Sellers Dorsey Digest

Federal Updates

News

Federal Legislation

Bipartisan, Bicameral Health Privacy Bill Proposed

• On April 7, the House Energy and Commerce Chair Cathy Rodgers (R-WA) and Senate Commerce Chair Maria Cantwell (D-WA) released draft federal privacy legislation. The bipartisan legislation sets national standards for data privacy rights and establishes measures to enforce violations of the law, including a private right to action for individuals. Previous attempts at privacy legislation have failed, but the new draft legislation does not overturn existing state laws around the privacy of health information, medical information, medical records, or HIV status and testing. Instead, federal preemption would occur in other privacy areas. In the draft legislation, the Federal Trade Commission is established as the federal privacy enforcer, including enforcement of requirements relating to health information (Inside Health Policy, April 7).

Hearing on the Change Healthcare Cyberattack Coming Up

• The Senate Finance Committee plans to hold a hearing in the next several weeks to discuss “lessons learned” from the Change Healthcare cyberattack that took place in February. The hearing will delve into topics relating to possible legislation or regulations to improve the response system in case of another cyber emergency (Inside Health Policy, April 4).

Federal Regulation/Guidance

CMS Releases Enrollment, Eligibility, and Renewal Processes Final Rule

• CMS released a final rule on April 2, 2024, titled, “Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes.” This final rule is intended to reduce barriers to enrollment and improve retention in Medicaid, CHIP, and the Basic Health Program (BHP). The final rule was first proposed in September 2022 and includes several provisions to streamline enrollment and provide for more simplified transitions between these programs in response to President Biden’s Executive Orders from January 2021 and April 2022 (CMS, and CMS, March 27).

Click here for an exclusive summary by Sellers Dorsey on the recently published CMS Final Regulations.

CDC Releases Health Alert Informing Public about Recent Avian Flu Infection

• On April 5, the CDC released a health alert to inform the public about the human avian flu infection that occurred in Texas. The alert included background information on the individual who tested positive for the virus and recommendations concerning the virus for clinicians, state health departments, farmers, live-stock owners, and the general public. The CDC has stated that it will work with the FDA, the Department of Agriculture, and state health departments to monitor those actively exposed to animals with the virus. Currently, there is limited knowledge regarding how infectious the virus is and whether available vaccines are effective in protecting individuals against it (Inside Health Policy, April 8).

Notice of Benefit and Payment Parameters for 2025 Final Rule is Published

• CMS released the Notice of Benefit and Payment Parameters for 2025 final rule on April 2, 2024, for Qualified Health Plans. The final rule allows states to provide routine adult dental services as an essential health benefit (EHB) starting January 1, 2027. The final rule also makes changes to certain EHB prescription drug benefit requirements, including requiring Pharmacy and Therapeutics Committees to have at least one patient representative. CMS has also codified current policy that prescription drugs covered by a plan in excess of a state’s benchmark plan are considered EHBs. The final rule also creates network adequacy standards for Marketplace health plans on the federal platform by limiting how far and long a consumer must travel to see certain providers. Special enrollment periods have been extended for consumers with household incomes at or below 150% of the FPL, and the dates of Open Enrollment periods across almost all Marketplaces have been aligned to generally begin on November 1 and end no earlier than January 15. The final rule also provides states flexibility in establishing an effective date of eligibility for enrollment in BHP coverage. Finally, the final rule codifies the reinterpretation of the State Marketplace and State Medicaid and CHIP agencies’ use of the Federal Data Services Hub so that the access and use of data provided by the Verify Current Income (VCI) Hub service is considered a state agency function. State Exchanges and State Medicaid and CHIP agencies will be required to pay to access and use the VCI Hub service starting July 1, 2024 (CMS, April 3; CMS, April 2; CMS, April 2).

CMS Releases Final Rule Greatly Impacting Medicare Advantage

• On April 4, CMS released a final rule that revises the Medicare Advantage (MA) Program, Medicare Part D, Medicare Cost Plan Program, PACE, Health IT Standards and Implementation Specifications. A few key provisions of the final rule include fixed rates for brokers, prohibitions of contracts between MA organizations and third-party marketing companies, a new outpatient behavior health provider category that includes mental health counselors, marriage and family therapist, opioid treatment centers, mental health centers, addiction medicine physicians, nurse practitioners and physician assistants, and limits for out-of-network cost sharing for D-SNP PPOs (CMS, April 4; Fierce Healthcare, April 5).

