Issue #132

Featured Content

No Surprises Act

• According to a survey released by the Urban Institute, the No Surprises Act (NSA) has been effective in curtailing balance bills for patients, but payers and providers are still experiencing some issues related to liability. The Urban Institute interviewed dozens of state and federal regulators, payers, providers, consumers, medical billing companies, and others. There have been limited disputes over the interpretation and enforcement of the NSA, but payers and providers alike remain concerned about coverage gaps and whether the NSA will restrict the growth in premiums and foster expansive provider networks (Health Payer Specialist, April 24).

Food Bank Demand Increasing

• U.S. food banks are straining to meet spiking demands as high food costs and decreasing federal benefits are causing more Americans to depend on free groceries. Food banks in Atlanta, New Jersey, Ohio, California, and Washington state report that demands are rising due to inflation and the end of a temporary expansion of federal food assistance benefits that kept millions of Americans out of poverty during the first two years of the COVID-19 pandemic. According to various food banks across the nation, demand is up between 46 and 125% since Spring 2022. Additionally, Congress is considering cuts to food assistance as a method to decrease federal spending while lawmakers debate whether to raise the country’s borrowing limit. A proposal on the debt issue released on April 19 included an expansion of work requirements for the Supplemental Nutrition Assistance Program (SNAP), which is the largest federal food aid program in the country (Reuters, April 21).

News

• The CEOs of the top three insulin makers (Eli Lily, Novo Nordisk, and Sanofi) and executives of the top three payer-owned pharmacy benefit managers/PBMs (CVS Health/Aetna, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx) are headed to Capitol Hill next month to testify before the Senate Health Committee on how to lower prices on drugs used to treat diabetes, particularly insulin. The three PBMs control 80% of the industry: The largest PBM in the U.S. is CVS Caremark, with 34% of total adjusted prescription claims managed in 2020, while Cigna’s Express Scripts has a 24% market share, and UnitedHealth Group’s OptumRx has a 21% national market share (Health Payer Specialist, April 24).
• CMS Principal Deputy Administrator and Chief Operating Officer Jonathan Blum was interviewed by Modern Healthcare during the 2023 Healthcare Information and Management Systems Society (HIMSS) conference. Blum discussed his top priorities of making state Medicaid programs stronger, increasing oversight of Medicaid Advantage programs, and boosting health equity efforts. Blum stated that Medicaid redeterminations will ultimately strengthen the public benefits program since states have invested in technology and eligibility systems. At the federal level, CMS has fine-tuned Healthcare.gov to automatically populate users’ information from their Medicaid file to an exchange application. Blum believes that by better connecting technology systems between Medicaid and exchange plans, there is hope to avoid consumer gaps in coverage moving forward (Modern Healthcare, April 21).

Federal Regulation

• On April 24, HHS released a notice of proposed rulemaking (NPRM) that would expand access to health care by reducing barriers for Deferred Action for Childhood Arrivals (DACA) recipients. If finalized, the proposed rule would remove the current exclusion that treats DACA recipients differently from other individuals with deferred action who would otherwise be eligible for coverage under select CMS programs. If the proposed rule is finalized as is, it could lead to 129,000 previously uninsured DACA recipients receiving health care coverage. The proposed change applies to the Health Insurance Marketplaces, the Basic Health Program, and some Medicaid and Children’s Health Insurance Programs (CHIP). If the proposed rule is finalized, DACA recipients would qualify for a special enrollment period to select a qualified health plan through a Marketplace during the 60 days following the effective date of the rule. The NPRM has a proposed effective date for all provisions of November 1, 2023. CMS is requesting public comment on the NPRM and on the feasibility of the effective date (HHS, April 24).
• On April 20, the White House Office of Management and Budget (OMB) began evaluating a proposed rule that addresses short-term health plans that are not required to comply with the Affordable Care Act’s (ACA) consumer protections. These plans, called short-term, limited duration (STLD) plans are less expensive than the comprehensive plans but are able to deny coverage, charge sick people more for benefits, are not required to cover essential health benefits, can set cost limits, and can rescind policies previously in place. Stakeholders want the longer duration allowed under the Trump administration to be thrown out and return to the time limit of three months allowed under the Obama administration. The proposed rule has been on the table since Spring 2021 and is designed to ensure that STLD plans do not undermine the ACA consumer protections for individuals with preexisting conditions, health insurance exchanges, or individual, small group, and large group health insurance markets (Inside Health Policy, April 21).

Federal Legislation

• The Expanding Care in the Home Act, bipartisan legislation introduced last week, would expand access to and reimbursement for various home care services delivered to Medicare beneficiaries. The bill proposes a baseline of 12 hours per week of personal care services benefit in Medicare, which would help support a population of beneficiaries that do not qualify for Medicaid but are also unable to afford out-of-pocket home care. Reimbursement funds and policy adjustments would open the door for primary care house calls; increase access to home dialysis, in-home advanced diagnostic, in-home lab testing and home infusion services; and help support the development of additional home-based care workers. The proposed bill is being championed by Moving Health Home, an advocacy group composed of DaVita Kidney Care, Ascension, Amazon, Signify Health, Current Health, Intermountain Healthcare and at least 15 other stakeholder industry groups (Fierce Healthcare, April 24).

