Sellers Dorsey Digest

Federal Updates

News

White House to Announce New Task Force with Focus on Healthcare Costs

• The Biden administration is planning to announce a new federal task force that will focus on healthcare costs and cracking down on high prices. Officials from the Justice Department (DOJ), the Federal Trade Commission (FTC), and the Department of Health and Human Services (HHS) will be on the task force, with drug pricing and health provider costs among the top priorities and central focus of the group. This new task force is meant to dovetail with the Biden administration’s effort to bring more transparency to housing and rental prices while also focusing on competition and economic policy (Politico, March 4).

CDC Updates Respiratory Virus Guidance for Community Settings

• On March 1, the CDC released revisions to their respiratory virus guidance, with regards to best practices for staying up-to-date with immunizations, maintaining good hygiene, improving air quality, preventing further spread of viruses, testing, physical distancing, and masking. Additionally, the guidance provides readers with information about individuals possessing higher risk factors, such as older adults and people with disabilities, as well as how to lower the risk of infection and provide protection for themselves and those around them. This guidance also includes updates to isolation protocols for individuals displaying symptoms, suggesting that they stay home and away from others for at least 24 hours after a fever and overall symptoms subside. The CDC emphasized that the updated guidance is only intended for community settings and there are no changes to healthcare setting guidance (CDC, March 1).

Biden Administration to Hold Listening Session on PBMs

• Representatives of the Biden administration announced plans to hold a listening session on March 11 regarding the business practices of pharmacy benefit managers (PBMs). Invitees include the federal government and drug industry representatives. PBMs have come under some scrutiny recently for engaging in business practices that some say increase drug prices and hurt consumers and businesses that provide group health coverage to their employees. The upcoming listening session is part of the Administration’s initiative to lower healthcare costs (Health Payer Specialist, March 1).

House Considering Medicaid Primary Care, Broadband Bills Under Rules Suspension

• The House will consider several health-related bills during the week of March 4 while under suspension of the House rules. During this time, amendments cannot be proposed, floor debate is limited, and bill passage requires a two-thirds majority vote. One bill under consideration would clarify that state Medicaid programs can enter into a direct primary care arrangement with a healthcare provider. Supporters suggest that the Medicaid bill will address healthcare costs, workforce challenges, and improve preventive care. Also under consideration is the reauthorization of the National Telecommunications and Information Administration (NTIA), which has not been reauthorized since 1992. This bill would allocate $62 million for two years and require the NTIA to work with other federal agencies to expand access to broadband. Other bills under consideration include addressing maternal mortality, expanding the dental workforce, and protecting the suicide hotline from cyberattacks (Inside Health Policy, February 29).

Federal Legislation

Congress Passes Another Continuing Resolution

• On February 29, Congress passed another continuing resolution (CR) to keep the government open in the short-term, leaving lawmakers a narrow window to finalize funding for agencies and decide which policy riders to attach to the 12 appropriations bills. Congressional leaders agreed to pass another short-term extension of funding along with finalizing negotiations on six of the 12 funding bills for federal agencies, including funds for the FDA. Lawmakers will have until March 8 to pass these bills under the CR, and until March 22 to pass funding for the remaining agencies, including HHS (Inside Health Policy, February 29).

New Healthcare Spending Package Released

• On March 3, lawmakers released the healthcare spending package, which includes a proposed 1.68% payment increase to Medicare physician pay, 1.88% increase to Advance Payment Model bonuses, and $4.27 billion in funding for Community Health Centers. The bill also includes behavioral health reforms and a provision to make behavioral health treatments more streamlined for justice-involved Medicaid beneficiaries (Inside Health Policy, March 5).

Federal Litigation

Judge Denies AstraZeneca’s Lawsuit Against Medicare Drug Price Negotiations

• On March 1, U.S. District Judge Colm Connolly granted the federal government’s request for summary judgment against AstraZeneca in its lawsuit challenging Medicare drug price negotiations. Judge Connolly found that AstraZeneca failed to properly establish standing in filing the lawsuit against the federal government to block Medicare drug price negotiations. The drugmaker had also sought summary judgment relief in the case, asking the judge to find the federal government’s definition of “qualifying single source drug” and “bona fide marketing” under the Inflation Reduction Act to be contrary to the law. The company also sought to block guidance from CMS on the drug price negotiations and requested the court to have the negotiation program itself declared unconstitutional (The Hill, March 1).

Federal Studies & Reports

CMS Releases Latest Enrollment Figures

• On February 29, CMS released the latest enrollment figures for Medicare, Medicaid, and CHIP. According to this report, as of November 2023 over 66.7 million people are enrolled in Medicare, an increase of about 154,000 people since the last report. Medicaid and CHIP have seen a decrease of over 1.5 million people with approximately 85.8 million total enrollees as of November 2023, The marketplace currently serves over 4 million consumers with state-based and federal marketplace plans (CMS, February 29).

