Sellers Dorsey Digest

Federal Updates

NEWS

Biden Administration Partners with Eight States and DC to Address Homelessness

• The Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD) have selected eight states and the District of Columbia (DC) to launch the “Housing and Services Partnership Accelerator” program to address homelessness. On February 9, the Biden Administration announced that they will be working with Arizona, California, DC, Hawaii, Maryland, Massachusetts, Minnesota, North Carolina, and Washington. To apply for the program, states had to form interdisciplinary teams across health, housing, aging, and disability sectors and provide information on the status of implementing Medicaid-covered housing supports, and their goals for the program. Over the next 12 months HUD and HHS will provide intensive technical assistance to support these programs. The projects will be run by the Medicaid agency in all states but Massachusetts, where the program will be led by a housing agency with assistance from the Medicaid agency. States that were not selected for the program had until February 13 to apply to the National Academy for State Health Policy’s Health and Housing Institute (HHI) for technical assistance (CMS, February 9; Inside Health Policy, February 9).

CMS Releases Updated Vaccine Toolkit

• On February 12, CMS released an updated Medicaid, CHIP, and Basic Health Program (BHP) Vaccine Toolkit. The updated toolkit includes a compilation of vaccination policies, including flexibilities and coverage and payment requirements for states as they transition from the COVID-19 public health emergency and start to implement Inflation Reduction Act coverage requirements. The toolkit also includes considerations for states to enhance vaccination coverage and access (CMS, February 12).

Medicaid Enrollment Down Almost 10 Million Halfway Through Unwinding

• According to the Kaiser Family Foundation (KFF), estimates compiled from state-level data show that states have removed over 16 million people from Medicaid since last April. While many beneficiaries no longer qualify because of growing incomes, millions of enrollees have been disenrolled from Medicaid coverage for procedural reasons. Simultaneously, millions of others have reenrolled or signed up for Medicaid for the first time. These changes have resulted in overall enrollment falling by about 9.5 million from the record high reached last April. This puts Medicaid and CHIP enrollment on track for ending the unwinding period with numbers that look similar to the beginning of the pandemic: about 71 million total enrollees (Modern Healthcare, February 7).

CMS Releases Quality Improvement Tools to Improve Behavioral Health Follow-Up Care

• Medicaid and CHIP are the largest payers of mental health services in the U.S. and nearly 40% of Medicaid/CHIP beneficiaries experience mental illness and/or Substance Use Disorder (SUD). Research has shown that timely follow-up care for behavioral health can improve long-term outcomes. Following the Improving Behavioral Health Follow-Up Care learning collaborative webinar series in 2021, CMS released a set of quality improvement (QI) tools to help improve follow-up care for behavioral health. The technical assistance in the QI tools includes approaches to getting started, a driver diagram and change table, measures for quality improvement, and specific state examples (Medicaid.gov, February 13).

Federal Regulation

CMS Releases Updated Medicaid and CHIP Telehealth Toolkit

• On February 8, CMS released an updated Telehealth Toolkit for state Medicaid programs and CHIP. Should states opt in to delivering Medicaid and CHIP services through telehealth, they can utilize this toolkit to better understand the policies and requirements within the following areas: coverage and reimbursement policies, providers and practitioners eligible to provide telehealth, technology requirements, considerations for specific populations, and state examples and strategies. Additionally, the updated toolkit contains information to educate states on available telehealth platforms, how to navigate telehealth after a public health emergency, how to ensure an accessible, value-based, and culturally competent level of care when utilizing telehealth, and resources for both providers and beneficiaries (Medicaid.gov, February 8).

