Sellers Dorsey Digest

Federal Updates

News

Medicaid Disenrollments Exceed HHS Predictions

• When states began coverage redeterminations on April 1, 2023, HHS projected 15 million beneficiaries would lose coverage. However, as of March 20, 2024, more than 18 million individuals have been disenrolled, far exceeding predictions. Additionally, 35 million beneficiaries’ eligibility redeterminations have either not been completed or have not been reported. Disenrollment numbers have varied across states with Texas disenrolling the most Medicaid beneficiaries so far at 2 million, and Wyoming the fewest at 5,300 beneficiaries. The majority of disenrollments were due to beneficiaries not completing the required renewal process in order to maintain coverage. Most individuals who have lost eligibility are now eligible for an employer-sponsored health plan. Those moving to a marketplace plan can enroll before July 31, 2024, as part of an extended unwinding special enrollment period (Health Payer Intelligence, March 25).

CMS Approves Medicare Part D to Cover Weight Loss Drug

• On March 21, CMS announced that Medicare Part D plans may cover Wegovy, the weight loss drug, when it is prescribed for the prevention of heart attacks, strokes, and other cardiovascular conditions. CMS made the distinction that they will not cover Wegovy solely for weight management but for individuals who have comorbidities of being overweight and having heart disease. This announcement comes two weeks after the FDA approved the use of Wegovy to reduce the risk of heart attack and stroke in obese or overweight adults with a history of cardiovascular disease (McKnights, March 25).

Federal Legislation

Minibus Bill Prevents Government Shutdown, Funds HHS and Healthcare Workforce

• On March 23, President Biden signed a $1.2 trillion spending package to cover federal government operations through September 30, 2024. This averts a partial government shutdown and provides funding for about three-quarters of federal government agency operations, including the Departments of Labor, Health and Human Services, and Education for the next six months. The spending bill allocated $117 billion for HHS, approximately a 1% increase over FY 2023. Policies around pharmacy benefit managers, price transparency, and site-neutral payments were not included in the spending package. According to the American Hospital Association, around $14 million will fund an assortment of healthcare workforce programs such as the National Health Service Corps, nursing programs, and Children’s Hospitals Graduate Medical Education (Becker’s Healthcare, March 25; Inside Health Policy, March 22).

CMS to Pilot New Payment Model for Primary Care Starting January 1, 2025

• On March 19, CMS released the details of a new model that would provide primary care-focused Accountable Care Organizations (ACOs) with both a one-time Advanced Shared Savings payment and monthly prospective, population-based payments, Prospective Primary Care Payments. The ACO Primary Care (PC) Flex Model will function within the Medicare Shared Savings Program, and ACOs that partake will jointly participate in both programs concurrently. The innovative model aims to ease financial burden for low revenue ACOs while encouraging primary care providers within them to apply a team-based, person-centered approach to care that impacts health outcomes, quality measures, and cost of care in a positive way. A total of 130 ACOs will be selected by CMS to participate in the ACO PC Flex Model starting January 1, 2025. To be eligible, ACOs must participate in the Shared Savings Program, be low revenue ACOs (as defined under 42 CFR § 425.20), and meet the ACO PC Flex Model eligibility requirements that will be outlined in the upcoming Request for Applications (RFA) (CMS, March 19; Modern Healthcare, March 20).

45 Million Individuals Covered by a Private Plan or Medicaid Because of Medicaid Expansion and the Affordable Care Act Exchanges

• According to the Health Insurance Marketplaces 2024 Open Enrollment Report released by CMS on March 22, 45 million individuals are covered by a private insurance plan or Medicaid because of the ACA exchanges and Medicaid expansion. The report features enrollment trends and how the ACA exchanges have progressed since they were originally rolled out in 2013. Highlights of the enrollment report include the following:
  • 4 million individuals selected or were auto-enrolled in an ACA plan through healthcare.gov or a state-run exchange, which is a 31% increase compared to 2023.
  • The number of new consumers on the exchanges increased by 41% from 2023.
  • 6 million more individuals are receiving ACA tax credits compared to 2023, which includes 1.5 million individuals earning more than 400% FPL who would be ineligible for assistance without the ACA enhanced subsidies.
  • Average monthly premiums when including the tax subsidies decreased by 32% from $164 in 2023 to $111 in 2024 (Inside Health Policy, March 25; CMS, March 22).

