Sellers Dorsey Digest

Federal Updates

News

Congressional Debates Could Derail Healthcare Spending Agenda

• Congressional lawmakers must pass another round of government funding before the start of the new fiscal year on October 1. House Republicans have released their proposal for a short-term continuing resolution to extend government funding for six months after October 1. This version includes provisions from the SAVE Act related to voting in federal elections. This proposal is unlikely to move forward due to disagreements with the SAVE Act provisions and the timeline for funding with House Democrats as well as the Senate. Many healthcare issues are highly expected to be addressed in an end-of-year package (Modern Healthcare, September 9; Politico Pro, September 10).

AMA Continues to Express its Opposition to MIPS Quality Measures

• In a September 5 letter to CMS regarding the 2025 Medicare physician pay rule, the American Medical Association (AMA) reiterated that the new quality measures are time consuming, costly, and are failing to properly reflect care provided to patients. AMA’s CEO, James Madera, spoke about how participating physicians can have their Medicare payments cut down by upwards of -9% and how the system unfairly punishes small, rural, and independent practices, adding to the existing health inequities. The AMA is urging CMS to retire the voluntary MIPS reporting program that runs until 2027 or instead make it mandatory and focus on the implementation of conditions-based reporting measures. The organization also hopes for Congress to pass the Data-Driven Performance Payment System (DPPS), which would replace MIPS (Inside Health Policy, September 5).

Eligibility Systems Overseen by Deloitte Continue to Cause Delays and Enrollment Issues While Costing States Millions

• In January, the National Law Health Program (NLHP) urged the Federal Trade Commission (FTC) to investigate Deloitte for “ongoing and nationwide errors and unfair and deceptive trade practices.” Since then, it has been found that the Deloitte-operated eligibility systems often experience errors that take years, and hundreds of millions of dollars, to update. Many of the states that Deloitte contracts with also use the systems to assess eligibility for other safety-net programs, including food benefits. Currently, Deloitte has contracts with 25 states to operate eligibility systems. These contracts are worth approximately $6 billion and cover 53 million enrollees. While Deloitte has stated that the allegations are “without merit,” many states, including Georgia and Tennessee, are awaiting fixes to the system while others are turning to the courts for assistance (KFF Health News, September 5).

Federal Regulation and Guidance

CMS Publishes New Templates, Instructional Guides for State Agencies to Confirm Compliance with Recently Finalized Mental Health Parity and Addiction Equity Act Requirements

• On September 9, CMS released an updated set of templates and instructional guides for state agencies to utilize when documenting mental health and substance use disorder (SUD) benefits in managed care programs, Medicaid alternative benefit plans (ABPs), and/or CHIP. The information is expected to regulate, simplify, and improve processes for states. CMS also informally requested comment to consider prior to finalizing these tools and will seek approval from the Office of Information and Regulatory Affairs in accordance with the Paperwork Reduction Act before delivering them for use (Medicaid.gov, September 9).

Final Rule Released for the Mental Health Parity and Addiction Equity Act

• On September 9, the U.S. Departments of Health and Human Services, Labor, and the Treasury released a new final rule implementing the Mental Health Parity and Addiction Equity Act (MHPAEA). The final rule amends certain provisions of the existing MHPAEA regulations and adds new regulations. Insurers must now evaluate and revise their non-quantitative treatment limitations (NQTL), including adequacy of provider networks, reimbursement for out-of-network providers and frequency of prior authorizations, to ensure compliance. The final rule closes a loophole that exempted state and local health plans from MHPAEA, which will extend the law’s protections to approximately 120,000 more individuals. The final rule reflects and addresses thousands of comments received from the public comment period on the proposed rules that were published on August 3, 2023 (Inside Health Policy, Fact Sheet, September 9).