Stakeholders Oppose CMS Proposal to Shift VCI Costs to States

• CMS is proposing to shift the costs of verifying income for Medicaid/CHIP eligibility from the agency to states starting July 1. The National Association of Medicaid Directors (NAMD) opposes the proposal, citing fiscal challenges and misalignment with the Biden administration’s goals. Other stakeholders agree with NAMD and urge CMS to reconsider the proposal, citing the ongoing Medicaid unwinding process in many states. NAMD suggests that Congress should increase funding to CMS and the Federal Data Hub and keep the income verification process costs with CMS. However, CMS argues that Verify Current Income (VCI) data falls under state functions, justifying the cost of the shift. States consider this proposal ill-timed with the budgeting process and may stop or decrease the use of VCI services if the proposal advances. California highlighted the significant impact this proposal has on their annual budget, with the new estimated state share coming in at around $9 million (Inside Health Policy, February 7).

State Updates

NEWS

Puerto Rico Hopes Now is the Time for Medicare Advantage Pay Fix

• Puerto Ricans are optimistic that the Biden administration will fulfill a campaign promise this year to fix the island’s low Medicare Advantage rates, which they believe contribute to its healthcare system’s deterioration. Advocates and members of Congress want CMS to raise government-funded private Medicare Advantage plan payments for the territory to match what the U.S. Virgin Islands receive. According to data from the Medicare and Medicaid Advantage Products Association of Puerto Rico, the average base payment to a Medicare Advantage plan in Puerto Rico in 2023 was $644, compared with $837 for the Virgin Islands and $1,099 for the U.S. The 2025 rates, due to be finalized in the spring, could be the last chance for the Biden administration to increase Medicare Advantage plan reimbursements to address the widening gap in pay between the mainland and the territory (Politico Pro, February 9).

Governor Josh Shapiro Allocates Funds in Proposed FY2025 Budget to Eliminate $400 Million of Medical Debt

• During his budget address, Pennsylvania Governor Josh Shapiro (D) announced a plan to eliminate approximately $400 million in medical debt for Pennsylvania residents. According to budget documents, nearly one million people throughout the Commonwealth have medical debt totaling $1.8 billion. Unlike Connecticut and New Jersey who used American Rescue Plan Act (ARPA) funds to cancel medical debt for state residents, the Pennsylvania proposal would use state funds and is expected to be an ongoing program. Minnesota would also announce a similar proposal with assisting their state’s medical debt shortly after (Politico Pro, February 6; MN.gov, February 9).

Governor Kim Reynolds Proposes Postpartum Medicaid Coverage

• On February 8, Iowa Governor Kim Reynolds (R) proposed to expand postpartum coverage for Medicaid beneficiaries. Senate Study Bill 3140 aims to increase the coverage of postpartum care under Medicaid from two months to 12 months. The governor’s proposal would change eligibility for Medicaid pregnancy and postpartum coverage to 215% FPL from the current 375% FPL to keep Medicaid costs for these services budget neutral. Fewer individuals would qualify should this change go into effect (Insurance News Net, February 8).

