Sellers Dorsey Digest

Federal Updates

NEWS

CMS’ Initial Price Offers Cause Concern among the Pharmaceutical Industry

• On February 1, HHS released their initial offer to the pharmaceutical companies that are participating in the first cycle of the “Medicare Drug Price Negotiation Program.” This proposal includes 10 drugs that were selected for the first cycle of price negotiations, for which the companies agreed to participate on October 3, 2023. Negotiations on prices are set to continue until August 1, 2024. Once a maximum fair price is decided on, the Medicare pricing changes will go into effect in early 2026. The Inflation Reduction Act (IRA) gives Medicare the power to negotiate prescription prices with pharmaceutical companies directly. Biden administration officials speak to how this new law will aid in increasing innovation, lowering costs, and driving market competition. Opponents of the program decried the lack of transparency around the process (HHS, February 1; Inside Health Policy, February 1).

Final Rule Solidifies Telehealth Flexibilities for Opioid Treatment Programs

• The Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) finalized the Medications for Opioid Use Disorder (MOUD) rule on January 31, permanently authorizing telehealth flexibilities for opioid treatment programs (OTP). This final rule allows audio-visual and audio-only telehealth visits for the initiation and ongoing management of opioid use disorder treatment with buprenorphine. It also allows some telehealth flexibilities for methadone. The rule does make permanent the flexibilities put into place in Spring 2020, and it does not apply to pharmacies or providers working outside of a certified opioid treatment program. Additionally, individual states may have more restrictive policies around MOUD. According to SAMHSA, these are the first substantial changes to OTP treatment and medication delivery standards since 2001 (Inside Health Policy, January 31 and Modern Healthcare, February 1).

State Updates

NEWS

Florida Blue and Humana Expand Senior Care Clinics

• Florida Blue is opening its first senior primary care clinic in Jacksonville, Florida while Humana’s senior focused CenterWell clinics continue to expand their presence across the state. Florida Blue is partnering with Sanitas Medical Center to provide primary care for members that are 50 and older and Medicare members of all ages. They will provide a range of services including preventive and primary care, chronic condition management, mental health services, labs, imaging, and a pharmacy. Additionally, they will offer a community space for education, wellness classes, and activities. Meanwhile, CenterWell plans to open primary care centers in Florida, Indiana, Kentucky, Louisiana, North Carolina, Mississippi, and Virginia (Health Payer Specialist, February 2).

Study Reports Public Option Could Cost Minnesota

• Last year, the Minnesota legislature required the Department of Human Services (DHS) contract for an independent study and report to analyze public option health models. The study looked at potential impacts of expansion for MinnesotaCare as the state considers expanding its public option health insurance. The report estimates that it could cost the state up to $364 million more each year and add up to 151,000 individuals to insurance rolls. MinnesotaCare is currently available to those who are financially ineligible to obtain Medicaid coverage and have an income of up to 200% of the federal poverty level (FPL). The report analyzes what could happen in different scenarios and concludes that additional research should be done to determine how an expanded public option would impact health disparities (Health Payer Specialist, February 5).

As Florida Lawmakers Maintain Opposition to Medicaid Expansion, Ballot Efforts Emerge to Create Change

• While healthcare is a focus of the current legislative session in Florida, Medicaid expansion is currently not part of the agenda. Medicaid expansion in Florida would mean that those residing in the state earning up to 138% of the FPL would qualify for health insurance. Estimates indicate that in the first two years of expansion, Florida would qualify for about $5.6 billion in federal aid, and $4.4 billion going forward. While Republican legislators continue to oppose Medicaid expansion, polls show a high percentage of Floridians support it. Advocacy groups are rallying together to launch a ballot effort to qualify for the 2026 ballot and get the topic of Medicaid expansion to the voters that November. If the ballot is approved and gets support from at least 60% of voters, an amendment requiring Medicaid expansion could be added to Florida’s constitution (USA Today, February 1).

