Sellers Dorsey Digest

Federal Updates

News

MACPAC April 2024 Meeting Highlights

• Medicaid Demographic Data Collection
  • MACPAC staff discussed the need to update and improve upon Medicaid demographic data collection by including data such as primary language and limited English proficiency (LEP), sexual orientation and gender identity (SOGI), and disability. This type of data can aid in providing meaningful information about certain marginalized groups. Staff also spoke on considerations for data quality, such as self-reported data, the ability to update information over time, standardization of questions, ensuring that collection methods are representative of the Medicaid population and that there are both federal and state policies in place to ensure data privacy.
• Improving the Transparency of Medicaid and CHIP Financing
  • This session followed up on the Commission’s December 2023 Public Meeting discussion. Staff presented ways to enhance transparency regarding the financing of the non-federal share of Medicaid and CHIP. During the session, staff shared a preliminary chapter and proposed two recommendations aimed at gathering and disclosing data on financing method sources and state and provider-level financing amounts. The proposed recommendations for Congress require states to submit an annual, comprehensive report on Medicaid financing methods and amounts as well as that Congress amend the Social Security Act to align CHIP financing transparency requirements with Medicaid.
  • Click here for an exclusive summarized breakdown provided by our Sellers Dorsey experts.
• Optimizing State Medicaid Agency Contracts
  • The Commission developed a draft chapter focusing on state Medicaid agency contracts (SMACs) for Medicare Advantage dual eligible special needs plans (D-SNPs). The draft chapter is based on a year-long review which included stakeholder interviews and analysis of contract provisions and administration. Findings highlighted in the chapter include challenges faced by states in overseeing their SMACs, which mirrors broader issues that previous Commission recommendations on integrated care for duals sought to address. The chapter offers two recommendations intended to provide an introduction for optimizing and overseeing SMACs and explaining the potential benefits of integrated care for beneficiaries. The Commission proposes that states use their contracting authority to require that MA D-SNPs regularly submit care coordination and MA encounter data for monitoring, oversight, and quality assurance purposes. The Commission also proposes CMS update guidance that supports states in their development of a strategy to integrate care tailored to each unique health coverage landscape and advance state policy goals.
• Timely Access to Home- and Community-Based Services: Environmental Scan Results
  • During this session MACPAC staff discussed key findings from a scan of existing policies affecting timely access to home- and community-based services (HCBS). Additionally, staff informed the public on their next steps, including holding stakeholder interviews and holding meetings later this year surrounding eligibility, level of care (LOC) determinations, and person-centered planning.
  • Some preliminary findings are as follows:
    • 9 states use presumptive eligibility for non-MAGI populations.
    • 6 states currently use, or plan to use, expedited eligibility for non-MAGI populations.
    • 32 states have time limits on how long assessors have to complete functional assessments, ranging from 2-45 days.
    • 17 states have time limits on LOC approvals, ranging from 5-30 days.
    • 47 states and DC reported their LOC methods, 47 states and DC offer in-person, 19 have over the phone or virtual options, and 32 allow for recorded reviews.
    • Most states require an individual to have a person-centered service plan (PCSP) before they receive HCBS, within 30-45 days of enrollment.
    • 17 states, across 41 waiver programs, allow provisional plans for Section 1915(c) waiver services to expedite the process.
    • 33 states allow e-signatures for person-centered specialty plans (PCSPs).
• Update on Hospital Supplemental Payment Analyses
  • This session follows up on the September 2023 meeting regarding the long-term plan for examining payments to hospitals. MACPAC staff discussed their review of the Consolidated Appropriations Act of 2021, specifically within the bounds of the usage of supplemental policy principles and analysis of non-DSH supplemental payment data. Staff also discussed next steps, including meeting with a panel of experts to discuss the possibility of creating a payment index to evaluate both total base and supplemental payments, in relation to external benchmarks (MACPAC, April 11; MACPAC, April 12).
  • Click here for an exclusive summarized breakdown provided by our Sellers Dorsey experts.

Alzheimer’s Disease Drug Expected to Surpass Initial Medicare Spending Estimates

• CMS anticipates a significant increase in spending on the Alzheimer’s disease drug, Leqembi, compared to the drugmaker’s initial estimates for the upcoming year. According to a CMS document obtained by Stat, spending per member per month on Leqembi is projected to rise from $1.67 in 2024 to $4.67 in 2025. This translates to approximately $550M in spending for traditional Medicare in 2024 and an estimated $3.5B across all Medicare programs in 2025. This anticipated substantial surge in spending on the drug is prompting a discussion on Medicare’s willingness to pay for similar products. Leqembi was fully approved by the FDA in July 2023, exempting the drug from CMS’ restrictive coverage determination on this class of drugs (Fierce Healthcare, April 11).