State Updates

News

L.A. Care Health Plan to Provide Grant Funds to Fight Against Homelessness

• L.A. Care Health Plan has pledged millions of dollars towards bolstering housing in its service area as payers increase participation in social determinants of health initiatives. The payer has approximately 2.7 million Medicaid enrollees in Los Angeles County and has pledged over $3 million to 12 organizations that are addressing the region’s homelessness crisis. This funding marks the first of several grants from the payer’s Housing Equity Initiative. L.A. Care is dedicating three grants of up to $300,000 each that will use innovative approaches to address homelessness and placement in housing, and another nine grants of up to $250,000 each will go to organizations that aim to build housing capacity (Health Payer Specialist, March 1).

Florida Could Become the Second State to Cover Skin Cancer Screenings

• On February 29, Florida’s House of Representatives passed legislation that would mandate group health plans to cover skin cancer screenings. In 2020, the CDC reported 7,313 cases of melanoma and 676 deaths from melanoma-related cancers in Florida. If the bill becomes law, Florida could become the second state to make this happen. The bill also prohibits payers from charging deductibles, coinsurance, or copayments for skin cancer screenings. This proposed benefit is estimated to cost payers approximately $357,580-$416,503 per year (Health Payer Specialist, March 1).

Application Deadline for Pennsylvania’s Community HealthChoices RFA Approaches

• March 15 is the deadline for applications for Pennsylvania’s state-wide, managed long-term services and supports program known as Community HealthChoices (CHC). The Commonwealth of Pennsylvania Department of Human Services (PA DHS) is hoping to award three to five managed care organization (MCO) contracts for each of the five CHC zones, covering all 67 counties in the state. The current contract holders are AmeriHealth Caritas, Centene, and the University of Pittsburgh Medical Center. PA DHS is interested in proposals that are focused on addressing health equity and health-related social needs. Applicants will also have to describe how they will work with the behavioral health MCOs to ensure access to services (Health Payer Specialist, March 4).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • Minnesota
    • On February 23, 2024, Minnesota submitted a request to extend its 1115(a) demonstration titled, “Minnesota Substance Use Disorder (SUD) System Reform,” for an additional five years, with a new expiration date of June 30, 2029. This demonstration provides federal funds for beneficiaries receiving SUD treatment in facilities that meet the federal definition of an Institution for Mental Disease (IMD). The federal public comment period will be open from February 29, 2024, through March 30, 2024.

SPAs

• Eligibility SPAs
  • Hawaii (HI-23-0004, effective January 1, 2023): Adopts changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
  • Rhode Island (RI-23-0012, effective October 1, 2023): Adopts the eligibility group authorized by the Ticket to Work Incentives Improvement Act to provide coverage for working individuals who have disabilities.
• Payment SPAs
  • Illinois (IL-23-0032, effective January 1, 2024): Updates the reimbursement rates for inpatient and outpatient hospital services.
  • Louisiana (LA-23-0043, effective October 1, 2023): Provides coverage for adult vaccines approved by the U.S. Food and Drug Administration (FDA) and administered in accordance with recommendation by the Advisory Committee on Immunization Practices (ACIP), and their administration, without cost sharing.
  • Maine (ME-23-0029, effective December 15, 2023): Establishes a one-time and ongoing Nursing Facility supplemental payment for facilities that provide comprehensive care to MaineCare veterans.
  • Massachusetts (MA-23-0059, effective October 1, 2023): Updates the methods and standards used to determine the rates for Acute Outpatient Hospital Services.
  • Massachusetts (MA-23-0064, effective January 2, 2024): Confirms compliance with Third Party Liability claims payment requirements under federal law.
  • Minnesota (MN-24-0005, effective January 1, 2024): Increases rates for behavioral health services by three percent from the rates in effect on December 31, 2023.
  • Mississippi (MS-23-0030, effective October 1, 2023): Authorizes an increase in reimbursement rates for orthodontic services by ten percent.
  • New Hampshire (NH-23-0053, effective October 1, 2023): Adjusts the payment methodology for out-of-state border hospitals, Federally Qualified Health Centers and Rural Health Centers.
  • New Hampshire (NH-23-0062, effective October 1, 2023): Updates the rates for Family Planning, Physician Services, and Other Licensed Practitioners.
  • North Dakota (ND-24-0006, effective January 1, 2024): Increases the number of therapeutic leave days for nursing facilities from 24 to 30, consistent with Intermediate Care Facilities.
  • Ohio (OH-23-0043, effective January 1, 2024): Revises the Comprehensive Primary Care (CPC) and CPC for Kids programs including simplified descriptions of program goals, total cost of care calculations, per-member per-month payments, and updated risk tier definitions.
  • Pennsylvania (PA-23-0017, effective December 24, 2023): Continues funding of multiple classes of inpatient disproportionate share hospital and supplemental payments to Medical Assistance enrolled, qualifying inpatient acute care general hospitals for state FY 2023-2024.
  • Washington (WA-24-0006, effective January 1, 2024): Increases the total compensated amount on all claim types to $250.00 in accordance with Title 42, Chapter IV, Subchapter C, Part 433 of the Code of Federal Regulations.
• Services SPAs
  • Louisiana (LA-23-0044, effective April 1, 2024): Provides coverage for enhanced mobile crisis services to the Medicaid state plan.
  • Montana (MT-23-0023, effective January 1, 2024): Allows Licensed Marriage and Family Therapists (LMFT) and LMFT Licensure Candidates in training to provide services as qualified behavioral health clinicians for covered rehabilitative services.
  • Ohio (OH-23-0047, effective January 1, 2024): Provides coverage for temporary lodging targeted to families of children with special needs when the child is required to travel to receive treatment.