State Updates

News

Arizona Decides to Not Rebid Long Term Care Contract Award

• Following the request to rebid last week, Arizona has indicated it will not redo a $1.6 billion request for proposals. Leadership at the Arizona Health Care Cost Containment System (AHCCCS) has previously declined the appeal of three payers who were seeking to redo the process for the Arizona Long Term Care System contract. Last month, administrative court judge Sondra Vanella determined that the initial process used to score responses to the RFP was inconsistent and should be restarted. This gave AHCCCS a 30-day window to decide whether to restart the process since the administrative court judge’s determination is only a recommendation for the AHCCCS. The AHCCCS determined that the appealing payers failed to timely file appeals and that the agency has followed the law, and therefore, the bid process would not be restarted (Health Payer Specialist, September 9).

Washington State Medicaid Funding to Support Homelessness Struggles to Meet Need

• Washington was among the original states that began to utilize Medicaid to pay for homelessness services in 2018, a decision tied to the notion that addressing housing inequalities would create a cost-effective way to increase quality of life and improve health. Homeless service providers received less funding than expected and were cut off due to the Health Care Authority’s budget cap and projections to exceed the 2024 budget, with 14,000 people enrolled currently. The agency says it expects additional funding, but nonprofit organizations are now unsure on whether they can rely on these funds going forward. The state made the move to pause enrollments in the program in April due to the “unprecedented increase in new enrollments” in 2023 that caused them to reach their budget limit. The decision was soon reversed, with providers receiving news about the program re-opening this month and enrolling those on the waitlist. The Health Care Authority is requesting additional funds from the legislature and federal government moving forward (Seattle Times, September 9).

EMS Leaders in New York Encourage Governor Hochul to Enact Senate Bill Related to Medicaid Reimbursement for Ambulance Services

• On September 6, EMS leaders and stakeholders gathered in New York’s Columbia County to advocate for SBS8486C, a Senate bill unanimously passed by the Senate and Assembly, that would allow Medicaid reimbursement for treatment in place and transportation to alternative healthcare settings by ambulance service providers. Bill sponsors, Senator Michelle Hinchley and Assemblywoman Anna Kelles, are encouraging Governor Hochul to sign the bill into law by September 30 so it can go into effect this year. Should Governor Hochul sign the bill after September 30, it will not be effective until October 1, 2025 (Times Union, September 9).