Federal Legislation

Senate Finance Committee Holds Hearing about Medicare Physician Payment Reforms

• On April 11, the Senate Finance Committee convened to discuss Medicare physician payment reforms and ideas on how they can best boost care for older adults with chronic illnesses. Committee members shared their thoughts and ideas for legislative reforms to tackle this issue (Inside Health Policy, April 11).

Federal Studies and Reports

Mental Health Care Provider Shortages Among Medicare and Medicaid in OIG Report

• HHS’ Office of the Inspector General (OIG) released a report at the end of March that detailed shortages of mental health care providers in Medicare and Medicaid. Though these programs serve more than 40% of the country’s population, the report found that there were fewer than five active mental health providers for every 1,000 enrollees in 2021. The report analyzed 20 counties in 10 states, choosing one urban and one rural county from each state. On average, the rural counties had less than half the number of active providers compared to urban counties across all government programs. Despite these low numbers, Medicare and Medicaid enrollees are likely to be living with a mental health need, 1 in 4 for Medicare and 1 in 3 for Medicaid. Additionally, 1 in 5 Medicaid enrollees have a substance use disorder. The OIG recommends that CMS take the following steps to increase access to behavioral health services: increase payments to providers, expand the provider types that can serve enrollees, strengthen network adequacy standards in managed care, and lower administrative requirements (NPR, April 3 and OIG, March 29).

State Updates

News

Pilot Program Promoting Healthy Food to Help with Chronic Conditions is Starting to See Positive Results

• A pilot program launched in the Pilson area of Chicago, providing Medicaid beneficiaries with chronic health conditions with healthy food is now entering its second year. Top Box Foods, Alivio Medical Center and Medical Home Network are working together to provide food to participants, track their progress, and analyze the data. While official results haven’t been released yet, leaders at Medical Home Network stated seeing improved blood pressure rates and lower healthcare costs for many participants within the first year (CBS Chicago, April 9).

KanCare Managed Care Plan Awards Postponed

• KanCare Medicaid managed care plan awards were to be announced on April 12 but were delayed for the second time. Currently, UnitedHealth Group, Centene, and Aetna hold contracts with the state’s Medicaid program. In addition to these plans, bids were received from CareSource, Molina Healthcare, UCare, and Healthy Blue. KanCare officials intend to award three contracts. Once announced, opportunities for bid protests will end on May 17, 2024. Current KanCare contracts are set to end on December 31, 2024, with the new two-year contracts (with the option for two, one-year renewals) beginning at the start of 2025 (Health Payer Specialist, April 15).

Delaware Supreme Court Reverses Lower Court Decision, Allows MA Plan for State Retirees

• The Delaware Supreme Court has reversed a previous decision that prevented officials from transitioning state government retirees to a Medicare Advantage (MA) plan from a Medicare supplemental plan. In February 2022, the State Employee Benefits Committee agreed to replace the Medicare part A and B supplemental plan with a MA plan, effective January 2023. However, the Superior Court judge determined that the state panel which approved the MA plan had violated the state’s Administrative Procedures Act (APA), claiming that it was considered a new regulation under the Act, subject to notice and public hearing requirements under the APA. However, the Supreme Court, in their decision on April 12, stated that the selection of a specific MA plan is not a regulation subject to APA notice and public hearing requirements. (Health Policy Specialist, April 15 and Associated Press, April 12).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • New Hampshire
    • By letter dated April 1, 2024, the state submitted a request for an amendment to its 1115(a) demonstration titled, “New Hampshire Substance Use Disorder, Serious Mental Illness, Serious Emotional Disturbance, Treatment, Recovery, and Access Demonstration.” The amendment requests authority to extend presumptive eligibility for individuals applying for home and community-based services under the state’s 1915(c) waiver, Choices for Independence (CFI). This is intended to prevent unnecessary institutionalization by allowing individuals who are otherwise Medicaid-eligible for a nursing facility level of care to exercise their choice to receive services in the community. The federal public comment period is open from April 12, 2024, though May 13, 2024.
  • Connecticut
    • By letter dated March 20, 2024, the state submitted a request for an amendment to its 1115(a) Connecticut Substance Use Disorder demonstration. The amendment focuses on delivery system reforms including providing limited services for justice-involved populations 90 days prior to release from the criminal justice system and services to address health-related social needs for this population in Medicaid. The state aims to address its goals which are: increasing coverage, continuity of coverage, and appropriate service uptake through assessment of eligibility and availability of coverage for benefits in carceral settings prior to release; improving access to services prior to release and improve transitions and continuity of care upon release; improving coordination and communication between carceral systems, Medicaid, administrative services, and community-based organizations; increasing additional investments in health care and related services to improve the quality of care for beneficiaries in these settings to maximize successful reentry; improving connection between carceral settings and community services to address whole person health; reducing all-cause deaths in the near-term post-release; and reducing the number of emergency department visits and inpatient hospitalization among justice-involved Medicaid beneficiaries. The federal public comment period is open from April 12, 2024, through May 13, 2024.
  • Ohio
    • By letter dated April 1, 2024, the state submitted a request to extend its 1115(a) Substance Use Disorder Demonstration. This waiver authorizes Ohio to enhance residential treatment services as a component in the continuum of SUD benefits by allowing receipt of federal funding for treatment in Institutions of Mental Disease (IMD). The renewal application requests authority for the state to continue to operate the Demonstration as approved without changes for an additional five years through September 30, 2029. The federal public comment period is open from April 12, 2024, though May 11, 2024.

