January 15, 2025
CMS Stays the Course with Proposed Payment Updates for Medicare Advantage and Part D Services in 2026
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Los Angeles County State of Children鈥檚 Health Report: Policy Briefs
Informed by research and exploration of the on some of the most complex challenges facing children in a post-pandemic world, experts from L.A. Care Health Plan, the nation鈥檚 largest publicly operated plan, and Children鈥檚 Hospital Los Angeles (CHLA), one of the nation鈥檚 leading pediatric hospitals, unveiled their first-ever Los Angeles County State of Children鈥檚 Health report. The report, made up of four policy briefs, identified core issues impacting kids and teens and key recommendations to proactively address them.
The report originated from roundtables held in November of 2023 that convened expert stakeholders resulting in four distinct policy briefs and action plans. Recommendation highlights include establishing new school-based programs to improve mental health services within educational settings, launching an effort to dispel vaccine myths to improve children鈥檚 health, and addressing resource challenges that children and youth with complex chronic conditions and in social welfare system experience in Los Angeles County and beyond.
量子资源网 experts in child welfare and behavioral health worked with the team of outside children’s health experts to prepare these four policy briefs with actionable solutions:
- Vaccine Catch-Up and Misinformation: How can we improve access to and the provision of immunizations to promote children鈥檚 health?
- Children and Families鈥� Resiliency: How can we improve the systems of care to improve well-being and address children鈥檚 mental health needs?
- Supporting Children and Youth Involved in the Child Welfare System聽: How can we improve the quality, appropriateness of supports, and ease of access to care to address the unique needs of children involved in the child welfare system?
- Children and Youth with Complex Medical Needs Transition to Adulthood: How can we facilitate the continuation of critical support as children with complex medical needs age out of care eligibility?
You can access the comprehensive reports and video series .
Federal election impacts on Ohio Medicaid
Ohio Medicaid is no stranger to change. Over the last several years, there have been several broad policy changes, from a new managed care system, to new programs like OhioRISE, to an expansion of MyCare Ohio. And, during this time, there have been complicating factors like the covid-19 public health emergency and the resultant impact of inflation on the basic delivery of services and care. Now, as the Trump administration comes in for the second time, questions arise as to what to expect in Medicaid policy and how it may impact Ohio.
While it鈥檚 often overlooked, federal rule making has a significant impact on the operations of states. Just in the last couple of years, the Biden Administration has implemented policies including:
- 罢丑别听, such as the 80/20 policy, implementation timelines, and other questions regarding Home and Community Based Services waivers that states and certain stakeholders elevate to the Centers for Medicare & Medicaid Services (CMS).
- 罢丑别听, which聽addresses Medicaid聽managed care聽access, financing, and quality, including strengthening standards for timely access to care and states鈥� monitoring and enforcement efforts.
- The Long-Term Care Facility (聽requires minimum聽聽for nursing facilities.
- Two rules streamline Medicaid enrollment and renewal processes for the聽聽(MSP) and for聽. Each rule is expected to increase Medicaid enrollment by about one million people.
These rules are set to be implemented over several years. The Trump Administration could delay implementation of certain provisions, which would eliminate regulations while rolling back enrollee protections, payment transparency, and improved access. Alternatively, the Trump Administration could adjust their enforcement strategy or issue new regulations that would undo or augment these final regulations.
Beyond regulation, there is still the potential for fundamental policy change to the program鈥檚 financing. Notably, the concept of block grants or per-capita caps has reemerged as a potential option, where states would no longer receive federal 鈥渕atch鈥�, but rather a fixed amount based on historical averages. In fact, Energy and Commerce as an area of active conversation in the House Republican Caucus.
Making a fundamental, national change in the financing arrangement of Medicaid would require an act of Congress. Many think this movement away from a traditional reimbursement structure was one of the main reasons for the failure to repeal the Affordable Care Act during the first Trump administration. Notably, as Ohio is a 鈥渞ecipient鈥� state, meaning it receives more in federal taxes than it provides for the Medicaid program, this could significantly impact the long-term financial stability in future state budgets. Often, this challenge is why block granting is usually associated with additional state powers around curbing enrollment, services and coverage, so states may more easily cut the program to accommodate tighter financing.
