Sellers Dorsey Digest

Federal Updates

News

CMS Releases Unwinding Renewal Timeline with Estimated End Dates for Nine States

• On June 13, CMS released a slide deck describing updates to state-specific unwinding renewal timelines. Initially, CMS gave states one year from April 1, 2023, when Medicaid continuous enrollment protections expired, to initiate unwinding procedures and 14 months to complete them. This was later extended to June 2024, but many states requested additional extensions for a variety of reasons, including the need for more time to complete renewals for vulnerable populations, such as children and individuals receiving long term care. Currently, there are 9 states that plan to forgo the deadline and end their unwinding later than scheduled. Illinois, Kentucky, Michigan, New Jersey, and Wisconsin are to finish in July, South Carolina and Hawaii in August, and North Carolina in November. Washington D.C. and Alaska, on the other hand, will finish their unwinding renewals in 2025, citing “unique and severe environmental and operational challenges.” (Inside Health Policy, June 13; CMS; June 13).

CMS to Recalculate Medicare Advantage Plan 2024 Star Ratings

• On June 13, CMS notified Medicare Advantage (MA) plans that it will recalculate the 2024 Star Ratings for the 2025 Quality Bonus Payment as a result of recent D.C. district court decisions. The D.C. district court judges largely sided with SCAN Health Plan and Elevance Health in their cases against CMS over the methodology behind the 2024 quality ratings. Health plans that earned a rating of at least 3.5 stars have from June 26 to June 28 to submit revised plan bids if their ratings increased by a half star or more with the new calculations but must notify CMS of their intent by June 18. If a plan’s score is lower with the new recalculation, its quality bonus payments rating will not decrease (Fierce Healthcare, June 14; Inside Health Policy, June 13).

Federal Legislation

Bipartisan Prior Authorization Legislation for MA Plans Reintroduced

• On June 12, a bipartisan group of lawmakers in both chambers of Congress reintroduced legislation to streamline Medicare Advantage (MA) prior authorizations (PA) after a previous effort stalled in the Senate in 2022. The “Improving Seniors’ Timely Access to Care Act of 2024” aims to establish an electronic PA process and increase transparency about its use and requirements. Additionally, the bill would require MA plans to report their PA data to HHS, set time frames for requests, and waive or modify PA requirements for qualified providers and suppliers. The legislation is supported by 42 Senators, 130 House members, and more than 370 organizations including CVS Health, the American Medical Association, and the American Hospital Association. The bill would codify provisions from a final rule released earlier this year by CMS that streamlines the PA process in MA, CHIP, and Medicaid (Health Payer Specialist, June 14).

Federal Studies and Reports

CBO Releases Report on Hepatitis C Treatment Cost Savings

• One June 14, the Congressional Budget Office (CBO) released a report detailing the cost savings of expanding hepatitis C treatment, specifically for Medicaid enrollees. The report also discussed the importance of additional research on treatments and patient outreach and the increased costs associated with not treating the disease. However, advocates noted that the report did not include patients outside of the government program and were hopeful of including a larger population in future implementation and advocacy. The report underscored the importance of long-term budgetary assessments beyond the standard 10-year window given the slow progression of the disease. According to sources in the Senate, there may be new legislation forthcoming to expand access to hepatitis C treatment given the positive CBO report (Inside Health Policy, June 14).

State Updates

News

New York Governor Unveils New Maternal Healthcare Initiatives

• On June 10, Governor Kathy Hochul announced New York will fund Medicaid coverage for doula care and, effective January 1, 2025, will also provide an additional 20 hours of paid time off for expectant mothers, becoming the first state to do so. New York also plans to open a maternal health center in the Bronx. The administration believes these initiatives will aid in the reduction of infant and maternal mortality rates by lowering racial and economic gaps within maternal and childbirth outcomes (Newsweek, June 13).