SPAs

• Eligibility SPAs
  • Hawaii (HI-24-0001, effective January 1, 2024): Increases the income standards for Medicaid coverage under the state’s optional supplement program for those residents living in a domiciliary care residence Level I or III.
  • New Hampshire (NH-24-0003, effective January 1, 2024): Establishes Medicaid coverage for lawfully residing individuals under age 19 and pregnant women who are otherwise Medicaid eligible.
• Payment SPAs
  • Connecticut (CT-24-0008, effective February 22, 2024): Establishes an emergency interim payment methodology for eligible provider types, that were affected by the Change Healthcare cybersecurity breach.
  • Florida (FL-24-0002, effective January 1, 2024): Updates reimbursement methodologies for practitioners based on a resource based relative value scale (RBRVS).
  • Illinois (IL-23-0011, effective November 1, 2023): Provides for coverage and payment of transportation network company services when prior authorized.
  • Illinois (IL-23-0028, effective January 1, 2024): Updates reimbursement rates for air and ground ambulance transportation.
  • Kentucky (KY-24-0005, effective February 21, 2024): Establishes an emergency interim payment methodology for inpatient and outpatient hospital services, clinic services, including kidney dialysis services, and long-term care services, that were affected by the Change Healthcare cybersecurity breach.
  • Maryland (MD-24-0009, effective February 21, 2024): Establishes an emergency interim payment methodology for inpatient and outpatient hospital services, nursing facility services, and hospice services, that were affected by the Change Healthcare cybersecurity breach.
  • Massachusetts (MA-24-0002, effective January 1, 2024): Updates the payment methodology for hospice services; specifically to apply the applicable 4% market basket reduction as a result of the Consolidated Appropriations Act of 2021 (CAA).
  • Massachusetts (MA-24-0006, effective March 1, 2024): Updates the fee schedule rates for psychiatric day treatment services.
  • Nevada (NV-23-0016, effective October 1, 2023): Provides for coverage and payment rates for doula services Additionally, increases rates for doula services provided during labor and delivery and provides for a 10% increase in these rates for recipients residing outside of urban Washoe and urban Clark counties.
  • New Hampshire (NH-24-0016, effective January 1, 2024): Updates payment methodologies for home health and private duty nursing services.
  • New Hampshire (NH-24-0017, effective January 1, 2024): Updates payment methodologies for community mental health centers.
  • New Hampshire (NH-24-0018, effective January 1, 2024): Updates payment methodologies for practitioners and other licensed practitioners (OLP).
  • New York (NY-21-0069, effective December 31, 2021): Increases minimum wage for service providers that work in psychiatric residential treatment facilities.
  • New York (NY-22-0011, effective February 1, 2022): Updates the rates for Psychiatric Residential Treatment Facility (PRTF) to add in a 25% adjustment for clinical and direct care components.
  • New York (NY-22-0054, effective April 1, 2022): Implements a 5.4% cost of living rate adjustment for psychiatric treatment facility services.
  • New York (NY-21-0045, effective July 1, 2021): Implements a 1% cost of living adjustment for psychiatric residential treatment facility rates.
  • New York (NY-23-0070, effective April 1, 2023): Implements a 4% cost of living adjustment to the fee schedule rates for Outpatient Addiction Rehabilitation Services, Outpatient Addiction Day Rehabilitation Services, and Opioid Treatment Programs, and in-community fees for these same services.
  • North Dakota (ND-24-0002, effective January 1, 2024): Implements an incentive program for in-state nursing facilities that meet certain criteria.
  • Oklahoma (OK-24-0014, effective February 21, 2024): Establishes provisional payment methodology for inpatient and outpatient hospitals that were affected by the Change Healthcare cybersecurity breach.
  • Washington (WA-24-0004, effective January 1, 2024): Updates payment rates and methodologies for psychiatric per diem rates and removes any remaining outdated terminology.
• Services SPAs
  • Maryland (MD-24-0001, effective May 1, 2024): Adds coverage for mobile crisis team and behavioral health crisis stabilization services, within the scope of the Other Diagnostic, Screening, Preventive and Rehabilitative Services benefit.