Depending on how all of these changes would unfold, Medicaid programs, including Ohio鈥檚 may have to adopt their systems to accommodate. However, the Trump administration may also pursue greater flexibility for states to design and innovate in Medicaid in ways that are consistent with their goals. This could include greater flexibility to limit covered services, raise cost-sharing requirements, limit enrollment or require more frequent determination of eligibility. There may also be programmatic refocusing away from initiatives which center health equity and expanded coverage, including alternatives to 鈥淢edicaid expansion鈥�, as well as a fundamental reorientation of the use of waivers.
Speaking of waivers, there is likely going to be a dramatic change in the way waivers are applied and executed. This can include, but is not limited to, waivers that test new policies the prioritize cost-cutting measures over access and coverage, including waivers which change how the Medicaid expansion group is managed in states. Included in this are 鈥淲ork Requirement鈥� waivers, something . While examples from other states have shown that such waivers are , the Trump administration and many policymakers see these requirements as a way to ensure labor force participation. Though there is evidence to suggest
As Ohio providers, plans and policymakers gear up for the next state budget, the landscape of Medicaid policy will be something to pay attention to. While Medicaid represents nearly 48% of the total state budget, . What鈥檚 more, nearly 1 in 3 Ohioans rely on the program, disproportionately in rural communities, and it supports Ohio鈥檚 second largest industry in healthcare. Make sure you stay on top of the latest updates to the program in Ohio and beyond and sign up for 量子资源网s Weekly Roundup.
Ohio Health Policy Snapshots
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CMS Announces 15 States Participating in the Transforming Maternal Health Model
The Centers for Medicare & Medicaid Services (CMS) on January 6, 2025, announced that 15 states have been selected to participate in the agency鈥檚 new TMaH) Model. They are: Alabama, Arkansas, California, the District of Columbia, Illinois, Kansas, Louisiana, Maine, Minnesota, Mississippi, New Jersey, Oklahoma, South Carolina, West Virginia, and Wisconsin. This week, our In Focus section reviews this initiative and the need for improved maternal healthcare for Medicaid and Children鈥檚 Health Insurance Plan (CHIP) enrollees.
Adverse Maternal Health Outcomes Among Medicaid and CHIP Enrollees
Medicaid and CHIP programs cover a large portion of all births in the United States. According to a CMS data brief published in December 2024, , the public health programs covered 41 percent of all births that year. In some states, Medicaid and CHIP-covered healthcare accounted for up to 67 percent of births.
The data brief examines the trends of premature births and severe maternal morbidity (SMM) events鈥攊ncluding blood transfusion, acute respiratory distress syndrome, sepsis, acute renal failure, ventilation, and other conditions鈥攊n Medicaid and CHIP-covered births for people ages 15 to 49 between 2019 and 2021. During this period, the percentage of preterm live births increased from 10.5 percent to 10.8 percent, and SMM rates increased from 209.6 per 10,000 live births to 252.7 per 10,000 live births.
Some demographic groups had higher rates of preterm births and SMM than others. Enrollees who were Medicaid-eligible because of disability had more than 1.5 times the percentage of preterm births, and nearly double the rate of SMM than enrollees in other eligibility categories. In addition, non-Hispanic Black enrollees and non-Hispanic Native American enrollees had the highest rates of preterm births and SMM compared with all other racial and ethnic groups.
With the increasing adverse maternal health outcomes facing Medicaid and CHIP enrollees, as well as people with private insurance, state leaders and their partners are looking toward different initiatives to help improve outcomes. As governors prepare for their 2025 State of the State Addresses, several are expected to identify maternal health as a key priority. Their priorities will initiate and build on policy changes and other actions in development since 2022, such as expanding Medicaid coverage to 12 months postpartum, collecting and publishing actionable data on pregnancy-associated and pregnancy-related mortality and causes, and directing funding to expand targeted high-quality care provided by doulas and community health workers (CHWs), for example.
