Sellers Dorsey Digest

Federal Updates

News

Novavax Receives FDA Emergency Use Approval for Protein-based COVID-19 Vaccine

• On August 30, the FDA announced it has granted emergency use authorization of an updated Novavax COVID-19 vaccine for individuals 12 years of age and older that targets recent variants using a protein-based formula. This is the only non-mRNA vaccine option against COVID-19 available in the U.S. However, this vaccine targets a less recent variant compared to the mRNA vaccines from Pfizer and Moderna, which were approved on August 22. The CDC’s Advisory Committee on Immunization has officially recommended a booster shot given the significant summer wave of COVID-19 infections. The committee hopes that Novavax’s protein-based vaccine option will help bolster vaccination rates among individuals hesitant of mRNA vaccines (Inside Health Policy, August 30).

CMS Awards $100M to Navigators for Open Enrollment

• CMS announced awards for $100 million in grants to navigators to assist with the upcoming Marketplace Open Enrollment. CMS awarded grants to 44 organizations whose navigators provide assistance in finding health insurance coverage in states that utilize the Federally-facilitated Marketplace (FFM), Healthcare.gov. The 2024 Navigator cooperative agreement awards were awarded for a five-year period of performance, which runs from August 27, 2024, through August 26, 2029. The cooperative agreement award amounts listed below under each awardee cover the first 12-month budget period (August 27, 2024, to August 26, 2025) (CMS, September 3; Fierce Healthcare, August 30; Modern Healthcare, August 26).

CMS Set to Reinstate Mandatory Respiratory Illness Reporting Within Hospitals

• Beginning November 1, CMS is reinstating the COVID-19, influenza and respiratory syncytial virus data reporting as part of hospitals’ condition of participation (CoP). This decision follows the agency’s prior decision to suspend hospital data reporting requirements on May 1. The FY2025 Hospital Inpatient Prospective Payment System (IPPS), which was released on August 1, reiterates the need for this type of reporting to obtain vital information on a local, regional and national level, and how it could potentially cause implications within the realm of patient care and public health mitigation. Patient advocacy groups like the American Hospital Association (AHA) believe that the mandatory reinstatement is inconsistent with the purpose of CoPs. The AHA approved of CMS’ prior decision to suspend these requirements as hospitals continue to deal with staffing shortages and financial pressures. The AHA is pushing for a voluntary reporting system that would utilize the pre-existing National Health Care Safety Network (NHSN) platform, with streamlined reporting fields (Inside Health Policy, August 26).

CMS Publishes Latest Enrollment Numbers for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP)

• On August 30, CMS released the most recent enrollment numbers for Medicare, Medicaid, and CHIP. As of May 2024, enrollment in Medicare increased by 122,882 since the last report to 67.41 million. Medicaid/CHIP enrollment decreased by 840,795 for a total of 80.85 million enrollees. Of the 80.85 million individuals, 7.06 million are enrolled in CHIP. There are also more than eight million individuals that are full-benefit dually eligible for Medicare and Medicaid and are counted in both program totals (Medicaid.gov, August 30).

Federal Infectious Disease Requirements in Nursing Homes Need Additional Reform Says the Association for Professionals in Infection Control and Epidemiology (APIC)

• APIC stakeholders believe that until the Office of the Inspector General (OIG) requires a full-time infection preventionist in nursing homes, along with other changes, infection control reforms will not be successful at getting nearly 25% of nursing homes into compliance with federal requirements. The OIG report studied 100 for-profit nursing homes in 31 states between July 1, 2021, through June 30, 2022. 76 of these facilities complied with federal regulations, but 17 facilities did not have an infection preventionist with specialized training and seven facilities did not have a preventionist designated at all. The American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL) believe that the OIG report is inaccurate because CMS data shows that less than 2% of providers have been cited for infection preventionist issues since 2021. While APIC supports the two recommendations given by OIG to have CMS follow-up with nursing homes that might be out of compliance to ensure corrective actions and to require state survey agencies to focus on preventionist training, APIC believes additional measures need to be taken to ensure compliance (Inside Health Policy, August 27).

Federal Litigation

HHS Withdraws Their Appeal on AHA Third-Party Tracking Case

• On August 29, the HHS withdrew its appeal to overturn a ruling from June that determined HHS overstepped its authority when it prevented providers from using certain third-party tracking technologies. on hospital websites. The HHS had originally filed an appeal notice on August 19 with the U.S. Fifth Circuit Court of Appeals, which was withdrawn only 10 days after with consent from AHA (Modern Healthcare, August 29; Fierce Healthcare, August 29).

State Updates

News

Michigan Payer to Offer Free Virtual Health Visits for Uninsured Through End of 2024

• Uninsured people in Michigan will have access to free virtual health visits until the end of the year through Priority Health. The health payer has partnered with Curai Health, a telehealth provider, to deliver these services. However, the virtual visits do not include the cost of any prescribed medications or other recommended care. There are estimated to be 400,000 people in Michigan without health insurance, and Priority Health aims to increase access to care for this population with this initiative. Priority Health does not intend to continue free virtual visits into 2025 but does plan to analyze the results of the initiative for future telehealth investments (Health Payer Specialist, August 30).

Blue Cross Blue Shield of Minnesota and Blue Shield of California Agree to Settlement of Fines for Sleep Disorder Treatment and Contraceptive Coverage Denials

• The California Department of Managed Care recently levied a fine of approximately $228,000 on Blue Shield of California for incorrectly charging enrollees for contraceptive coverage services. Additionally, the Minnesota Department of Commerce fined Blue Cross Blue Shield of Minnesota $83,890 for inaccurately denying coverage for approximately 8,389 claims regarding medical equipment and related supplies for treatment of sleep disorders. Both plans opted to pay the fine to resolve the issues, and no corrective actions were agreed to as part of the settlement (Health Payer Specialist, August 30).

