In This Week’s Update:
- Consolidation and Private Equity in Healthcare
- CMS Rescinds Section 1115 Medicaid Opportunities
- CMS’ Health Equity Data Book
- Providing Continuous Eligibility to Children
- New Resources to Support Medicaid Advisory Committees & Beneficiary Advisory Councils
- Medicaid Opportunities to Support Incarcerated Children
Consolidation and Private Equity in Healthcare
Last week, the U.S. Department of Health and Human Services (HHS) released a report on consolidation and private equity in healthcare markets. The report highlights how growing consolidation and the lack of competition is contributing to unsustainable healthcare inflation.
CMS Rescinds Section 1115 Medicaid Opportunities
In case you missed it, CMS recently released a State Medicaid Director Letter (SMDL) rescinding January 2020 guidance that invited states to apply for section 1115 “Healthy Adult Opportunity” (HAO) demonstrations. The new SDML asserts that a HAO demonstration “would raise legal conflicts with the core statutory objective of Medicaid,” citing the HHS General Counsel’s recent discussion of Medicaid objectives in an advisory opinion focused on work requirements.
CMS’ Health Equity Data Book
CMS recently released a Health Equity Data Book looking at Medicare, Medicaid, and the Marketplace populations. The Data Book presents an overview of data at-a-glance as well as CMS data focused on demographics, chronic conditions, behavioral health conditions, and social determinants of health (SDOH). Updates follow.
Providing Continuous Eligibility to Children
On January 15, 2025, CMS released an updated State Health Official (SHO) letter and Frequently Asked Questions (FAQs) guidance, which replaces a previously issued SHO letter and FAQs on the requirement in the Consolidated Appropriations Act, 2023 (CAA) that states provide one year of continuous eligibility for children enrolled in Medicaid and CHIP, effective as of January 1, 2024. State Health and Value Strategies (SHVS) published an expert perspective summarizing the newly updated guidance.
New Resources to Support Medicaid Advisory Committees & Beneficiary Advisory Councils
CMS released a new toolkit and slide deck to support the implementation of provisions in the Medicaid Program: Ensuring Access to Medicaid Services final rule to establish a Beneficiary Advisory Council (BAC) and Medicaid Advisory Committee (MAC). The Toolkit: Medicaid Advisory Committees & Beneficiary Advisory Councils – Implementation Considerations covers the following topics: MAC and BAC composition; effective planning and execution of MAC and BAC meetings; and promoting transparency of meetings. The toolkit includes examples taken from strategies that states have used in existing Medical Care Advisory Committees design and operation. The slide deck is from a webinar CMS hosted for states and provides an overview of the provisions in the final rule as well as considerations for MACs.
Medicaid Opportunities to Support Incarcerated Children
On January 10, 2025, CMS released the final versions of the CAA-specific state plan amendment templates regarding the provision of Medicaid/CHIP Services to incarcerated children and youth —the Section 5121 State Plan, the CAA Targeted Case Management State Plan, and the optional Section 5122 State Plan. These templates are due to CMS by March 31, 2025 with a retroactive effective date of January 1, 2025.
State updates: AZ, CA, CO, IL, MD, MI, MS, NC, ND, NM, NV, NY, OR, TN & WA
- Arizona – The Arizona Health Care Cost Containment System received CMS approval to provide reentry services to incarcerated individuals as part of its 1115 demonstration waiver.
- California – The Department of Health Care Services (DHCS) published quality ratings for Medi-Cal managed care plans (MCP) and county behavioral health plans. Monetary sanctions are being imposed on MCPs that did not meet or exceed the established minimum performance levels, meaning the plans failed to provide members with a level of care that reached the quality standards established by DHCS. These actions are the result of the MCP contract, effective January 1, 2024, which strengthened quality and health equity requirements for MCPs.
- Colorado – HHS and the U.S. Department of Treasury announced that the Colorado Division of Insurance (DOI) will receive $339 million in pass-through funding for the state’s section 1332 waiver. Additionally, DOI is highlighting recent findings from a report that determined the addition of Colorado Option plans to the state’s individual market led to premium reductions of over $100, even for non-option plans.
- Illinois
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- Governor JB Pritzker and the Illinois Children’s Behavioral Health Transformation Initiative announced the public launch of the Behavioral Health Care and Ongoing Navigation (BEACON) care portal, a centralized resource for Illinois youth and families seeking youth mental health services and care, including state agency support and community-based programs.