Federal Litigation

• On April 20, Judge Reed O’Connor, from the Texas district court, asked the Department of Justice (DOJ) to address and show evidence of its claim that 150 million people would lose preventative coverage unless a stay is issued of his recent decision to invalidate the ACA’s cost-free preventative care mandate. The information provided by the DOJ will be taken into consideration when the district court evaluates the DOJ’s request for emergency relief. Should Judge O’Connor decide to deny the DOJ’s request for emergency relief, the DOJ may request the Fifth Circuit Court of Appeals to impose a stay If the matter eventually ends up in the U.S. Supreme Court will likely not be heard on the merits until 2024 or later (Inside Health Policy, April 21).
• The U.S. Supreme Court issued an order on Friday that it is allowing the FDA’s approval and access of the abortion drug mifepristone to stay in effect, for now. The high court specifically suspended a district court ruling that aimed to restrict access to mifepristone, including via telehealth, and reverse the FDA’s approval of the generic version of the drug. The Supreme Court’s order allows mifepristone to stay on the market under the current prescribing and dispensing restrictions, while the Fifth Circuit Court of Appeals reconsiders the district court’s adverse ruling in the case, Alliance for Hippocratic Medicine v. FDA (Inside Health Policy, April 21; Modern Healthcare, April 21).

SPAs

• COVID-19 SPAs
  • Kentucky (KY-22-0014, effective March 11, 2021): Provides assurances that the state covers and reimburses COVID-19 vaccine administration, testing, and treatment as required under section 9811 of the American Rescue Plan (ARP).
  • Louisiana (LA-23-0015, effective March 24, 2020): Waives signature requirements for the dispensing of prescription drugs. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Michigan (MI-23-0007, effective January 1, 2023): Makes a temporary change to the rate setting methodology for nursing facilities which will increase the Variable Cost Component for the periods of October 1, 2022, through December 31, 2022, and January 1, 2023, through May 11, 2023. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Montana (MT-23-0014, effective March 1, 2020): Waives signature requirements for the dispensing of prescription drugs. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • New Mexico (NM-22-0017, effective March 11, 2021): Attests to the coverage and reimbursement for COVID-19 vaccines and vaccine administration and COVID-19 testing and treatments, including preventative therapies, in accordance with section 9811 of the American Rescue Plan (ARP).
  • Oregon (OR-23-0011, effective March 1, 2020): Waives signature requirements for the dispensing of prescription drugs. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
• Payment SPAs
  • Minnesota (MN-23-0001, effective January 1, 2023): Updates the state’s third-party liability obligations.
  • Mississippi (MS-23-0023, effective July 1, 2022): Allows the Division of Medicaid (DOM) to establish a Medicaid Supplemental Payment Program for emergency ambulance transportation providers.
  • New Hampshire (NH-23-0015, effective January 1, 2023): Increases the rates for Individual Service Options (ISO).
  • New Hampshire (NH-23-0017, effective January 1, 2023): Increases the rates for Medically Monitored Residential Withdrawal Management.
• Services SPAs
  • Alabama (AL-22-0009, effective October 1, 2022): Provides for the provision of services to identified recipients under age 21 to improve family functioning by clinically stabilizing the living arrangement, promoting reunification, or preventing the utilization of out-of-home therapeutic venues (i.e., psychiatric hospitals, psychiatric residential treatment facilities, or residential treatment services).
  • North Dakota (ND-23-0003, effective January 1, 2023): Updates the dental limits for examinations and prophylaxis for individuals over the age of twenty-one.
  • Oregon (OR-23-0007, effective January 1, 2023): Aligns the Health Evidence Review Commission (HERC) list and SPA with current law and clinical practice related to transplants. This SPA also streamlines processes and definitions, minimizing duplicative content.
• Eligibility SPAs
  • Wisconsin (WI-23-0007, effective January 1, 2023): Adjusts the home maintenance allowance for the elderly, blind and disabled population based on the cost of living adjustment (COLA) for year 2023.

News

• Nineteen states across the country are experimenting within their Medicaid programs to cover services addressing members’ social determinants of health. States are specifically adopting new flexibilities that allow Medicaid funds to be used to pay for rent, utilities, and other housing accommodations as well as cover nutrition counseling and education, clinically tailored meals, or pantry stocking (MSN, April 21).
• On April 20, the Texas House advanced House Bill 12 (125-11) that would allow mothers on Medicaid to stay covered for up to one year postpartum. Currently, Texas mothers covered by Medicaid lose coverage two months postpartum. During the 2021 legislative session, the House passed a similar bill, but the Senate reduced the coverage expansion from one year to six months. Texas is one of 11 states that does not offer a 12-month coverage policy for mothers postpartum. The bill needs a final vote of approval before heading to the Senate (KVUE, April 20).