HealthCare Roundtable e-News – January 22, 2024


Top News

CMS Releases New Model Advancing Integration in Behavioral Health

The Centers for Medicare and Medicaid Services (CMS) released a new model to test approaches for addressing the behavioral and physical health, as well as health-related social needs, of people with Medicaid and Medicare. The Innovation in Behavioral Health (IBH) Model aims to improve the overall quality of care and outcomes for adults with mental health conditions and/or substance use disorder by connecting them with the physical, behavioral, and social supports needed to manage their care.  Practice participants in the IBH Model will be community-based behavioral health organizations and providers, including Community Mental Health Centers, public or private practices, opioid treatment programs, and safety net providers where individuals can receive outpatient mental health and SUD services. IBH is a state-based model, led by state Medicaid Agencies, with a goal of aligning payment between Medicaid and Medicare for integrated services. The model will launch in Fall 2024 and is anticipated to operate for eight years in up to eight states and includes a pre-implementation period (model years 1-3). CMS will release a Notice of Funding Opportunity for the model in Spring 2024.


CMS Releases Interoperability and Prior Authorization Final Rule

The Centers for Medicare and Medicaid Services (CMS) published the Interoperability and Prior Authorization Final Rule, which requires Medicare Advantage (MA) organizations, state Medicaid and Children’s Health Insurance Program (CHIP) Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs) to implement and maintain certain Health Level 7® (HL7®) Fast Healthcare Interoperability Resources® (FHIR®) application programming interfaces (APIs) to improve the electronic exchange of health care data, as well as to streamline prior authorization processes. To encourage providers to adopt electronic prior authorization processes, CMS is also adding a new measure titled “Electronic Prior Authorization,” to the Health Information Exchange (HIE) objective for the MIPS Promoting Interoperability performance category and the Medicare Promoting Interoperability Program. Impacted payers must implement certain operational provisions, generally beginning January 1, 2026. In response to public comment on the proposed rule, impacted payers have until compliance dates, generally beginning January 1, 2027, to meet the API development and enhancement requirements in this final rule. The exact compliance dates vary by the type of payer.


Recent Study Examines Trends of Underserved Beneficiaries in Medicare Advantage (MA) Plans Offering Dental, Vision, and Hearing Benefits

recent study published in JAMA Health Forum suggests that racial and ethnic minority group beneficiaries as well as individuals with lower income and education levels tend to select Medicare Advantage (MA) plans with dental, vision, or hearing benefits. This research carries significance due to the growing enrollment of racial and ethnic minority groups and low-income beneficiaries in MA plans. The study focuses on traditionally underserved MA beneficiaries who experience economic, cultural, and linguistic barriers when seeking health care services. The observational cross-sectional analysis examined a national sample of MA and traditional Medicare (TM) beneficiaries from 2018 to 2020 from the Medicare Current Beneficiary Survey (MCBS). Data found that Black or Hispanic individuals, those with lower income, or with lower educational attainment have a higher likelihood of enrolling in plans with dental benefits. The study also concluded that it was common for racial and ethnic minority group individuals to enroll in plans with vision benefits and Hispanic beneficiaries to enroll in plans with hearing aid benefits. This study is significant as its findings could offer new information to CMS as it regulates MA benefits as well as empower MA plans to address underserved beneficiaries’ health care needs.

Administrative Action

The Advanced Research Projects Agency for Health (APRA-H) announced the launch of the Platform Accelerating Rural Access to Distributed & InteGrated Medical Care (PARADIGM). The program aims to support President Biden’s Unity Agenda by enhancing early detection and management of diseases in rural communities throughout the nation. Through this program, the Administration hopes to reduce the significantly higher mortality rates in rural areas compared to their urban counterparts. Rural areas across the country are in dire need of better access to care, with more than 100 rural hospitals closing and 600 more on the brink. PARADIGM itself is a multi-functional, electric vehicle platform that integrates several medical devices to treat a large variety of health conditions. More specifically, the program builds software that connects on-board and remote medical devices with any electronic health record system. PARADIGM is seeking a wide range of parties to help achieve the multidisciplinary goals of the program.

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