TMaH Model
The TMaH Model, which CMS introduced in December 2023, is designed to improve maternal healthcare, improve health outcomes for Medicaid and CHIP-covered births, and lower healthcare expenditures. The model centers on three main pillars described in Table 1.
Notably, the model is intended to facilitate design and implementation of a value-based alternative payment model for maternity care services. It also includes a health equity strategy to address disparities among racial and ethnic minorities, as well as people who live in rural and underserved areas.
The 10-year TMaH Model has an initial three-year implementation period that began January 1, 2025. During that time, states will receive targeted technical assistance to develop and implement elements of the model while achieving pre-implementation milestones. Moreover, participating states will receive up to $17 million in cooperative agreement funding to support planning and implementation over 10 years.
Obstetrical Quality Measures and Standards
To further support the goals of the TMaH Model, CMS has new national health and safety standards, known as conditions of participation (CoPs), for hospitals and critical access hospitals that offer obstetrical services. These CoPs represent a significant step in advancing maternal health outcomes by requiring maternal quality assessment and performance improvement programs, setting baseline standards for the organization, staffing, and delivery of obstetrical care, and mandating staff training in evidence-based maternal health practices.
By establishing a consistent standard of high-quality maternity care for all Medicaid participating facilities, the CoPs complement the TMaH Model鈥檚 pillars of quality improvement and safety, as well as whole-person care. Together, these initiatives are intended to produce a unified framework for reducing maternal morbidity and mortality, addressing health disparities, and fostering equitable, patient-centered care across participating states.
Key Considerations
The new TMaH Model provides participating state Medicaid agencies (SMA) with an opportunity to accelerate their efforts to improve maternal health outcomes for a large percentage of their maternal population. State TMaH planning initiatives will need to consider the model requirements and include:
Strengthening partnerships. The model provides states with an opportunity to strengthen collaboration with and build capacity among key partners, including Perinatal Quality Collaboratives, hospitals, birth centers, healthcare centers and rural health clinics, maternity care providers, and CBOs, to successfully implement the model. Specifically, states can work with providers to use provider infrastructure payments to support their engagement with CBOs that can address the HRSNs and behavioral health needs of beneficiaries and integrate them into screening, referral, and follow-up activities.
Defining the role for managed care organizations (MCOs). Agencies will need to work with MCOs and stakeholder groups to support the model. SMAs may designate some of their Cooperative Agreement funding to MCOs to support infrastructure and capacity building for the TMaH Model.
Integrating TMaH with existing and other planned initiatives. Optimizing the TMaH Model requires states and their partners to consider how the framework complements and may be incorporated into other state initiatives. Specifically, the TMaH Model will require reporting on screening for three domains of HRSNs: food insecurity, housing instability, and transportation. The TMaH Model will require use of a validated health IT-encoded HRSN screening instrument, such as the Accountable Health Communities HRSN screening tool. States and their partners can integrate existing HRSN tools and Medicaid section 1115 demonstration initiatives with efforts carried out using the TMaH Model.
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Join 量子资源网 (量子资源网) experts聽Michelle Hurst,聽Marilyn Johnson, and聽Zipatly V. Mendoza聽for the聽Improving Maternal Health Outcomes: Navigating CMS Guidance for Better Care聽webinar on January 28, 2025. They will dive deeper into recent CMS regulations and other federal developments that affect maternal health, actionable strategies to implement regulations, and approaches to reduce maternal health disparities and ensure equitable care.
January 8, 2025
CMS Announces 15 States Participating in the Transforming Maternal Health Model
量子资源网鈥檚 Strategy & Transformation Practice collaborates with Stanford University to drive public health innovation
Through a new collaboration with , 量子资源网鈥檚 Strategy & Transformation practice aims to foster innovation in Medicaid and public healthcare. This collaboration seeks to support a new generation of public health innovators, focusing on transformative approaches to healthcare payment, policy, and delivery.