Private Sector Updates

News

CareSource Proposes Partnership with ACA Co-op

• CareSource signed a letter of intent to bring on Wisconsin-based Common Ground Healthcare Cooperative as a subsidiary. If federal regulators approve this deal, it could give CareSource a solid footing in Wisconsin’s competitive insurance market (Modern Healthcare, February 27).

UnitedHealth Group Sets Up Temporary Payment System as Cyberattack Continues

• UnitedHealth Group has set up a new, temporary payment system to work around the ongoing cyberattack on its subsidiary, Change Healthcare. The cyberattack was discovered on February 21. Though UnitedHealth had hoped to resolve the issue quickly, the hack, linked to the ransomware group “Blackcat,” has disrupted the U.S. healthcare system for two weeks. Pharmacies have experienced prescription delays and hospitals have struggled to process claims and verify patients’ insurance coverage. Senate Majority Leader Chuck Schumer called on CMS to fast-track payments to providers affected by the outage. On Tuesday, CMS announced that it will consider granting accelerated Medicare payments to doctors and hospitals impacted by the cyberattack. CMS also instructed independent Medicare contractors to expedite a provider’s request to change to a new processing platform and to confirm that they are able to receive paper claims. Additionally, CMS requested that Medicare Advantage and Medicaid managed care plans relax requirements for prior authorizations. On Wednesday, it was announced that two potential class action lawsuits were filed in the U.S. District Court for the District of Minnesota on behalf of individuals in California. The lawsuits allege that the individuals’ personal health information (PHI) was compromised because of the hack, a direct violation of HIPAA federal patient privacy laws. The filings claim damages in excess of $5 million  (Health Payer Specialist, March 6; POLITICO Pro, March 5; Health Payer Specialist, March 4; The Washington Post, March 3).

Growth of Outpatient Care in Ambulatory Surgery Centers

• Providers are heavily investing in expanded outpatient services as the demand increases for less invasive, time-consuming procedures that are closer to home. According to CMS data, over the last decade, there has been a 25% increase in the number of surgery centers across the country, totaling approximately 5,400 centers. As ambulatory surgery centers offer an increasing number of services, payers are aligning with the shift to ambulatory care. Health systems are investing substantially in projects to build infrastructure, enter partnerships, and reorient their strategies to focus on more ambulatory alternatives. Many health systems are opting for joint ventures and partnerships with physicians and healthcare companies to achieve efficient operations, cut costs, and navigate the balance of providing higher-acuity care in an outpatient setting (Modern Healthcare, February 28).

Pennsylvania’s Geisinger Health Names its Next President and CEO

• Terry Gillihand, MD has been named the next president and CEO of Geisinger Health. Dr. Gillihand was the former Chief Medical Officer and chief science officer of an AI and machine learning healthcare company called Cogitativo. In his role as president and CEO, Gillihand will oversee Geisinger’s health system that serves over 1 million people annually (Becker Hospital Review, March 4).

Sellers Dorsey Updates

New Webinar: Aligning Payers and Providers to Maximize Impact on Quality

• In case you missed it last week, check out this engaging, on-demand webinar with current and former Sellers Dorsey experts Karen Brach, Jill Hayden, Karla Richardson, and Mari Cantwell. Explore the challenges and opportunities in aligning quality measures between providers and payers. Plus, learn more about the new CMS requirements for quality and how aligning these measures can increase healthcare access and equity for vulnerable populations. Click here to view the webinar.