Federal Regulation/Guidance

CMS to Release New Unwinding Timeline for States

• CMS is set to release an updated unwinding timeline within the next few weeks, informing states of when they will be required to complete Medicaid redeterminations. Experts believe that the document will include information regarding the ex-parte glitch caused by faulty programming, and other possible renewal process issues that may come up. In September 2023, approximately 30 states informed CMS about the numerous renewal issues they encountered. While many experts think this problem could force states to extend unwinding through 2025, Medicaid managed care executives believe most states will complete the unwinding process by mid-2024 (Inside Health Policy, March 22).

State Updates

News

Nevada Governor Proposes Use of $200 Million from Hospital Assessment to Fund Expansion of Children’s Behavioral Health Services

• Governor Joe Lombardo (R-NV) has announced his proposed plan to use $200 million from Medicaid funds generated by the new hospital assessment to improve children’s behavioral healthcare. The governor’s proposal would use the funding over a three-year period to expand Medicaid services for children with behavioral needs and increase the quality of care within Nevada’s behavioral provider system. The governor’s proposal will be put to a vote by the Interim Finance Committee in April (Reno KOLO-TV, March 22).

Missouri Politicians Push for Doula Reimbursements and Birth Center Changes

• Maternal health has been a rising issue within Missouri, as women on Medicaid are more than 10 times as likely to experience a pregnancy-related death than those covered by private insurance plans. A bipartisan group of Missouri legislators have introduced various bills to help improve access to maternal healthcare within the state. Wendy Hausman (R-MO) and Jamie Johnson (D-MO) put out bills that call for doulas to be reimbursed through their client’s insurance, and Kent Haden (R-MO) put out a bill that would remove the ambulatory surgical center label from birthing centers to lessen the restrictions and make the centers more accessible across Missouri (KCUR NPR, March 19).

DeSantis Signs Live Healthy Bills to Support and Increase Providers in Florida

• Governor Ron DeSantis (R-FL), signed five bills into law on March 21 with the goal of improving access to care, increasing the number of providers in the state, and addressing mental health treatment challenges. These bills, known as the “Live Healthy” initiative, were a priority for Senate President Kathleen Passidomo. The bill pertaining to providers includes $717 million for increased residency slots and loan-forgiveness programs for healthcare professionals. It also takes steps to allow foreign-trained physicians to practice in the state. Other measures in the Live Healthy bills include $50 million a year for a revolving loan fund program for health innovation projects and $100 million a year for the next three years for four behavioral health teaching hospitals (Orlando Sentinel, March 21).

Illinois Medicaid Health Plan to Begin Covering Part of Fee for Hospital Health Equity Certification

• Meridian Health Plan of Illinois, Inc. (Meridian), a subsidiary of Centene, will begin covering part of the fee for health equity certification through the Joint Commission for certain hospitals. Meridian will pay 25% of the annual application fee for safety net or critical access hospitals that are in-network for the plan. Other hospitals can be reimbursed at 15%. According to the president and CEO of the health plan, Meridian is the first in the country to assist in paying for the certification (Health Payer Intelligence, March 22).

Missouri Continues to Have Delays in Medicaid Application Process

• While CMS requires that Medicaid applications be processed within 45 days, Missouri finds itself exceeding federal limits in application delays for the third month in a row. Missouri’s backlog of Medicaid applications dropped in February, but the average time it took to determine eligibility was 77 days. Processing issues affect new applicants as well as those who may have lost coverage during the eligibility verification process and need to reapply. The state’s Department of Social Services has said they are shifting efforts to overcome the backlog and that the average processing time should decline soon (NPR, March 23).

Wisconsin to Cover Full Cost of Over-the-Counter Birth Control Pills for Medicaid Enrollees

• On March 19, Governor Tony Evers (D-WI) published a press release announcing that the Department of Health Services (DHS) will be issuing a standing order to ensure that BadgerCare Plus members will have access to the over-the-counter birth control pill, Opill, at no cost. Sales of Opill began at some Medicaid-participating pharmacies on March 20 and will continue to expand across the state in the coming weeks (MSN, March 19; State of Wisconsin, March 19; State of Wisconsin, March 18).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • Alaska
    • On March 26, 2024, CMS approved Alaska’s 1115 Waiver extension, newly named “Behavioral Health Reform,” effective through December 31, 2028. This waiver continues the state’s existing authority to receive FFP for providing clinically appropriate SUD treatment services for short-term residents in residential and inpatient settings that qualify as Institution for Mental Disease (IMD) as well as additional services to enhance the comprehensive and integrated behavioral health system for children, youth, and adults with serious mental illness (SMI), severe emotional disturbance (SED), and/or SUD. However, there were no changes made other than the title change.
  • Georgia
    • On March 11, 2024, Georgia submitted an amendment to its 1115 demonstration titled, “Georgia Planning for Healthy Babies.” The amendment permits legally responsible individuals, including legally responsible family caregivers, to be reimbursed for the provision of medically necessary personal care services to medically fragile children under the age of 21 enrolled in the Georgia Pediatric Program (GAPP). The federal public comment period will be open from March 27 through April 26.
  • Rhode Island
    • On March 21, 2024, CMS approved an amendment to Rhode Island’s waiver titled, “Rhode Island Comprehensive Demonstration.” The amendment’s purpose is to expand access to care, improve quality, and increase flexibilities for beneficiaries and providers. The amendment is effective as of March 21, 2024, through December 31, 2024. The approved amendment allows the state to include personal care services in acute care hospital settings; expand eligibility for HCBS Waiver-Like services for adults with disabilities at risk of institutional long-term care; update the two 1115 expenditure authority populations to reference the 12 month postpartum coverage expansion; add the option for remote supports and monitoring in HCBS; modify provider education requirements for home stabilization services; and allow several Appendix K HCBS flexibilities.
    • Click here to read an exclusive summarized version provided by Sellers Dorsey.