Kyle Murphy and R.J. Briscione presenting.
Kyle Murphy and R.J. Briscione of 量子资源网鈥檚 Strategy & Transformation Practice will mentor early-stage companies, deliver guest lectures on the U.S. public healthcare system, and co-develop thought leadership pieces with Stanford faculty and students at Stanford Emergence Program.
This multi-faceted collaboration is designed to provide real-world insights to aspiring healthcare entrepreneurs aiming to improve public health outcomes and equity.
Prof. Narges Baniasadi, who is the founder and executive director of Emergence program says: 鈥淲e are excited about our growing collaboration with 量子资源网 team to catalyze the translation of academic research to impactful innovations for public health and to educate budding entrepreneurs on ways they can scale their impact through working with the public sector.鈥�
Dr. Narges Baniasadi oversees this new initiative that strives to 1) catalyze impact entrepreneurship to address systemic challenges in the health of our society and planet and 2) shift the culture of the innovation ecosystem to be more mission-driven and inclusive. At the core of Emergence is its mission to inspire, educate, and support the next generation of innovators to improve societal and planetary health through impact entrepreneurship.
Early in January, 量子资源网鈥檚 Strategy & Transformation Practice will also participate in the 鈥檚 implementation bootcamp for its 2024-25 cohort of Innovation Fellows. Murphy and Briscione will focus on expanding the Innovation Fellows鈥� understanding of Medicaid and assessing its viability as a go-to-market strategy for innovative solutions. Since 2001, Stanford Biodesign has educated and empowered aspiring and experienced innovators interested in improving healthcare with technology innovation through fellowships, graduate and undergraduate courses, faculty training, and executive education.
To date, the center has trained 219 Innovation Fellows through a 10-month program where they learn to identify and screen important unmet health needs, invent technology-based solutions to address the most promising ones (including medical devices, diagnostics, digital health, drug delivery, and biotechnology solutions), and prepare to implement them into patient care. The Strategy & Transformation Practice brings valuable experience to this collaboration, having previously worked with companies that have emerged from Biodesign trainee projects.
This collaboration elevates 量子资源网鈥檚 position within the innovation ecosystem and prepares founders to build and scale products designed for Medicaid populations. By bridging the gap between evidence-based research and practical implementation, this effort has the potential to drive changes in public healthcare policy and delivery, generate the development of cost-effective healthcare solutions, and improve healthcare access for vulnerable populations. As 量子资源网 continues to lead in healthcare consulting,supporting the Emergence Program and Stanford Biodesign reinforces its commitment to fostering innovation and improving public health outcomes across the country.
Webinar Replay: Improving Maternal Health Outcomes – Navigating CMS Guidance for Better Care
This webinar was held on January 28, 2025.
The information presented in this webinar is based on market knowledge and guidance prior to the new Trump administration; due to the rapidly evolving healthcare and policy landscape, these issues are likely to change moving forward.
Maternal health is at a critical turning point, and healthcare professionals are seeking innovative solutions to improve outcomes, reduce disparities, and ensure equitable access to care. This webinar highlighted the latest CMS policies and guidance designed to address maternal mortality, expand access to high-quality care, and advance health equity for diverse populations. This session is ideal for hospital and critical access administrators, healthcare professionals, and policymakers dedicated to advancing maternal health and achieving better outcomes.
Learning Objectives:
- Gain a clear understanding of the latest CMS regulations, policies, and quality measures related to maternal health outcomes.
- Discover actionable strategies and best practices for implementing CMS guidance to improve care delivery and patient outcomes.
- Explore approaches to reduce disparities in maternal health, ensuring equitable care for underserved populations.
MyCare Ohio: The Next Generation鈥檚 Impact on the Ohio Medicare and Medicaid Landscape
This week, our In Focus section also reviews the significant efforts under way in Ohio to transform how the state provides healthcare services to its Medicare and Medicaid dual-eligible population. Effective January 1, 2026, MyCare Ohio will transition to the Next Generation of its program for people who are dually eligible for both programs.