Mississippi House Passes Bill to Address Infant Mortality Ranking While State Hospitals Continue to Push for Medicaid Expansion

• According to the 2023 Mississippi Public Health Report Card, the state is ranked 50^th in the country for infant mortality, with Black infants nearly twice as likely to die when compared to white infants. To improve poor health outcomes for mothers and babies, the Mississippi House passed a bill on Wednesday that would permit up to 60 days of Medicaid presumptive eligibility for pregnant individuals 19 years of age and older, starting July 1. Presumptive eligibility is estimated to cost the state less than $600,000 a year. This bill comes just before state hospital owners called on Governor Reeves to expand Medicaid. Significant research highlights the financial and health benefits of expansion, and most Mississippians want Medicaid eligibility expanded. Should Medicaid presumptive eligibility for pregnant women occur in the state, it is expected to provide health insurance to 200,000 to 300,000 additional individuals while helping strained hospitals and bringing additional federal dollars into the state (ABC News, January 31; Yahoo, February 2).

Oklahoma Enacts “Any Willing Provider” Law After Caremark Sues Oklahoma Attorney General

• Oklahoma is the latest state to enact an “any willing provider” law that permits any pharmacy to fill prescriptions for health plan members. This new law comes on the heels of Caremark suing Oklahoma’s Attorney General, Gentner Drummond, claiming that the state is incorrectly imposing its freedom of choice law on health plans that are regulated by federal regulations. The any willing provider laws generally benefit small pharmacy providers and such laws often conflict with pharmacy benefit manager (PBM) guidelines that require plan members to use certain, approved pharmacies when filling prescriptions. Health law specialists throughout the country believe that this case, and others similar to it, could be heard by the U.S. Supreme Court (Health Payer Specialist, February 2).

Florida and Georgia File Suit Against HHS Over Medicaid Program Requirements

• Florida and Georgia both filed suits against HHS on February 2 regarding their Medicaid programs. Florida has filed a suit regarding the 12-month continuous coverage requirement for children. As a part of the 2023 federal spending bill, states are required to maintain one year of Medicaid or CHIP eligibility for children, beginning on January 1, 2024. However, Florida seeks an exception so that it can drop beneficiaries if their families don’t pay the CHIP monthly premiums, which are currently between $15 and $20. Georgia is suing the Biden Administration after CMS denied the state’s request to extend its partial Medicaid expansion known as the Pathways program. Pathways was initially approved for a five-year period (October 15, 2020 through September 30, 2025), but implementation was delayed due to a court battle over the program’s work requirements (Inside Health Policy, February 2).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • Hawaii
    • On January 17, 2024, Hawaii submitted a five-year extension request for its Medicaid section 1115(a) demonstration titled “Hawaii QUEST Integration.” This request aims to implement new authorities including continuous eligibility for children up to age 6 and continuous two-year eligibility for children ages 6 through 18; pre-release services for justice-involved individuals; nutrition supports; and contingency management. The extension request also builds on existing authorities by expanding rental assistance and adding medical respite to the state’s Community Integration Services (CIS) program. The federal public comment period is open from February 5, 2024, through March 6, 2024.
  • Minnesota
    • On January 25, 2024, the Minnesota Department of Human Services requested an amendment to its Prepaid Medical Assistance Program Plus (PMAP+) waiver to expand and extend continuous eligibility for children. This amendment expands the 12-month continuous eligibility policy for children under 18 to include 19- and 20-year-olds and provides continuous eligibility for eligible children up to age 6. The federal public comment period is open from February 5, 2024, through March 6, 2024.
  • Minnesota
    • On January 24, 2024 (as revised on February 2, 2024), the Minnesota Department of Human Services requested an amendment to its PMAP+ waiver to provide Medicaid eligibility for former foster care youth who turned 18 prior to January 1, 2023, and are under the age of 26. The federal public comment period is open from February 5, 2024, through March 6, 2024.

