November 20, 2024
Improving Culturally Relevant Care for AI/AN Populations: Insights into Federal Approval of Medicaid-Covered Traditional Healing
1312 Results found.
Health policy priorities on the table: Understanding the post-election landscape for Marketplace, Medicaid, and Medicare programs
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:
November 13, 2024
Health Policy Priorities on the Table: Understanding the Post-Election Landscape for Marketplace, Medicaid, and Medicare Programs
Webinar Replay: 2024 Political Checkpoint
This webinar was held on November 12, 2024.
In the 2024 Political Checkpoint hosted by Leavitt Partners, an 量子资源网 company, we explored up-to-the-minute insights on the election results, discussed both confirmed outcomes and remaining uncertainties, along with the mandate for change that has emerged. Our expert panelists 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:
2024 Wrap Up
Lame duck session in Congress, end of year regulatory action
A New President
Implementing campaign promises through appointments
2025 Policy Agendas
Where committees, agencies may set their sights
Key Issues
Healthcare priorities that could see the spotlight
Comprehensive 50-state survey explores Medicaid policy landscape for FY 2025
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
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
- 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.
Webinar Replay: How Community Care Hubs Can Enhance Family Caregiver Support Services
This webinar was held on December 3, 2024.
To better support family caregivers and the older adults who they care for, Area Agencies on Aging and other aging network agencies are creating Community Care Hubs (CCH) to address social determinants of health, integrate health and social care, and reduce care costs. In this webinar with LTSS policy experts and providers, we described the implementation of the CCH model in projects in Massachusetts and New York.
Learning Objectives:
- Describe the Community Care Hub (CCH) model for integrating health and social care
- Identify key CCH features to enhance family caregiver support services
- Illustrate the implementation of the CCH model for supporting family caregivers with projects in Massachusetts and New York
Featured Speakers:
- Kristie Kulinski, MSW, Director of Office for Network Advancement, Administration for Community Living
- Nikki Kmicinski, MS, RD, CDH, Chief Executive Officer, Western New York Integrated Care Collaborative
- Jennifer Raymond, JD, MBA, Chief Strategy Officer, AgeSpan
How satisfaction impacts Medicare Advantage plans Star ratings聽
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.
In behavioral health, parity is essential, but not enough
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.
Nevada releases Medicaid managed care RFP: State will expand managed care statewide into rural areas
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.
October 30, 2024
Nevada Releases Medicaid Managed Care RFP: State Will Expand Managed Care Statewide Into Rural Areas