Overview of Ohio鈥檚 Transition to Next Generation MyCare Ohio
This evolution moves Ohio to a fully integrated dual-eligible special needs plan (FIDE-SNP) model that seeks to achieve several key goals through a population-based health approach designed to address inequities and disparities in care for dual-eligible individuals. Examples include:
- Improved Care Coordination: Strengthening integration between Medicare and Medicaid services to provide seamless, holistic care for individuals, thereby reducing fragmentation and ensuring comprehensive management of medical, behavioral, and social needs
- Personalized Care:聽Applying 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 people with chronic conditions
- Expanded Access to Services: Increasing accessibility, particularly through telehealth and digital tools, to reach underserved populations and improve accessibility, particularly for people living in rural or remote regions
- Enhanced Quality of Care:聽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:聽Leveraging advanced technologies like mobile apps, predictive analytics, and telemedicine to monitor patient health, improve communication between patients and providers, and deliver care more efficiently
The program currently is offered in 29 counties across Ohio but will transition to a statewide program as a part of the Next Generation changes. In addition, 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 and evaluated submitted proposals, the agency selected four managed care organizations (MCOs), which will become the Next Generation MyCare plans. The ODM contracts to the following MCOs that will serve MyCare members beginning in January 2026: Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina HealthCare of Ohio.
Considerations for the Market
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 may affect both selected and non-selected participants in different ways, including:
- Increased competition among 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 in terms of the volume of services provided, but also to the quality and effectiveness of healthcare delivery. Those plans that 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 members because they were not selected or are unable to offer CO-DSNPs moving forward, will likely strategize to gain membership through other product lines or benefit design to offset losses. Strategies may vary but might include tactics such as: enhancing benefits or decreasing member cost sharing to entice member movement across carriers for non-D-SNP plans; finding innovative ways to further reach different segments of the Medicare population, such as Special Supplemental Benefits for the Chronically Ill (SSBCI) packages or Chronic Condition SNP plans; or shifting their focus to product lines outside of Medicare Advantage and Medicaid.
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Ohio is one of many states transitioning to a FIDE model beginning January 2026. 量子资源网, Inc. (量子资源网), has successfully supported participating and nonparticipating carriers throughout the transition process and continues to be a dedicated partner to organizations navigating Medicare and Medicaid changes across the country.
Contact our featured experts below, to learn more about the Ohio FIDE-SNP initiative and 量子资源网鈥檚 capabilities and expertise to support states, carriers, and other key partners with these transitions.
CMS Announces Medicare Advantage Value-Based Insurance Design Model Will End After 2025
The Centers for Medicare & Medicaid Services (CMS) announced on December 16, 2024, that it will be terminating the (VBID) model at the end of 2025 because of the model鈥檚 鈥渟ubstantial and unmitigable costs to the Medicare Trust Funds.鈥� This In Focus article delves into the factors driving CMS鈥檚 decision and considerations for policymakers, Medicare Advantage Organizations and other interested stakeholders.
VBID Outcomes
VBID, run by the CMS Innovation Center, is not a permanent part of the Medicare Advantage (MA) program. Innovation Center models are required to be modified or terminated if they are a cost to the program.
CMS found that costs for the VBID model totaled $2.3 billion in calendar year (CY) 2021 and $2.2 billion in CY 2022, an unprecedent amount for an Innovation Center model. CMS concluded that these substantial expenses鈥攄riven by increased risk score growth and Part D expenditures鈥攚ere unmitigable through policy modifications. Therefore, consistent with statutory requirements, CMS took action to terminate the model by the end of 2025. Earlier this year, CMS announced it would discontinue the part of VBID that allowed MA plans to offer hospice services.