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- The Illinois Department of Healthcare and Family Services submitted to the governor and the general assembly its first report from the Advisory Council on Financing and Access to Sickle Cell Disease Treatment and other High-Cost Drugs and Treatment. The report evaluates various value and outcome-based payment approaches implemented in other states and includes recommendations for financing and increasing equitable access for these drugs in Illinois.
- Maryland – HHS approved Maryland’s section 1332 waiver application, permitting all Maryland residents, regardless of immigration status to enroll in qualified health plans and qualified dental plans through the Maryland Health Connection, the state’s official health insurance Marketplace.
- Michigan
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- The Michigan Department of Health and Human Services (MDHHS) is seeking applicants to serve on the SDOH Hubs Advisory Council from local organizations and community members. The Advisory Council is a key component of Michigan’s Roadmap to Healthy Communities and helps guide implementation of the SDOH Hubs’ initiatives.
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- As part of efforts to expand behavioral health services for Michigan families, MDHHS has issued a competitive grant funding opportunity for crisis response initiatives that would establish or expand community-based mobile crisis intervention services statewide. The purpose of this program is to increase behavioral health crisis services across the state for all Michigan residents, regardless of location, diagnosis, or insurance status.
- Mississippi – The Mississippi Division of Medicaid is seeking applications for its new BAC to advise the state regarding their experience with program matters related to policy and effective administration of the Medicaid program. SHVS created template materials designed to support state agencies in recruiting members for the BAC. States can customize the content of the materials, which include a recruitment flyer, template social media graphics, core messages, website copy, and newsletter copy.
- Nevada – HHS approved Nevada’s section 1332 waiver application, approving the state to sell public option plans, known as Battle Born State Plans (BBSPs), through the state’s Exchange. Under state law, BBSPs are required to reduce premiums by certain targets, including by at least 3% in 2026 and 15% by 2029. The state’s waiver also includes implementation of a premium relief program using reinsurance.
- New Mexico
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- The Health Care Authority (HCA) announced that some Medicaid provider rates increased effective January 1, including for behavioral health, primary care, and maternal/child health services, with many rising to 150% of the Medicare 2024 benchmarks. HCA also received CMS approval to increase Medicaid rates for services provided to individuals with intellectual and developmental disabilities that will apply to three programs and will increase in mid-January.
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- HCA announced the launch of its new Office of Data and Analytics (ODA), dedicated to leveraging data-driven strategies to improve health outcomes across New Mexico. The ODA will also lead HCA’s evolution to using automation to provide guidance in decision making.
- New York – HHS approved an extension of New York’s section 1332 waiver for an additional year through plan year 2029. As a reminder, SHVS published a state spotlight, New York’s Essential Plan Expansion: A Novel Use of Section 1332 Waiver Authority, which highlights how the program will provide premium-free coverage with minimal cost-sharing for individuals with incomes up to 250% of the federal poverty level, including DACA recipients.
- North Carolina – Governor Josh Stein announced an executive order to protect women’s reproductive freedom. The executive order directs cabinet agencies to safeguard medical privacy, ensures women receive accurate information about their pregnancies, and protects doctors providing lawful reproductive healthcare.
- North Dakota – North Dakota Health and Human Services (HHS) announced it is accepting applications for three student loan repayment programs for qualifying health, behavioral health and dental professionals. HHS is working to recruit and retain healthcare providers, especially in underserved and rural areas.
- Oregon – The Oregon Health Authority has awarded $23 million to the nine federally recognized tribes of Oregon and 34 local organizations to repair and rehabilitate homes of residents with low incomes to eliminate risks to residents’ health. Improved housing conditions for low-income families can prevent illness and reduce their healthcare costs, improve safety, conserve natural resources and reduce energy costs for occupants.
- Tennessee – TennCare, Tennessee’s Medicaid program, announced the awarding of grants to ten psychiatric hospitals across the state. Each hospital will receive $1.5 million annually for two years to support infrastructure improvements, workforce development, and enhanced clinical services to better care for child, adolescent, and adult TennCare members. The funding is provided through the state’s TennCare III Medicaid waiver.
- Washington
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- The Washington State Health Care Authority (HCA) launched a new birth doula benefit on January 1, 2025. Birth doulas in Washington can now get reimbursed for services provided to people enrolled in Medicaid. The benefit launch follows a joint statewide recommendation for doula services from HCA and the Department of Health.
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- Governor Bob Ferguson signed an executive order directing the Department of Health to convene a roundtable of medical providers, reproductive health experts, and policymakers to recommend strategies for protecting reproductive freedom in the state.