SPA and Waiver Approvals

Waivers

• 1115(a)
  • Tennessee
    • On August 21, 2024, Tennessee submitted a request to amend its 1115 demonstration titled, “TennCare III.” The proposed amendment would extend TennCare coverage to additional working individuals with disabilities and would be called the Work Incentives Group. Individuals who are newly qualifying for coverage under this amendment would be subject to premiums. Tennessee aims to remove barriers to employment for individuals with disabilities who would otherwise be eligible for coverage under the demonstration if not for their income and resources. The federal public comment period is open from August 28 through September 28.

SPAs

• Payment SPAs
  • Colorado (CO-24-0018, effective July 1, 2024): Authorizes a 2% rate increase for inpatient hospital services.
  • Connecticut (CT-23-0018, effective September 1, 2023): Adds select evaluation and management services to the dental fee schedule for adults and children.
  • Connecticut (CT-23-0023, effective October 1, 2023): Increases the Community First Choice attendant care per diem and overnight rates to align with increases in state minimum wage and increases rates for home delivered meals by 12.5%.
  • Indiana (IN-24-0004, effective December 1, 2024): Updates payment methodologies for the 1915(i) HCBS Community Mental Health Wraparound service benefit for children with mental illnesses.
  • Indiana (IN-24-0005, effective April 1, 2024): Revises Medicaid reimbursement for physician services to align with the Medicare physician fee schedule.
  • Kentucky (KY-24-0011, effective July 1, 2024): Grants an extension for an exception to establish a recovery audit contractor through June 30, 2026.
  • New Hampshire (NH-24-0033, effective July 1, 2024): Indicates the state’s compliance with third-party liability requirements under the Consolidated Appropriations Act of 2022.
  • South Carolina (SC-24-0016, effective July 1, 2024): Aligns the South Carolina Medicaid State Plan with the Third-Party Liability federal requirements.
  • Texas (TX-24-0022, effective May 1, 2024): Updates the physicians’ and other practitioners’ program fee schedules.
  • Washington (WA-24-0031, effective July 1, 2024): Decreases the sole community hospital rate multiplier to 1.25, from the previous 1.50.
  • Washington (WA-24-0032, effective July 1, 2024): Updates GME payments for state universities with Level 1 trauma centers, clarifies Certified Public Expenditures and supplemental trauma payments, and removes outdated DRG payment information.
• Services SPAs
  • Idaho (ID-24-0002, effective July 1, 2024): Adds the following services to the Alternative Benefit Plan: Assertive Community Treatment (ACT), Parenting with Love and Limits (PLL), and Inpatient Psychiatric Services for Individuals under Age 21 in Psychiatric Facilities or Programs.
  • Kansas (KS-24-0014, effective July 1, 2024): Expands dental services to cover Medicaid beneficiaries age 20 and older.
  • Mississippi (MS-24-0006, effective July 1, 2024): Allows coverage of home health services provided by a licensed practical nurse under the supervision of a registered nurse.
  • Oregon (OR-24-0017, effective July 1, 2024): Authorizes the coverage of drug imports in the case of inadequate supply of fully FDA-approved, non-imported drugs in the event of a recognized critical drug shortage.

Private Sector Updates

News

Elevance Enters the ACA Marketplace in Three New States

• On September 4, Elevance Health announced its Wellpoint subsidiary will enter the ACA marketplace in Florida, Maryland, and Texas in 2025. This will be the first individual ACA marketplace plans offered by Elevance in these three states. Plans will be sold in 24 of the 67 counties and 24 of the 254 counties in Florida and Texas, respectively. They have not specified where Wellpoint will sell plans in Maryland yet (Health Payer Specialist, September 4).

Centene Faces Challenges with Increased Medicaid Utilization and Costs

• Centene’s medical loss ratio has continued to rise this year and could reach 93.2% in the third quarter from the current 91.6%. This increase is driven by the demographics of the unwinding process and Medicaid redeterminations over the last 18 months. Centene is the nation’s largest Medicaid managed care provider, with programs reaching across 31 states with over 13 million members. While approximately 30% of the members who initially lost eligibility due to administrative glitches are now being provided coverage, the period of time the individuals were without coverage meant lost premium revenue for Centene. To cut costs, Centene is looking at restricting private duty nursing hours and details of state contracts with pharmacy benefit managers (Health Payer Specialist, September 4).

Financial Challenges of Remote Patient Monitoring in Health Systems

• Health systems are increasingly integrating remote patient monitoring to expand access to care and improve outcomes for patients. However, there are challenges in achieving a return on investment (ROI) due to reimbursement uncertainty from both commercial payers and CMS. The upfront costs for these monitoring programs are substantial, impacting financial viability and necessitating a large patient base to achieve any ROI. These financial challenges often contribute to health systems partnering with a vendor to achieve remote monitoring. However, many vendors specialize in specific chronic diseases which limits the number of patients served. Some large health systems like Mayo Clinic opt for in-house programs to focus on quality and engagement despite costs (Modern Healthcare, August 30).

Sellers Dorsey Updates

Sellers Dorsey Welcomes Marko Mijic as Managing Director

• Sellers Dorsey is pleased to welcome Marko Mijic as a Managing Director in the Firm’s California practice to lead expansion of our consulting services. Marko joins the Firm with an impressive background in public service and a proven track record in health and human services. Most recently, Marko served as Undersecretary at the California Health and Human Services Agency. Click here to learn more about Marko and his new role at the Firm.