Next year, the VBID model will have 62 participating MA plans and is projected to offer 7 million Medicare beneficiaries additional benefits and/or rewards, including those designed to address social determinants of health and reduce cost-sharing for prescription drugs used to treat and manage chronic conditions. As part of the announcement, CMS pledged to support a stable transition for all enrollees in MA plans participating in the MA-VBID model and emphasized that key benefits available under the model will continue to be widely available, including supplemental benefits that address the whole-person healthcare needs of beneficiaries. In addition, CMS noted beneficiary cost-sharing for prescription drugs will be reduced as the result of the expansion of the low-income subsidy program under the Inflation Reduction Act and the CMS Innovation Center鈥檚 Medicare $2 Drug List Model, which is slated to begin in 2027.
As part of the announcement, CMS released an executive summary of a forthcoming evaluation report, with the full report expected to be released in early 2025.
Key Considerations
Since the MA-VBID model鈥檚 launch in 2017, the program has experienced significant growth through a series of legislative and model changes, including requirements in the Bipartisan Budget Act of 2018 that expanded eligibility to MA plans in all 50 states and allowing all types of MA special needs plans to participate in MA-VBID. Previous CMS found that the MA-VBID model led to improvements in the quality of care for beneficiaries and promoted greater adherence to prescription drugs used to treat and manage chronic conditions. Though CMS has concluded that excess costs require the termination of MA-VBID by the end of 2025, the incoming Trump Administration can be expected to closely examine this decision and look at the entire Innovation Center portfolio.
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量子资源网, Inc. (量子资源网), Medicare experts will continue to assess and analyze the response to CMS鈥檚 announcement, including the incoming administration鈥檚 views on the decision and potential alternatives. 量子资源网鈥檚 experts have the depth of knowledge, experience, and subject matter expertise to assist MA organizations and interested stakeholders in analyzing and adapting to the marketplace as the MA-VBID program ends.
For further analysis of the MA-VBID decision and its impact on the market, contact our experts below.
Congress Continues Negotiations on 2025 Spending and End-of-Year Package
This week, our In Focus section reviews the year-end legislative package congressional leaders announced as part of the stopgap funding to prevent a government shutdown. The , which was unveiled December 18, 2024, would extend expiring Medicaid and Medicare policies, reauthorize health and human services programs, and extend federal funding for discretionary programs through March 14, 2025. The existing temporary funding measure expires December 20, 2024.
Following is a summary of several major healthcare policies that, if approved, will inform the shifting federal policy landscape and state and local programs in 2025.
Pharmacy Benefit Managers
The healthcare package includes policies that reflect several years of increased scrutiny on pharmacy benefit managers (PBMs), including:
- Prohibiting PBMs from charging a Medicaid managed care organization more for a drug than the amount that a PBM pays a pharmacy (i.e., spread pricing)
- Requiring consistency and additional transparency in contracts between Part D plans and PBMs
- Prohibiting Medicare Part D plans from linking payments to drug list prices
- Adding report requirements for PBMs
Medicaid Policies and Programs
The legislative text includes 13 separate sections that address Medicaid policies, including extensions on expiring policies, establishment of new programs, and plans to codify certain other policies related to Medicaid eligibility and renewals. These policy changes include:
- Medicaid Disproportionate Share Hospital (DSH) allotment: Eliminates reductions for fiscal year (FY) 2025; delays the effective date of the two remaining years of Medicaid DSH allotment reductions until January 1, 2027; and changes the definition of the Medicaid shortfall component of the Medicaid DSH cap to include costs and payments for patients who have Medicaid as their primary source of coverage and for patients who are dually eligible for Medicare and Medicaid.
- Home and community-based services (HCBS) waiver: Establishes a three-year, five-state Medicaid HCBS waiver program, which would allow states to cover these services for individuals who need them but do not meet the current statutory requirement of needing 鈥渋nstitutional level of care.鈥� States will have an opportunity to apply for planning grants.
- Services for juveniles leaving public institutions: Delays by 12 months the requirement that state Medicaid programs provide screenings, diagnostic services, and targeted case management services for eligible juveniles within 30 days of their scheduled date of release from a public institution following adjudication.
