data-driven approaches to care management, quality improvement, and operational efficiency. Success lies in the ability to optimize data integrity, streamline care coordination, and proactively resolve member concerns.

Accelerating Star Rating Performance

The 量子资源网 Stars Accelerator Solution offers a comprehensive, results-oriented approach to Star Rating performance improvement that addresses the multifaceted challenges faced by health plans and makes sure that your intensified 4th quarter effort is productive.  The 量子资源网 Stars Accelerator Solution analytics provides information to plans about prioritizing measures during the fourth quarter push. It examines your plans leadership structure, operational processes, technology, reporting, member-centric engagement, provider partnerships, and develops a strategy for your organization using a data-driven approach for continuous improvement. Multiple 鈥渨hat-if鈥� scenarios are developed that identify top priorities. Measure thresholds that are too far to reach are replaced by measures that are within reach during the final months of the year. The Accelerator approach includes 鈥渁ll-hands-on-deck鈥� 鈥� care coordination, customer service, network development, marketing, analytics, and others.  Accelerator plans introduce provider and member incentives and/or fee schedule adjustments to increase interest.  These plans also provide information to providers on those attributed members who have measure gaps to facilitate provider outreach that is coordinated with plan outreach.

As the fourth quarter push occurs in the middle of the Annual Enrollment Period, lessons learned can be applied immediately. The 量子资源网 team can backstop your organization during this very busy time, avoiding missed opportunities. The fourth quarter push does not end until midnight January 31st of each year.

The 量子资源网 Stars Accelerator Solution will create a permanent change in your organization that is designed to yield a 4-star rating or higher each year.  The Accelerator is a cultural transformation designed to strengthen star performance. Click here to learn more about the 量子资源网 Stars Accelerator Solution鈥檚 capabilities, where you can request a copy of the 量子资源网 Stars Accelerator Playbook. Let鈥檚 have a conversation about how your fourth quarter push is designed and unfolding.

We are also holding two webinars that may be of interest:

Falling Stars: Who’s Who in the 2025 Star Ratings
November 7, 2024 – 3:30 PM ET


Colleagues from Wakely Consulting Group, an 量子资源网 Company, will discuss trends in Overall Star Ratings, the appeals and lawsuits filed in response, and future changes to the Star Rating program that are likely to depress Star Ratings even further over the next few years.

Mastering Star Performance: Strategies from the 量子资源网 Stars Accelerator Program
November 13, 2024 – 12:00 PM ET
Register now

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