Sellers Dorsey Digest

Federal Updates

News

MACPAC Holds March 2024 Meeting

• The Medicaid and CHIP Payment and Access Commission (MACPAC) met on March 7 and 8 to discuss the following topics (MACPAC, March 7):
  • Proposed Recommendations for Improving the Transparency of Medicaid Financing: MACPAC staff introduced draft text of the proposed recommendations for MACPAC’s June 2024 report to Congress. The proposal included the following recommendations: “Congress should amend Section 1903(d)(6) of the Social Security Act to require states to submit an annual, comprehensive report on their Medicaid financing methods and the amounts of the non-federal share of Medicaid spending derived from specific providers and Congress should amend Section 2107(e) of the Social Security Act to apply the Medicaid financing transparency requirements of Section 1903(d)(6) of the Social Security Act to CHIP.” These recommendations are projected to enhance the transparency of Medicaid financing methods, and state and provider financing amounts.
  • Medicaid Home- and Community-Based Services: Addressing Administrative Requirements: MACPAC staff presented follow-up information from their November 2023 meeting. MACPAC analysts presented results from supplementary interviews with federal officials and policy experts that examined three specific areas: lack of technical guidance, the resource intensive renewal process, and the cost neutrality requirement. Staff also presented the following three policy options for commissioner consideration: “The Secretary of the U.S. Department of Health and Human Services should direct the Centers for Medicare & Medicaid Services to develop an authority-specific technical guide for Section 1915(i), Congress should amend Section 1915(c)(3) and Section 1915(i)(7)(C) of Title XIX of the Social Security Act to increase the renewal period beyond five years, and Congress should amend Section 1915(c)(2)(D) of Title XIX of the Social Security Act to remove the cost neutrality requirement.”
  • Optimizing State Medicaid Agency Contracts: Policy Options: MACPAC staff presented policy options on how states use their state Medicaid agency contracts with Medicare Advantage (MA) dual eligible special needs plans to integrate care for dually eligible beneficiaries, how these contracts are overseen, and the barriers that states face to leveraging these contracts. These options are based on findings initially presented in the January 2024 meeting. Staff described two policy options for consideration: states collect data on care coordination and MA encounters; and, CMS issue guidance supporting states in developing an integration strategy.
  • Findings from Interviews about Medicaid Payment Policies to Support the Home- and Community-Based Services Workforce: The MACPAC session reviewed findings from interviews focused on Medicaid payment policies for home- and community-based services (HCBS) that are used to support HCBS workers, including direct care workers, direct support professionals, and independent providers. Potential practices addressed include: conducting data-driven rate studies that account for current needs in place of budget-based rate studies; aligning payment rate assumptions across populations, services, and delivery systems; and routinely updating rates to account for a changing HCBS policy environment. The presentation also focused on challenges states face in funding HCBS rates at recommended levels and ensuring rate increases result in increased HCBS worker wages.
  • Themes from Expert Roundtable on Physician-Administered Drugs: MACPAC staff discussed background information regarding the Medicaid Drug Rebate Program (MDRP) and policy differences between pharmacy and Physician-Administered Drugs (PADs). Additionally, the staff hosted a roundtable discussion on possible strategies states can use to better manage spending for related treatments and how to help states address the existing challenges related to PADs.
  • Transitions of Coverage and Care for Children and Youth with Special Healthcare Needs (CYSHCN): MACPAC staff discussed the vital role that Medicaid plays for the coverage of CYSHCN services and the need for a smooth transition to adult coverage when they come of age. Additionally, staff spoke about the barriers that beneficiaries and their families face during the transition, such as lack of care coordination, provider availability, few CPT transition codes, and limited coordination between pediatric and adult providers. MACPAC staff also noted there is significant variability in terms of population definition, plan options and eligibility for the CYSHCN population.
  • Medicare Savings Program: Enrollment Trends: The Commission previewed a draft of the Medicare Savings Programs (MSPs) chapter for the June 2024 report to Congress. This chapter describes MSPs and their role in providing Medicaid assistance with Medicare premiums and cost sharing to individuals who are dual eligibles. The chapter provides an overview of MSPs, discusses prior work in analyzing participation rates, and discusses research into participation in each of the MSPs for calendar years 2010 through 2021, including enrollment trends by demographic characteristics.
  • Panel Discussion on Authorities and State Medicaid Approached for Covering Health-Related Social Needs: Panelists Dave Baden, Deputy Director for Programs and Policy at the Oregon Health Authority; Amir Bassiri, Medicaid Director at the New York State Department of Health; Elizabeth Hinton, Associate Director at KFF; and Hemi Tewarson, Executive Director at the National Association of Health Policy discussed a variety of authorities and state Medicaid approaches for covering health-related social needs (HRSN). Panelists illustrated how they are providing services, such as housing and nutritional supports, through Medicaid authorities with a focus on design considerations, implementation, and future trends.