SPA and Waiver Approvals

SPAs

• Payment Services
  • Alaska (AK-23-0010, effective January 1, 2024): Adds an inpatient hospital diagnosis-related group reimbursement methodology and a new disproportionate share hospital category, and removes outdated language, revises grammar, and updates the organizational structure.
  • Alaska (AK-23-0012, effective October 1, 2023): Provides for mandatory coverage of Medicaid adult vaccinations and the administration of vaccines without cost sharing to align with the Inflation Reduction Act.
  • Colorado (CO-23-0003, effective July 1, 2023): Revises the inpatient hospital base rate methodology and provides for add-on payments for inpatient services, revises language for outpatient hospital services to reflect the use of the most recent available Medicare cost report and updates factors in the outpatient hospital services calculation.
  • New York (NY-22-0027-A, effective April 1, 2022): Provides for Physician Supplemental UPL payments to the State University of New York (SUNY).
  • New York (NY-22-0027-B, effective April 1, 2022): Provides for Physician Supplemental UPL payments to Roswell Park Cancer Institute.
  • New York (NY-22-0027-D, effective April 1, 2022): Provides for Physician Supplemental UPL payments to New York City Health and Hospitals.
  • New York (NY-23-0064, effective June 1, 2023): Provides for supplemental payments to assisted living program sites.
  • North Carolina (NC-23-0049, effective December 1, 2023): Authorizes a Medicaid postpartum proxy methodology to provide for increased FFP for newly eligible individuals receiving postpartum coverage.
  • Oregon (OR-23-0026, effective July 1, 2023): Clarifies that client related GME is not included in the MCO capitation.
  • Oregon (OR-23-0039, effective October 1, 2023): Increases reimbursement rates for behavioral health services with a 3.4% cost of living adjustment.
• Services SPAs
  • New Mexico (NM-23-0011, effective July 1, 2023): Adds coverage for Community Health Workers/Community Health Representatives as a new reimbursable preventive service.
  • Texas (TX-23-0003, effective March 11, 2021): Documents coverage of COVID-19 tests as a benefit in Texas Medicaid, including at-home tests provided through a pharmacy.
• Eligibility SPAs
  • Oregon (OR-23-0033, effective October 1, 2023): Provides for new disregards in the determination of financial eligibility to non-MAGI populations. The new disregards include compensation for Medicaid Advisory Committee (MAC) participation and Community Advisory Council (CAC) participation.

Private Sector Updates

NEWS

Yale Medicine Promotes New Care Pathway

• Yale Medicine, a Connecticut-based academic health system, is implementing a care path initiative to increase equity, accessibility, and close gaps in healthcare within populations they serve. Since its launch in 2020, Yale Medicine has developed over 650 care paths. These care pathways track steps in treatment, utilize electronic health records, social determinants of health, and current research studies to ensure that the same level of care is being distributed to every patient, regardless of their race and ethnicity (Modern Healthcare, February 8).

Using Large Language Models as Tools to Formulate Diagnoses in Pediatric Cases

• A study published in JAMA Pediatrics utilized a large language model (LLM), version 3.5 of ChatGPT, to formulate diagnoses in 100 pediatric cases. According to researchers, approximately 83 of the diagnostic results were incorrect, with 72 being fully incorrect and 11 being clinically related but too broad to be considered accurate. The study also highlighted the significance of physician oversight when utilizing AI and large language tools in clinical healthcare. A proper diagnosis in a pediatric patient involves pattern recognition of symptoms, consideration of age, and additional patient information. Researchers discuss that while AI has been successful in pattern recognition, it needs more development and advancement when it comes to complex health scenarios where symptoms and diagnoses could overlap. Overall, researchers believe that LLM-based chatbots and AI should be used as a tool, but not a solution for healthcare (JAMA Pediatrics, January 2; Forbes, February 11).

Medica Lays Off 162 Employees

• The nonprofit health insurance company Medica has laid off 162 employees. The job cuts account for approximately 6% of Medica’s workforce which totals around 3,000. The Minnesota-based company provides coverage to about 1.5 million customers, spanning 12 states in the U.S.: Arizona, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, Wisconsin, and Wyoming (Modern Healthcare, February 5).

Survey Shows Insurers Will Add Jobs at Slowest Pace in Over a Decade

• According to a new survey by The Jacobson Group and Aon, despite many layoffs at insurance companies, 52% still plan to increase staff over the next year. However, that is the lowest percentage of increased staff since 2012. In the health insurance industry, many company layoffs have involved 100 to 200 people. Despite layoffs, 625 million people remain employed by insurance carriers and the unemployment rate in the insurance industry is stable (Health Payer Specialist, February 9).

Sellers Dorsey Updates

Honoring National Caregivers Day

• Did you know more than 1 in 5 Americans has provided unpaid caregiving, totaling an estimated economic value of $600 billion? Sellers Dorsey is pleased to honor National Caregivers Day on February 16 to raise awareness for this essential healthcare community and provide support. For more information on supporting family caregivers, visit supportcaregiving.org and get additional insights from Sellers Dorsey on long-term services and supports by clicking here.

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