Federal Studies and Reports

Mayo Clinic Study Finds that Patients in Rural Areas with COVID-19 Had Higher Susceptibility to Hospital Re-Admission and Death

• A recent study by the Mayo Clinic has found that, patients with COVID-19 living in rural areas experienced greater rates of hospital re-admission and loss of life following hospitalization compared with those residing in urban areas, even after the roll out of multiple vaccinations and booster shots. The study results point to gaps in access to high-quality and comprehensive healthcare among the individuals residing in rural areas, specifically in the realms of post-acute, primary, and specialty care (Axios, April 9; Oxford Academic, April 2024).

State Updates

News

Recent Idaho Bill to Disrupt Medicaid Services

• On April 4, Governor Brad Little (R-ID) signed HB 398 into law, which requires legislative approval of Medicaid state plan amendments and waivers. The law took effect immediately. However, soon after it became law, Governor Little’s office received about a hundred emails from providers requesting a trailer bill because of concerns of payment disruptions to providers and disruptions in the provision of healthcare services. State Representative Megan Blanksma, who sponsored HB 398, has a trailer bill draft ready to clarify and fix the language causing the providers’ concerns (Idaho Capitol Sun, April 9).

Iowa Postpartum Medicaid Expansion Passes House, Goes to Governor’s Desk

• The Iowa legislature passed Senate File 2251 last week and now goes to Governor Kim Reynold for signature. The legislation expands postpartum Medicaid coverage from 60 days to one year. If signed, Iowa is expected to join almost every state in providing expanded postpartum coverage. However, the legislation also limits eligibility to families with an income at or below 215% of the FPL, down from the previous 375% limit for postpartum coverage. Families who are currently receiving postpartum Medicaid coverage but exceed the new income thresholds will be grandfathered into the extended program (Des Moines Register, April 4; Iowa Capital Dispatch, April 3).

Individuals Covered Under New York’s Essential Health Plan Expected to Increase

• On March 1, New York’s Essential Plan public health insurance program took effect, allowing residents with incomes up to 250% of the FPL to be enrolled, up from the previous 200% FPL threshold. The state estimates that an additional 100,000 New Yorkers will enroll, joining the existing 1.2 million enrollees. The program is authorized under a Section 1332 state innovation waiver and New York will spend $5.8 billion in federal funding to increase provider rates and continue a quality incentive pool for health plans. The program also allocates $25 million for an annual grant program for social determinants of health, as well as $49 million to compensate insurers for premium revenue as some Qualified Health Plan enrollees transition to the Essential Plan (Politico, April 1).

North Carolina to Roll Out Tailored Medicaid Plans this Summer

• On July 1, North Carolina will implement the delayed tailored Medicaid plans for individuals that need extensive care and support systems, including individuals with developmental disabilities, complex psychiatric disorders, traumatic brain injuries, and substance use disorders. The new tailored Medicaid plans are expected to cover approximately 150,000 residents in North Carolina. Four Local Management Entity (LME)-MCOs will be administering these plans: Partners Health Management, Alliance Health, Vaya Health, and Trillium Health Resources (North Carolina Health News, April 4).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • Texas
    • On March 28, 2024, Texas submitted a request to extend its 1115(a) demonstration, titled “Healthy Texas Women,” which is currently set to expire on December 31, 2024, for another five years. The demonstration aims to increase and strengthen coverage for low-income women in the state by providing a benefit package for those who would not otherwise be eligible for family planning and preventative services under Texas Medicaid. These benefits include family planning services and other women’s health services that are intended to contribute to preconception care, better birth outcomes, and improved maternal health. The federal public comment period is open from April 5, 2024, through May 5, 2024.