Colorado Prescription Drug Affordability Board Votes Cosentyx as Unaffordable

• On June 14, Colorado’s Prescription Drug Affordability Board (PDAB) deemed Novartis’ Cosentyx unaffordable for residents, citing significant cost increases. The drug’s wholesale cost rose by 116.64% from 2015 to 2024, with an average annual cost of $44,963 for payers and around $3,297 in out-of-pocket costs for consumers. In total, payments for Cosentyx were over $66M across a variety of payers including private insurance and Medicaid. The PDAB reported that there were seven alternatives to Cosentyx. The PDAB report also included a statement from Novartis that claimed that many moderate and low-income patients do not pay any out-of-pocket costs. This comes as Colorado’s PDAB voted Stelara and Enbrel were unaffordable earlier this year (Inside Health Policy, June 14).

California Medicaid Providers Get Ballot Measure for Rate Increases

• Governor Gavin Newsom approved multiple tax increases last year to address budget shortfalls and increase Medicaid payments to doctors. However, many providers say that they haven’t seen rate increases due to the ongoing budget deficits. Recently, providers have qualified a ballot measure for November to secure mandated raises for treating Medicaid patients, bypassing legislative decisions. Budgeting in California often involves voter-approved measures, limiting lawmakers’ flexibility during economic downturns. As a result, there are ongoing discussions between the Newsom administration and providers to potentially withdraw the ballot measure by finding a legislative compromise on Medicaid rate increases (Associated Press, June 12).

SPA and Waiver Approvals

SPAs

• Eligibility SPAs
  • Wisconsin (WI-24-0007, effective January 1, 2024): Clarifies MAGI-based methodologies for monthly household income calculations will account for reasonably predictable increases and decreases in future income and family size.
• Payment SPAs
  • New York (NY-21-0045-A, effective July 1, 2021): Implements a 1% COLA for Inpatient Specialty Hospital rates.
  • Pennsylvania (PA-24-0001, effective April 1, 2024): Updates the alternative payment methodology for public FQHCs located in a city of the first class, which is a city with more than one million residents.
• Services SPAs
  • Minnesota (MN-24-0011, effective January 1, 2024): Expands coverage for prescription contraceptives from a three-month to up to a 12-month supply without prior authorization.
  • Mississippi (MS-24-0001, effective January 1, 2024): Updates the coverage and payment for End-Stage Renal Disease Services.

Private Sector Updates

News

Walgreens Health Chief Announces Plans to Work Closer with Payers

• During the AHIP conference in Las Vegas last week, Walgreens senior executive Mary Langowski announced plans for the company to continue to more closely collaborate with health payers. Langowski is a former CVS Health development officer and CEO at Solera Health, and joined Walgreens as their new Health Chief in March. In the past, Walgreens has had a hard time connecting retailers with medical providers, with their previous primary care venture with VillageMD taking a $1.7 billion loss last year, resulting in nearly 60 clinics (out of approximately 200) closing their doors. Langowski is hoping new collaborations that bring pharmacists who see patients frequently together with payers will result in improved health for patients (Health Payer Specialist, June 17).

Ascension Restores Access to Electronic Health Records, Patient Portals Following Cyberattack

• Ascension restored access to its electronic health records and patient portals on June 14, following a cyberattack on May 8. Though patients should have a more streamlined experience scheduling appointments and filling prescriptions, some information from medical records may be inaccessible until the system is completely updated. No information has been provided on what data was affected from the cyberattack, though there is an ongoing investigation (Modern Healthcare, June 14).

California Medicaid Plan Increases Reimbursement to Providers

• CalOptima, a county-run health plan in California, approved a $526.6M increase to its Medicaid providers in Orange County. Funds are set to be distributed from July 2024 to December 2026 to hospitals, community health clinics, safety-net providers, physicians, and behavioral health providers in Southern California. This increase aims to enhance financial stability in CalOptima’s managed care network given state budget deficits. Previously, the health plan offered temporary payments to support providers during the COVID-19 pandemic (Modern Healthcare, June 17).

Sellers Dorsey Updates

Sellers Dorsey Acquires HealthDataViz

• Sellers Dorsey is pleased to announce the acquisition of HealthDataViz, a data analytics and visualization firm that helps clients access and understand data to achieve better health, healthcare, and healthier communities. The acquisition expands the firm’s abilities to partner with clients on innovative solutions based on data that can drive positive health outcomes. Click here to learn more!