SPAs

• Payment Services
  • Arizona (AZ-23-0023, effective October 1, 2023): Updates the fee schedule for long-term acute care and rehabilitation hospital rates.
  • Arizona (AZ-23-0026, effective October 1, 2023): Updates APR-DRG reimbursement rates for inpatient hospital services.
  • Illinois (IL-23-0031, effective January 1, 2024): Updates the rates for substance use disorder services.
  • Michigan (MI-23-0030, effective February 1, 2024): Increases the rate for 1915(i) Transition Navigator Case Management Services.
  • New York (NY-22-0029, effective April 1, 2022): Authorizes outpatient supplemental payment limit distributions for certain non-government owned or operated general hospitals.
  • New York (NY-22-0030, effective April 1, 2022): Authorizes a single lump sum supplemental payment for outpatient hospital services to certain non-state public hospitals.
  • Ohio (OH-23-0037, effective January 1, 2024): Updates payment for Inpatient Hospital Reimbursement and Capital Costs.
  • Oregon (OR-23-0035, effective October 1, 2023): Increases the reimbursement rates for dental services and includes a flat fee for dental anesthesia services.
  • Rhode Island (RI-23-0014, effective October 1, 2023): Provides coverage of all approved vaccines recommended by the Advisory Committee on Immunization Practices and vaccine administration when furnished by a qualified provider.
• Services SPAs
  • California (CA-24-0001, effective February 1, 2024): Expands the needs-based criteria for children under five; adds Participant-Directed Services and related budget authority; and adds incentive payments to providers who assist individuals with obtaining competitive and integrated employment for HCBS.
  • Missouri (MO-23-0023, effective October 1, 2023): Allows doctoral level psychology interns under the supervision of a licensed psychologist to provide services for MO HealthNet participants.
  • New Jersey (NJ-23-0026, effective October 1, 2023): Provides assurances that the state complies with vaccine requirements consistent with the Inflation Reduction Act.
  • New Mexico (NM-23-0006, effective July 1, 2023): Includes community-based mobile crisis intervention services authorized by the American Rescue Plan and incorporates additional evidence-based practices; updates provisions to Multi-Systemic Therapy services and Peer Support Provider qualifications; and, adds provisions to allow involuntary admission to Crisis Triage Centers to align with state law passed in 2023.
  • South Carolina (SC-23-0017, effective October 1, 2023): Updates preventive services to align with the U.S. Preventive Services Task Force recommendations for preventive screening services and the Advisory Committee on Immunization Practices recommendations for immunizations, including the current reimbursement methodology for vaccines for both children and adults. Additionally, this SPA removes the limits previously applied to ambulatory care annual visits.
• Eligibility SPAs
  • North Dakota (ND-23-0034, effective January 1, 2024): Changes the income disregards and financial methodologies applied to certain medically needy groups.
  • Puerto Rico (PR-23-0003, effective July 1, 2023): Proposes to use the Federal Poverty Level in determining income eligibility under Puerto Rico’s State Plan.

Private Sector Updates

NEWS

Report Finds Risks of In-Home Medical Equipment

• A report released by the non-profit patient safety organization, ECRI, lists major technology hazards to look out for in 2024 and points to numerous instances where the use of medical devices in a home setting led to patient harm and death. From medication errors related to infusion pumps to skin injuries caused by cardiac monitors, the report notes risks associated with using complex equipment at home. ECRI recommends providers educate patients on all medical technology being used in the home and only give out equipment compatible with the educational level, environment, and cognitive and physical abilities of patients or their caregivers (Modern Healthcare, February 1).

Home Care Wage Violations’ Potential Impact on Industry

• Over the last three years the Department of Labor has recovered more than $103 million in back wages for healthcare workers, including individuals who provide home care services. According to labor attorney Angelo Spinola, most violations concerning home care worker wages come from poor record keeping and changes to the Fair Labor Standards Act. Prior to 2015, workers who provided non-medical care in the home were exempt from overtime pay. After 2015 when overtime pay was allowed, some home care providers either ignored the law or decided they did not have the funds to pay the additional wages. Draft legislation in the House would reinstitute the exemption from overtime pay in an attempt to increase access to home care by reducing the financial burden on home care companies (Modern Healthcare, February 5).

Sellers Dorsey Updates

Sellers Dorsey at NACHC Policy and Issues Forum

• We’re thrilled to sponsor the NACHC Policy and Issues Forum, where thousands of community health center leaders share insights on how political change will impact healthcare priorities and shape the future of community health centers. Click here to learn more about the Forum.

Sellers Dorsey Welcomes New SVP of Product Development

• In case you missed it last week, we are pleased to welcome Deborah Grier to the Firm as Senior Vice President of Product Development. Deborah will lead the Firm’s efforts to bring innovative products to our clients to help them fulfill their missions. Click here to explore Deborah’s new role.