Private Sector Updates

News

Elevance Health Acquires New York Managed Long-Term Care Plan

• Elevance Health has reached an agreement to purchase the Centers Plan for Healthy Living and one of its affiliates. Both plans currently provide long-term care services for Medicaid enrollees in New York. The deal is expected to close in the third quarter of this year. With this acquisition, Elevance will be responsible for providing long-term services and support (LTSS) for 110,000 individuals, or 38% of New York’s managed care LTSS population. This purchase by Elevance follows the acquisitions of Integra in New York and Paragon Healthcare in Texas (Health Payer Specialist, April 12 and Empire Center, April 11).

Kaiser Permanente Opens Food is Medicine Center of Excellence

• On April 11, Kaiser Permanente launched their “Food is Medicine Center of Excellence.” This new center sets in motion their Food is Medicine programs across the U.S. and provides support to frontline clinicians and care teams by expanding food and nutrition training and partnerships. The new center also looks to introduce new screening methods to better identify individuals who are at a higher risk of food and nutrition insecurity by utilizing social determinants of health. Kaiser Permanente plans to expand training in clinical nutrition for those interested in pursuing a career in the healthcare landscape (Modern Healthcare, April 11).

QuikMedic and WellBe Senior Medical Plan to Expand Partnership to Four New States

• QuikMedic and WellBe Senior Medical are expanding their partnership in 2024 to include at least four new states. QuikMedic provides in-home urgent and other care and WellBe is an in-home primary care provider. According to a press release from QuikMedic, the two companies will provide 24/7 services to WellBe patients in Utah and Oregon, with additional states to be announced later this year. QuikMedic operates in 11 markets in Georgia, Illinois, Ohio, Oregon, and West Virginia with plans to eventually reach 18 markets across eight states. WellBe Senior Medical offers services in Alabama, Georgia, Illinois, Michigan, Ohio, Oregon, Pennsylvania, Utah, and West Virginia (Modern Healthcare, April 11).

Second VBP Playbook Released on ACO Best

• The National Association of Accountable Care Organizations, the American Medical Association, and Association of Health Insurance Plans (AHIP) have partnered to create a series of best practice playbooks for accountable care organizations (ACOs) to encourage value-based care arrangements. A playbook on voluntary best practices was released on April 10 and aims to improve quality, equity, and affordability of care. This is the second in a set announced in late July 2023. The playbook released last week outlines seven major domains of best practices from total cost of care (TCOC) models including patient attribution, risk adjustment, levels of financial risk, benchmarking, quality payments and performance, payment timing and accuracy, and incentivizing value-based care (VBC) participant performance. The playbook emphasizes the unique needs of rural communities and the importance of addressing health equity for underserved communities while recognizing the need for flexibility in VBC arrangements. Other playbooks in the future may focus on care delivery, actionable quality metrics, specialty-primary care coordination, and patient engagement, as announced by the group last summer (Health Payer Specialist, April 12 and Inside Health Policy, April 11).

Sellers Dorsey Updates

Sellers Dorsey Summary: CMS Final Rule “Streamlining Medicaid, CHIP, and BHP Enrollment”

• On April 2, CMS published a final rule titled, “Medicaid Program: Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes.” No time to read the final rule? Sellers Dorsey summarized the provisions, covering everything you need to know. Click here for the full summary.