SPAs

• Eligibility SPAs
  • Arkansas (AR-24-0001, effective April 1, 2024): Creates Developmental Screen for Children by adding language allowing PCPs to preform developmental screenings for children between the ages of 48 and 60 months, within EPSDT and AR Kids-B Medicaid manuals.
  • Arkansas (AR-24-0008, effective January 1, 2024): Provides 12 months of continuous eligibility for children under the age of 19.
  • North Dakota (ND-24-0001, effective January 1, 2024): Updates the non-alignment alternative benefit plan (ABP) for beneficiaries ages 21-64 to remove language from the 1915(i) SPA regarding the World Health Organization Disability Assessment Scores (WHODAS).
  • North Dakota (ND-24-0001-B, effective January 1, 2024): Updates the non-alignment alternative benefit plan (ABP) for beneficiaries ages 19 and 20 to remove language from the 1915(i) SPA regarding WHODAS and PCCM service delivery model.
  • Oklahoma (OK-24-0006, effective January 1, 2024): Provides 12 months of continuous eligibility for children under the age of 19 in accordance with the Consolidated Appropriations Act of 2023.
  • South Dakota (SD-24-0002, effective April 1, 2024): Adds coverage of vaccines and administration without cost sharing for adults and primary care case management services for pregnant individuals.
• Payment SPAs
  • Kansas (KS-24-0002, effective January 1, 2024): Removes cost sharing (deductibles, co-insurance or copayments) for Medicaid FFS beneficiaries.
  • New Jersey (NJ-23-0014, effective July 1, 2023): Provides Graduate Medical Education (GME) subsidy supplemental payments at the same aggregate level as the prior fiscal year and updates the amount allocated to each qualifying hospital.
  • New Jersey (NJ-23-0015, effective July 1, 2023): Updates the allocations of individual provider payments for the state fiscal year 2024 GME Supplemental program and adds a procedure for redistributing overpayments.
  • New Jersey (NJ-23-0016, effective July 1, 2023): Provides for GME Trauma payments and the distribution amounts for each qualifying hospital.
• Services SPAs
  • Oregon (OR-24-0001, effective March 2, 2024): Removes the Targeted Case Management program, which ended in July 2023, for beneficiaries with poorly controlled asthma and history of environmentally induced respiratory distress. After the program ended, its participants received services from Oregon Health Plan’s disease management program.
  • Vermont (VT-24-0005, effective January 1, 2024): Adds coverage for community-based mobile crisis services for specialized mental health and substance use intervention and establishes provider qualifications.

Private Sector Updates

News

Evernorth Opens New Innovation Hub in Ireland

• Evernorth Health Services, a division of Cigna, is locating its new innovation hub in Galway, Ireland. The company plans to eventually fill 100 positions, focusing on software strategy, IT architecture, and product management. Evernorth is currently recruiting product managers, solutions architects, and UI designers (Health Payer Specialist, April 8).

CVS to Launch Tuition Assistance Programs for Future Pharmacists

• On April 3, CVS announced its plans to launch PharmD, a tuition assistance program for CVS interns and the Community Pharmacy Health Equity Award for pharmacy students across the U.S. The PharmD tuition assistance program provides individuals currently interning with CVS to apply for up to $20,000 that can be used toward their final year’s tuition. Starting in June 2024, CVS plans to expand assistance to interns that are in their 5^th and 6^th year of pharmacy training, amounting to $20,000 per school year. The Community Pharmacy Health Equity Award is a collaboration between CVS Health Foundation and the American Association of Colleges of Pharmacy (AACP). This program will grant $20,000 to 21 students studying pharmacy who are facing financial barriers to promote diversity and commitment to the profession and patient care (CVS Health, April 3; Fierce Healthcare, April 3).

Community Health Centers Face Financial Cuts due to Medicaid Redetermination

• As Medicaid rolls have declined during the redetermination period, community health centers (CHCs), whose client base mostly consists of individuals with incomes 200% or less of the FPL, have lost on average $600,000 per center due to the loss of 23% of Medicaid patients based on data from the National Association of Community Health Centers. While 77% of CHCs were able to avoid cutting services and their staff, other CHCs were forced to, on average, reduce personnel by 12%, reduce services by 11%, and reduce appointments by 9%. Additionally, CHCs report increased administrative and outreach costs as people need assistance to understand their eligibility and options for coverage during the redetermination period (Stat News, April 8).

Sellers Dorsey Updates

Sellers Dorsey at the American Ambulance Association (AAA) Annual Conference — Medicaid Financing for EMS Providers 

• How can EMS providers receive better reimbursement for treating Medicaid patients? Find out in this engaging session at AAA with Sellers Dorsey Managing Director, Mason Lane, Sellers Dorsey Associate Director, Alexa Altman, and Bridge Partner’s Donna Newchurch, on April 23 at 2 pm. Click here to learn more.

Don’t Miss Gary Jessee and Bill Lucia at i2i Client Conference

• At the 2024 i2i Client Conference, Gary Jessee will lead a session that explores the current state of Medicaid, answering the question, where do we go from here? And Bill Lucia will be part of a featured panel discussing the topic of People, Culture, and Purpose. Click here to learn more.