Biden Releases $7.3 Trillion Budget Proposal for FY2025

• On Monday, President Biden released his proposed budget for FY2025. The $7.3 trillion dollar budget aims to build on the administration’s progress to lower costs for working families, protecting and strengthening Social Security and Medicare, investing in America and the American people, and reducing the deficit by cracking down on fraud, cutting wasteful spending, and making wealthy populations and corporations pay higher taxes. The proposed FY2025 budget also reduces the deficit by $3 trillion over the next 10 years. Additionally, the budget proposal aims to protect and increase access to quality, affordable healthcare, increase access to affordable housing, and advance equity. Fact sheets for each piece of President Biden’s budget are located here (The White House, March 11; Inside Health Policy, March 11).

CMS Releases an Informational Bulletin on Strategies to Improve Delivery of Tobacco Cessation Services

• Smoking is the cause of approximately 480 thousand deaths in the U.S. every year, leading to over $600 billion a year in medical costs and productivity loss. Research shows that in 2021, one in five adult Medicaid enrollees smoke cigarettes. On March 7, CMS released a Center for Medicaid and CHIP Services informational bulletin to delve into possible strategies to improve the delivery and impact of tobacco cessation services. It includes information regarding the burden of smoking and related diseases prevalent in Medicaid and CHIP enrollees; benefits of cessation, evidence-based treatment, and how to create opportunities for enrollees to quit smoking; tobacco cessation coverage requirements for states; strategies for states to improve delivery of services; quality measures to track improvement, and additional resources (CMS, March 7).

CMS Releases Website Focused on Sickle Cell Disease Treatment Access and Quality

• CMS has released information on Medicaid and CHIP coverage of new treatments for sickle cell disease (SCD) through a new webpage. The webpage includes information presented to state Medicaid and CHIP officials in February 2024, reports on demographics, health, and healthcare of individuals with SCD, and quality improvement tools that states can use to improve SCD care (CMS, March 11).

Fertility Coverage Mandated in CMS’ Cell and Gene Therapy (CGT) Model

• According to a Request for Application (RFA) released by CMS, cell and gene therapy (CGT) manufacturers who voluntarily participate in the CMS innovation center’s new CGT model will be required to pay for fertility preservation services at no cost to patients. CMS previously announced that it will focus on sickle cell treatment for the initial CGT model. Responses to the RFA are due on May 1 for sickle cell treatment providers and negotiations are expected to occur between May 2 and November 29. Additionally, CMS also intends to release an RFA and notice of funding opportunity to states interested in participating in the CGT model sometime this summer. States will be able to opt into the program on a rolling basis, but CMS is asking for interested states to submit nonbinding letters of intent by April 1 (Inside Health Policy, March 7).

HHS Issues Letter Urging Providers to Remain Strong Despite Change Healthcare Cyberattack

• On March 10, HHS issued a letter to healthcare leaders asking them to ensure that providers stay afloat after the cyberattack on Change Healthcare, a subsidiary of UnitedHealth Group. Change Healthcare suffered a ransomware cyberattack late in February, which put payments for hundreds of millions of insurance claims in abeyance. The hacking group was purportedly paid $22 million in bitcoin to release the information, but Change Healthcare’s systems remain in disarray and claims are still not being paid. The company processes approximately 15 billion claims per year, about half of the U.S. market. In their letter, HHS urges other payers to make interim payments to providers, particularly those participating in the Medicaid program (Health Payer Specialist, March 11).

