Sellers Dorsey Digest

Federal Updates

News

Following Up on Issues with Medicare Advantage (MA) Plan Star Ratings, CMS Releases Updated Scores

• On July 2, CMS released updated star ratings for the Medicare Advantage (MA) plans. The revisions follow two court rulings finding the agency’s computation methods confusing and unfair to payers. The new star rankings have identified seven more MA plans with a five-star rating, increasing the number of plans to 38 from the previous 31. SCAN Health, Elevance Health, and Cigna are among the companies that had their scores recalculated and will be awarded bonuses based on their improved ratings (Health Payer Specialist, July 3; CMS, July 2).

Congress Grapples with Moving Forward Post-Chevron Overturn

• Following the U.S. Supreme Court’s decision overturning Chevron agency deference principles in the case of Loper Bright Enterprises v. Raimondo and Relentless, Inc. v. Department of Commerce on June 28, some lawmakers are suggesting Congress should begin writing more prescriptive laws and increase their regulatory oversight of federal agencies. The Government Accountability Office (GAO) has also presented ideas to address the new regulatory landscape, such as changing the rulemaking process to require agencies to publish information about the writing of rules published in the Federal Register and requiring agencies to conduct retrospective reviews of substantial rules. The GAO is also floating the idea of lawmakers establishing a new regulatory agency to help implement new bills should and oversee agencies’ regulatory actions (Inside Health Policy, July 5).

Health Insurance Companies Concerned About Potential Burden of Gene Therapies on Risk-Adjustment System

• CMS plans to reveal amounts that insurance companies owe or will receive based on the revised risk-adjustment system later in July. While CMS initially updated the system to account for higher cost members, insurers are concerned that new, costly gene therapies will negatively impact the system even with these adjustments. Providers have expressed concern that because of the cost of the new treatments, insurers might react by reducing services and other benefits and decreasing the size of provider networks (Modern Healthcare, July 5).

Federal Litigation

Federal Court Grants Stay for Gender Non-Discrimination Rule in 15 States

• Following lawsuits filed by 15 states to halt implementation of a rule interpreting Section 1557 of the Affordable Care Act (ACA) that prohibits discrimination in medical coverage and treatment on the basis of gender identity, a federal district court in Mississippi granted a nationwide preliminary injunction and stay two days before the rule was set to go into effect. The states that filed the lawsuits argue that because the rule does not define sex, HHS cannot say what is meant by discrimination on the basis of sex. The District Court Judge, Louis Guirola Jr, based his decision on the likely compliance costs and federal funding losses states would face and burden on providers if the rule was to go into effect. LGBTQ+ advocates note the devastating effects the stay can have on the population, as this new rule would have aided in the protection of both equitable and nondiscriminatory standards of care (Modern Healthcare, July 3).

Federal Studies and Reports

Urban Institute Study Shows Fewer Adults Skipping Medical Care Because of Cost

• A new Urban Institute study found that fewer people delayed medical care in 2022 than in 2019-2021. Researchers concluded that the following outcomes are the result of the Medicaid continuous coverage requirements and enhanced tax credits.
  • 75 million non-elderly individuals neglected to receive necessary medical care in 2022, dropping from 12.1% in 2019 to 9.7%;
  • Adults below 138% of the federal poverty level (FPL) saw a 27% reduction in cost barriers, and
  • A 19% cost barrier reduction was seen for families between 138% and 249% FPL.

Over the same time period, the number of uninsured adults decreased to 12.4% from 14.5% and states that had Medicaid expansion saw the largest decline in uninsured adults (Fierce Healthcare, July 8).

State Updates

News

Doula Care Now Covered by Medicaid in Colorado for Pregnant and Postpartum Individuals

• Colorado joins 12 other states and the District of Columbia in covering doula care for all pregnant and postpartum individuals. The newly introduced benefit package includes 180 minutes of prenatal and postpartum doula care, in addition to birth assistance. The provision of doula services was driven, in part, by the 2023 Maternal Mortality Review Committee’s legislative report that found Black women in Colorado having approximately twice the rate of pregnancy-related deaths as their White counterparts. The committee subsequently proposed that pregnant and postpartum individuals have access to a broader selection of providers and support staff and that insurance should pay for such care (The Denver Post, July 8).

CMS Announces First States Awarded Participation in the AHEAD Model

• On July 3, CMS announced the first states to be awarded participation in the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. Connecticut, Maryland, and Vermont have been chosen, with Hawaii’s ability to participate pending satisfaction of certain requirements. CMS will issue Cooperative Agreements to these states, which will then receive up to $12 million during the first five and a half years of the model implementation. CMS and the awarded states will work to curb healthcare cost growth, improve population health, and advance health equity. Four additional states will receive Cooperative Agreements in the Fall, and states that are interested in applying must submit a Letter of Intent by July 16 (CMS, July 3).

SPA and Waiver Approvals

Waivers

• 1115
  • Utah
    • On June 25, Utah requested to amend its Medicaid Reform 1115 Demonstration to provide health-related social services to additional Medicaid-eligible groups and to change the eligibility age for fertility preservation treatment for individuals who have been diagnosed with cancer. The federal comment period is open from July 8, 2024, through August 7, 2024.

SPAs

• Eligibility SPAs
  • Nebraska (NE-24-00016, effective May 1, 2024): Updates premiums for beneficiaries enrolled in the Medicaid Insurance for Workers with Disabilities (MIWD) program, to a rate range of 1.5% to 7.5%, based on adjusted income in excess of 200% of the FPL.

• Service SPAs
  • Montana (MT-24-0012, effective July 1, 2024): Removes restrictions on porcelain or ceramic substrate crowns for individuals aged 21 and older and increases the monetary limit on dental services provided to this population.

Private Sector Updates

News

Hospital Gun Violence Research Grant Protocols to Potentially Become Universal

• New York-based Northwell Health would like to have its gun violence research grant protocol used in emergency departments become a model that spreads nationwide. The intent behind its protocol is not to control guns, but to control the public health threat that has seen firearms become the leading cause of death among children and teenagers. U.S. Surgeon General Vivek Murthy recently declared gun violence a public health crisis and is calling for more research and for hospitals to routinely discuss firearms safety with patients. Some hospitals, such as Northwell Health hospitals, have already established firearms safety protocol through a research grant that could transform into a universal screening practice (Modern Healthcare, July 8).

AMA Survey Finds Decline in Physician Burnout and Increased Levels in Job Satisfaction

• Based on an annual survey by the American Medical Association (AMA), the number of physicians exhibiting at least one symptom related to burnout has dropped below 50%. The AMA has reported a consistent decline in burnout within physicians, from 62.8% in 2021, 53% in 2022, and 48.2% as of the recent 2023 study. The survey polled approximately 12,400 physicians on factors such as job stress, self-value within the institution, and job satisfaction, for which the results were an increase from 68% in 2022 to 72.1% in 2023 for job satisfaction, and an increase from 46.3% in 2022 to 50.4% in 2023 for feeling valued within their institution (Fierce Healthcare, July 9).

Sellers Dorsey Updates

5 Considerations for MCOs to Successfully Navigate the Medicaid Managed Care Rule

What do managed care organizations (MCOs) need to consider to successfully navigate and comply with CMS’ new Medicaid managed care rule? Sellers Dorsey Managing Director, Karen Brach, answers this question and more in her article with Healthcare NOW Radio. Discover the top five considerations for MCOs and what they can do to navigate the new rule.

Click here to explore Karen’s article.