SPA and Waiver Approvals

SPAs

• Administrative SPAs
  • Mississippi (MS-24-0013, effective July 1, 2024): Approves the Division of Medicaid’s request for an exemption to contract with an Recovery Audit Contractor (RAC).
• Payment SPAs
  • Arizona (AZ-23-0014, effective September 30, 2023): Updates the FY2024 payment methodology for General Fund GME, for new programs and expanded positions on or after July 1, 2020.
  • Arkansas (AR-24-0012, effective October 1, 2024): Implements a hospital cost settlement reopening process to make sure federal claiming standards align with Medicare rules and timelines.
  • Colorado (CO-24-0020, effective July 1, 2024): Increases per diem rate reimbursements for Specialty-Acute and Rehabilitation hospitals by 2%.
  • Colorado (CO-24-0016, effective July 1, 2024): Implements an across-the-board rate increase of 2.0% for certain services, targeted rate increases and rate rebalances for certain services.
  • Colorado (CO-24-0017, effective July 1, 2024): Increases per diem rate reimbursements for outpatient hospital services by 2.0%.
  • Connecticut (CT-23-0022, effective October 1, 2023): Updates fee schedules for physician and outpatient and behavioral health clinics and adds Beyfortus RSV vaccines to the fee schedules.
  • Kansas (KS-24-0018, effective August 1, 2024): Increases physician provider reimbursement rates.
  • Kentucky (KY-24-0013, effective January 1, 2025): Updates the payment methodology for Class I through III emergency transportation providers and sets the interim emergent rate to $453.16.
  • Maine (ME-16-0010, effective July 1, 2016): Increases rates for certain rehabilitative services.
  • Maine (ME-16-0012, effective July 1, 2016): Updates the payment methodology for personal care services provided by Private Non-Medical Institutions Appendix C facilities.
  • Maine (ME-17-0013, effective July 1, 2017): Updates payment methodology for personal care services provided by Adult Family Care Homes.
  • Maryland (MD-24-0014, effective July 1, 2024): Provides a 3.0% rate increase for the Home Health Program.
  • Massachusetts (MA-24-0008, effective March 1, 2024): Updates the payment methodology for Targeted Case Management for individuals eligible for Department of Children and Families services.
  • Minnesota (MN-24-0024, effective July 1, 2024): Provides for a 3.0% rate increase for partial hospitalization services.
  • Montana (MT-24-0016, effective July 1, 2024): Adds Pediatric Complex Care Assistant Services (PCCAS) as a licensed practitioner service and establishes a payment methodology for the service class.
  • Montana (MT-24-0018, effective July 1, 2024): Removes certain per diem rates for Comprehensive Behavioral Health Treatment (CBHT) services.
  • Nebraska (NE-24-0018-A, effective May 1, 2024): Discontinues the assessment of copayments for certain services.
  • New Hampshire (NH-24-0027, effective July 1, 2024): Updates the manually priced rate methodology for dental services.
  • New Hampshire (NH-24-0030, effective July 1, 2024): Updates the payment methodology for 1915(i) Supportive Housing services.
  • New York (NY-23-0014, effective March 1, 2023): Provides a temporary rate adjustment for hospitals undergoing a closure, merger, consolidation, acquisition or restructuring process, such as that of the VAP Rutland Nursing Home and Schulman and Schachne Institute.
  • New York (NY-23-0025, effective January 1, 2023): Updates minimum wage amount for nursing home workers to align with the state authorized minimum wage of $15.
  • New York (NY-24-0043, effective April 1, 2024): Freezes the case mix adjustment component of the nursing home daily rate to allow for updates in Patient Driven Payment Model (PDPM) methodology.
  • Virginia (VA-24-0015, effective July 1, 2024): Updates the payment methodology for EPSDT Therapeutic Group Homes.
• Services SPAs
  • Hawaii (HI-24-0010, effective July 1, 2024): Adds a general definition and eligible services of an Advance Practice Registered Nurse to align with those identified under Medicare.
  • Kansas (KS-024-0015, effective July 1, 2024): Adds adult dental coverage to the Working ABP population, following expansion in dental services in the state’s Medicaid plan.
  • Kansas (KS-24-0016, effective July 1, 2024): Adds adult dental benefits to the STEPS ABP population, following expansion in dental services in the state’s Medicaid plan.
  • Maine (ME-16-0008, effective May 10, 2016): Adds mental health clubhouse services and specialized group services in the state’s Medicaid plan.

Private Sector Updates

News

Insurers Launch Innovative Plans and Care Programs for Special Needs, Kidney Disease, and Diabetes

• Four payers recently established provider partnerships or rolled out new plans to help beneficiaries with specialized and cost-effective care. Health Care Service Corporation (HCSC) designed a new health plan that encourages enrollees to utilize positively-rated, cost-effective providers in exchange for not having to pay a deductible or coinsurance. Additionally, Gold Kidney Health Plan, in partnership with Cleveland Clinic, expanded its provider and facility network to offer more options to members with chronic special needs. Humana has also introduced a new program for individuals with chronic or end-stage kidney disease and has selected Evergreen Nephrology as a partner to increase quality of care and health results. Lastly, Banner|Aetna, deployed a diabetes reversal program in a joint venture with Virta Health (Health Payer Specialist, September 6).

Sellers Dorsey Updates

Meet Our Team: Q&A with Managing Director for Data Analytics and Visualization, Kathy Rowell

• Managing Director for Data Analytics and Visualization, Kathy Rowell, cofounder of HealthDataViz, a Sellers Dorsey Solution, helps lead the Firm’s efforts to support healthcare quality and access through robust data analysis and visualization. We recently sat down with Kathy to talk about her experience, the work she does, and the role data analysis and visualization plays in advancing the healthcare space. Click here to explore our Q&A with Kathy!