Federal Legislation

Senate Passes First Set of FY2024 Appropriations Bills

• On March 8, the Senate passed the first set of FY2024 appropriations bills that included FDA spending and a lean package of healthcare payment patches and extenders, most of which expire in December 2024. The health package that was passed included a partial fix for the Medicare physician pay cut, an extension to Advanced Alternative Payment Model bonuses, and a continuation of disproportionate share hospital and community health center funding, along with other policies while omitting pharmacy benefit manager reform, site-neutral and transparency pricing provisions, and a full reauthorization of the pandemic and opioid response laws. Congress must pass the second round of FY2024 appropriations bills before March 22, which will include funding for HHS (Inside Health Policy, March 8; Modern Healthcare, March 6).

House Committee Votes to Stop CMS Nursing Home Staffing Mandates

• On March 6, the House Ways and Means Committee voted to extend the Protecting American Seniors’ Access to Care Act of 2023 with a 26-17 vote, which would block CMS’ proposed rule mandating minimum nursing home staffing standards. Party viewpoints are split, with Republicans perceiving the CMS mandate as costly and impractical, while Democrats believe it will aid in improving the quality of care in nursing homes (Modern Healthcare, March 6).

Biden Expresses Support for Drug Pricing Controls and Affordable Care Act Subsidies

• During President Biden’s State of the Union address last week, he proposed expanding the Medicare drug negotiations over the next decade to include 500 drugs, expanding the $2,000 cap on drugs and $35 cap on insulin to all plans. He also proposed to make permanent the enhanced Affordable Care Act (ACA) subsidies. Some stakeholders expressed support for his policies, such as the AARP and the Association of Community Affiliated Plans (ACAP). However, the pharmaceutical industry along with the Council for Affordable Health Coverage expressed concerns about the Inflation Reduction Act and the proposed policy changes. Additionally, Republicans in the House Budget Committee have advanced a 2025 Budget Resolution that does not align with Biden’s policies and proposes repealing drug price negotiation and the enhanced ACA subsidies as well as supporting policies to allow Medicaid work requirements (Inside Health Policy, March 8).

State Updates

News

Utah Expands Postpartum Coverage for Medicaid and CHIP to 12 Months

• On March 8, HHS issued a press release announcing Utah’s Medicaid and CHIP postpartum benefit expansion to 12 months. Utah’s approval marks 45 states that currently offer a full year of coverage after pregnancy. The announcement also signifies progress in implementing the CMS Maternity Care Action Plan, which supports the Biden administration’s Maternal Health Blueprint, a comprehensive strategy to improve maternal health in underserved communities. With the extension of postpartum coverage, an additional 4,000 people in Utah are eligible for Medicaid and CHIP coverage for one year post-pregnancy. Medicaid currently covers 41% of all births in the U.S. and over half of all children in the U.S. (Medicaid.gov, March 8).

Colorado Bill Calls for the Coverage of Obesity Treatment and Medication

• Colorado’s SB24-054 seeks to require private insurance companies and Medicaid to cover chronic obesity treatment and medication. If passed, weight loss drugs such as Ozempic and Wegovy will be covered. A fiscal analysis estimates that the coverage of these services will cost Colorado’s Medicaid program over $200 million a year. On March 14, the bill will be heard by the Senate Committee (CBS Colorado, March 7).

New York State Ambulette Providers Shut Down Services in Westchester County

• Ten Medicaid ambulette providers in Westchester County, New York shut down on March 8. The providers claim that the New York State Department of Health is not reimbursing them fairly for the services they provide. According to a rate study from the Department of Health, the average cost of an ambulette trip is $70, while the reimbursement is around $53 from the state. At least 35 ambulette companies in New York have closed since 2019, despite efforts from state and local lawmakers to change reimbursement rates (CBS New York, March 8).