Medicare Payments
The compromise package also increases the Medicare Physician Fee Schedule conversion factor by 2.5 percent in 2025 to partially offset a 2.83 percent cut that the Centers for Medicare & Medicaid Services (CMS) finalized in November. Providers consider this a short-term fix, however, and Congress, provider advocates, and other interested parties are engaged in discussions about making broader changes to Medicare physician pay in 2025.
Notably, the agreement includes a payment policy consistent with a bill that the House of Representatives passed earlier this year鈥攖he Lower Cost More Transparency Act鈥攖o provide enhanced information about payment differentials between off鈥恈ampus outpatient departments and other outpatient facilities. The provision requires each off-campus outpatient department to obtain and bill for services under a unique national provider identifier.
Other notable Medicare policies include:
- Telehealth: Extends Medicare telehealth flexibilities through December 31, 2026; establishes special rules for telehealth services provided by Federally Qualified Health Centers and Rural Health Clinics for prospective payment and all-inclusive rates; adds modifiers for telehealth services provided incident-to other services and those offered via contracts with virtual platform vendors; expands services that can be provided via telehealth; and enhances tracking of telehealth use
- Payment extensions: Extends the Medicare low-volume hospital payment adjustment and Medicare-dependent hospital program through December 31, 2025; Medicare ground ambulance add-on payments through December 31, 2026; incentive payments for advanced alternative payment models through payment year 2027 at an adjusted amount of 3.53 percent; and Qualifying Participant eligibility thresholds in effect for performance year 2023 through payment year 2027
- Hospital at-home program: Extends the Acute Hospital Care at Home initiative through December 31, 2029
- Part D: Prohibits cost sharing for generic drugs for Part D beneficiaries who are eligible for the low-income subsidy
- Provider directories: Requires Medicare Advantage plans to maintain accurate provider directories on a public website beginning in plan year 2027
- Screening: Adds multi-cancer early detection screening tests as a covered benefit beginning in 2029
- Home infusion: Allows coverage of home infusion treatments by classifying certain approved infusion treatments as Durable Medical Equipment (DME)
Other Notable Provisions
- Reauthorizes and revises the Second Chance Reauthorization Act of 2024, including allowing substance use disorder (SUD) services to be provided through the State and Local Reentry Demonstration Projects program
- Reauthorizes and modernizes several aspects of child welfare programs
- Provides mandatory funding for community health centers and the National Health Service Corps through FY2026, the Teaching Health Center Graduate Medical Education Program through FY2029, and the Special Diabetes Programs (SDP) for Type I diabetes and the SDP for Indians through FY2026
- Reauthorizes through FY 2029 the SUPPORT for Patients and Communities Act, which includes a range of mental health and SUD prevention, treatment, and recovery programs
- Reauthorizes Older Americans Act programs
- Reauthorizes several programs and authorities related to preparedness and response through FY2026, including the Public Health Emergency Preparedness Program and the Hospital Preparedness Program
What鈥檚 Next
Funding for the federal government expires December 20, 2024. Congress will need to approve another temporary measure to avert a government shutdown. The length and scope of such an extension remains under discussion, though the current continuing resolution would push the funding deadline into the first few months of the incoming Trump Administration and new Congress. Healthcare stakeholders, including payers, state and local governments, providers, and community organizations, should continue to monitor the congressional negotiations and be prepared to analyze the impact of legislation that Congress ultimately approves.
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量子资源网, Inc. (量子资源网) experts will continue analyzing the implications of the funding and policy updates in the December 18 package and ongoing congressional discussions to reach an agreement. 量子资源网鈥檚 experts have the depth of knowledge, experience, and subject matter expertise to assist organizations with navigating these changes and the impact for health and health adjacent sectors. Please contact Laura Pence and Andrea Maresca to connect with our experts.
December 18, 2024
Congress Continues Negotiations on 2025 Spending and End-of-Year Package