SPAs

• Eligibility SPAs
  • New Hampshire (NH-24-0002, effective January 1, 2024): Maintains eligibility and enrollment for children under the age of 19 for 12 months without consideration of changes in circumstances for these children.
  • New Mexico (NM-23-0005, effective January 1, 2023): Changes eligibility rules for the Former Foster Care eligibility group, enacted by the SUPPORT Act.
• Service SPAs
  • Utah (UT-12-0016, 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
  • Colorado (CO-23-0042, effective January 1, 2024): Updates pricing for hospital services that use established specialty drugs within an inpatient setting, and the percentage of the net invoice cost that will be paid.
  • District of Columbia (DC-24-0001, effective January 1, 2024): Adds consultation and collaborative care services as a physician benefit.
  • Minnesota (MN-23-0032, effective January 1, 2024): Updates rates for Adult Day Treatment and Adult Residential Crisis Stabilization Services.
  • Massachusetts (MA-23-0061, effective October 1, 2023): Updates reimbursement methodologies and standards for chronic disease and rehabilitation inpatient hospitals for the 2024 rate year.
  • Massachusetts (MA-23-0060, effective October 1, 2023): Updates reimbursement methodologies and standards for psychiatric impatient hospital services for the 2024 rate year.
  • Massachusetts (MA-23-0058, effective October 1, 2023): Updates reimbursement methodologies and standards for acute inpatient hospital services for the 2024 rate year.
  • Nevada (NV-23-0023, effective January 1, 2024): Increases reimbursement rates for nursing facilities and establishes special care rates for patients with specific factors.
  • New Hampshire (NH-24-0023, effective January 1, 2024): Updates descriptions of reimbursement for inpatient hospital services provided out of state.
  • South Carolina (SC-23-0018, effective October 1, 2023): Updates the methods and standards that establish DSH payments, and rates for impatient hospital swing beds and administrative days, based on redeterminations of nursing facility payment rates.
  • South Carolina (SC-23-0020, effective January 1, 2024): Establishes reimbursement methodology for hospital-based stabilization services that are provided in specialized emergency health settings, specifically for behavioral health patients.

Private Sector Updates

News

Ascension to Use Private Equity Staffing Firm for Chicago Hospitals

• The nonprofit health system, Ascension, has decided to terminate over 110 doctors and other providers at all 10 of its Chicago-area hospitals and turn them over to a private-equity backed staffing firm. This decision is intended to cut costs for Ascension, with affected employees raising concerns about working conditions and patient safety (Modern Healthcare, March 25).

UnitedHealth to Require New Login Credentials After Change Healthcare Cyberattack

• Last week, UnitedHealth Group announced that it is close to processing the billions of dollars in claims that were paused after the Change Healthcare cyberattack over a month ago. As of Friday, the medical claims software had returned to online operations, with more than $14 billion in claims waiting to be processed. The Relay Exchange claims processing site was expected to resume activities on Saturday, March 23, but there has not yet been confirmation on whether this occurred. UnitedHealth also informed payers using Relay Exchange that they will be required to create “new log-in credentials for secure file transfer protocol to establish new secure batch claims and electronic remittance advice connections” (Health Payer Specialist, March 25).

Sellers Dorsey Updates

Meet Our Team: Q&A with Director, Mike McCabe

• In case you missed it last week, explore this engaging Q&A with former Health Plan President, CIO, and current Sellers Dorsey Director, Mike McCabe. Mike supports Sellers Dorsey clients by providing strategic guidance in healthcare operations, payment model design, Medicaid network contracting, and more. Click here for the Q&A!