Kentucky Medicaid Managed Care Contract Dispute Heads to State Supreme Court

• Last week, the Kentucky Supreme Court heard oral arguments regarding the state’s Medicaid managed care contracts. The case stems from objections filed by Elevance Health in 2019, operating under its previous name of Anthem, when the payer was first denied a contract to provide services to Medicaid beneficiaries. Governor Beshear required a redo of the bidding process, and the same five payers, Aetna, Humana, UnitedHealthcare, Centene affiliate Wellcare, and Molina Healthcare, who were initially awarded contracts, were awarded contracts once again. Elevance was not successful at the trial and appellate court levels in 2022 but has been allowed to keep their Medicaid contract in the state until the case is resolved (Health Payer Specialist, March 11).

SPA and Waiver Approvals

SPAs

• Administrative SPAs
  • Missouri (MO-24-0004, effective January 1, 2024): Corrects a typographical error made in MO-23-0030, relating to the resource standard for a couple in Ticket to Work Basic and Medical Improvements eligibility groups.
  • Oklahoma (OK-23-0032, effective November 1, 2023): Removes the COVID-19 vaccine counseling CPT code, with modifier CR from the state plan.
• Eligibility SPAs
  • South Carolina (SC-23-0019, effective October 1, 2023): Aligns the limitations on non-covered medical expenses with the current Medicaid coverage and benefits.
  • Utah (UT-23-0017, effective January 1, 2024): Provides for 12 months of extended postpartum coverage to individuals who were eligible and enrolled under the Medicaid state plan during their pregnancies (including during a period of retroactive eligibility).
• Payment SPAs
  • Illinois (IL-23-0024, effective July 1, 2023): Approves a template that will authorize the state to enter into Value/Outcomes-Based Agreements with drug manufacturers for drugs provided under the Medicaid program.
  • Kansas (KS-23-0045, effective January 1, 2024): Covers the Continuous Glucose Monitors (CGM) under the Durable Medical Equipment (DME) benefit.
  • Louisiana (LA-23-0020, effective July 1, 2023): Amends provisions governing medical transportation services in order to link emergency medical transportation to the Louisiana Medicaid fee schedule.
  • Nevada (NV-24-0001, effective October 1, 2023): Adds a reimbursement methodology for clinic benefits provided by special clinics that provide treatment primarily to children with cancer and other rare diseases.
  • New Jersey (NJ-23-0013, effective July 1, 2023): Updates the redistribution methodology for disproportionate share hospital (DSH) payments.
  • New York (NY-22-0007, effective April 1, 2022): Authorizes a supplemental payment to allow eligible nursing homes to increase resident facing staffing services.
  • Washington (WA-24-0010, effective January 1, 2024): Updates inpatient hospital uniform cost reporting information.
• Services SPAs
  • South Dakota (SD-24-0003, effective February 1, 2024): Revises provider qualifications for Community Mental Health Centers (CMHCs) to align with revised state standards.
  • Washington (WA-23-0051, January 1, 2024): Incorporates updates that were made previously in WA-23-0010 to the service names and practitioners related to rehabilitative services delivered through managed care. In addition, WA-23-0051 corrects page number references and adds practitioner types to align with practitioners that have been added to the Other Licensed Practitioners section of the state plan.

Private Sector Updates

News

Northwell Health and Nuvance Health Intend to Merge by End of 2024

• Northwell Health plans to acquire Nuvance Health by the end of the year in a deal that would create a system with 28 hospitals and over 1,000 care sites across Connecticut and New York. Northwell leadership has expressed it is ready to expand and grow. The deal could mean opportunities for employees and improved access to care between the long-time clinical affiliates. If regulatory approvals are obtained, Nuvance’s board would dissolve after five years. Until then six Nuvance board members will join Northwell’s board, and seven Northwell board members will join Nuvance’s board. All local hospital boards will not change and will remain in place (Modern Healthcare, March 6; Modern Healthcare, February 28).

Sellers Dorsey Updates

The Meaning Behind our Mission: Q&A with SVP of Talent Management

• In case you missed it, check out this engaging Q&A with Senior Vice President of Talent Management, Charity Hughes, as she explores the meaning behind our mission to improve quality, equity, and access in the Medicaid program. Explore the Q&A by clicking here.

2024 State of Medicaid Managed Care Report

• If you want to learn more about MLTSS and how states are utilizing their programs to better integrate care and achieve more predictable costs, this year’s Medicaid Managed Care Report takes a closer look. Download the report by clicking here.