Issue #133

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CMS Rules on Access to Care

• On May 3, CMS released two notices of proposed rulemaking (NPRMs): Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM). The NPRMs are intended to strengthen access and quality of care across Medicaid and CHIP. The proposed rules, if adopted, would standardize access to care for services provided through managed care and FFS. Some highlights from the proposed rules include:
  • Establishing national maximum standards for certain appointment wait times for Medicaid and CHIP managed care enrollees, and stronger state monitoring and reporting requirements related to access and network adequacy for Medicaid and CHIP managed care plans.
  • Requiring states to conduct independent secret shopper surveys of Medicaid and CHIP managed care plans to verify compliance with appointment wait time standards and to identify where online provider directories are inaccurate.
  • Creating new payment transparency requirements for states by requiring disclosure of provider payment rates in both fee-for-service and managed care, with the goal of greater insight into how Medicaid payment levels affect access to care.
  • Establishing additional transparency and interested party engagement requirements for setting Medicaid payment rates for HCBS, as well as a requirement that at least 80 percent of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for direct care workers (as opposed to administrative overhead or profit).
  • Creating timeliness-of-access measures for HCBS and strengthening necessary safeguards to ensure beneficiary health and welfare as well as promoting health equity.
  • Strengthening how states use state Medical Care Advisory Committees.
  • Requiring states to conduct enrollee experience surveys in Medicaid managed care annually for each managed care plan to gather input directly from enrollees.
  • Establishing a framework for states to implement a Medicaid or CHIP quality rating system, a “one-stop-shop” for enrollees to compare Medicaid and CHIP managed care plans based on quality of care, access to providers, covered benefits and drugs, cost, and other plan performance indicators (CMS, April 27).

Concern Over Work Requirements

• HHS has expressed significant concern over the House Republicans’ proposal to link Medicaid to work requirements. According to an analysis released by HHS, with supporting data from a Congressional Budget Office (CBO) letter, millions of people would lose their health insurance coverage should this proposal go through. The HHS report utilized data from CMS and focused on the impact in five of the most heavily populated states that have expanded Medicaid (California, Ohio, Pennsylvania, Illinois, and New York). The report found that up to 21 million Medicaid enrollees could lose coverage should work requirements be imposed in their current state, and the CBO letter supported that conclusion. In its letter, the CBO also noted that in Arkansas, the only state with work requirements, that neither employment nor the number of hours worked increased (Health Payer Specialist, May 1).

Federal Employee Vaccine Requirements Ending

• On May 1, the Biden administration announced they will end the COVID-19 vaccine requirements for federal employees, federal contractors, and international air travelers on May 11, the day that the COVID-19 public health emergency ends. Additionally, HHS and the Department of Homeland Security announced they will start the process to end their vaccination requirements for Head Start educators, CMS-certified healthcare facilities, and certain noncitizens at the land border (The White House, May 1).

News

• With the recent release of two new proposed rules by CMS, senior living organizations like the National Center for Assisted Living are praising the federal government for taking steps to ensure equitable access to home- and community-based services (HCBS) in the Medicaid program. The proposed rules would make some HCBS quality measures mandatory, as well as place new performance and reporting responsibilities on states and managed care plans. Senior living organizations, however, have noted that there are still concerns about inadequate provider reimbursement in the direct care labor market. (McKnight Senior Living, May 1)
• On April 28, the Food and Drug Administration (FDA) finalized its comprehensive guidance related to the development of nicotine replacement therapy (NRT) drug products. This guidance recommends abbreviated pathways for drug sponsors and establishes efficacy endpoints. The efficacy endpoints include the following: reduction in the urge to smoke, relief of cue-induced craving in former smokers, and relief of withdrawal symptoms that aren’t associated with attempts to stop smoking. The FDA’s guidance is meant to encourage further innovation in NRT drug development while providing clarity on development strategies. The final guidance also profiles the development of two new prospective treatment regimens – pretreatment before quit day and quitting by gradual reduction. It also considers the potential to combine more than one NRT drug (Inside Health Policy, April 28).

Federal Regulation

• On April 28, CMS released a proposed rule, Medicare Program: Extending the Medicare Diabetes Prevention Program’s (MDPP) Expanded Model Emergency Policy through CY 2023. At the start of the pandemic in 2020, CMS decided to suspend in-person delivery of MDPP services and offered alternatives for in-person weight measurement requirements such as using scales that transmit weights securely via wireless or cellular transmission or self-reported measurements. CMS wants to continue these flexibilities through December 31, 2023, and believes it could take at least six months to adequately prepare to resume in-person services (Inside Health Policy, April 28).

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).

COVID-19

• The White House’s ProjectNextGen could stimulate the creation of innovative vaccine technologies for other viruses, such as the flu, as well as combination vaccines for the flu and COVID-19. The initiative is meant to replicate the success of Operation Warp Speed, with less funding. The $5 billion would come from unexpended dollars appropriated for COVID-19 testing, personal protective equipment, and other COVID-19-related uses. House Republicans plan to take back all this funding as planned in the recently passed debt ceiling reduction bill. President Biden has stated that he will veto the House debt ceiling reduction bill should it come across his desk in its current form (Inside Health Policy, May 2).

Waivers

• 1915(c) Appendix K
  • District of Columbia
    • Allows for the staffing ratio for day programs to be temporarily adjusted to support community-based day services for Day Habilitation, Small Group Day Habilitation and Employment Readiness under the Individuals with Intellectual and Developmental Disabilities (IDD) and the Individual and Family Support (IFS) waivers through six months after the end of the public health emergency.
  • Nevada
    • Increases various rates for providers under the HCBS Waiver for Intellectual and Developmental Disabilities based on a rate study completed by a third-party vendor.

SPAs

• COVID-19 SPAs
  • Arkansas (AR-23-0008, effective May 12, 2023): Temporarily extends Behavioral Health Counseling Service payments originally approved in AR-22-0025.
  • Idaho (ID-23-0018, effective March 13, 2020): Modifies the processes for Idaho’s 1915(i) Serious Emotional Disturbance HCBS State plan benefit to allow the option to conduct evaluations, assessments, and person-centered service planning meetings virtually/remotely in lieu of face-to-face meetings, and add an electronic and fax authorization method of signing off on required documents. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Maryland (MD-23-0007, effective May 12, 2023): Continues a premium resumption delay for the following group from the day after the end of the federal PHE through December 31, 2023: Employed Individuals With Disabilities (§1902(a)(10)(A)(ii)(XV) TWWIIA Basic group) and a premium resumption delay for the following group from the day after the end of the PHE through April 30, 2024: Maryland Children’s Health Program (MCHP) (§1902(a)(10)(A)(ii)(XIV) targeted low-income children).
  • Massachusetts (MA-23-0024, 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 Hampshire (NH-23-0026, effective July 1, 2021): Shifts non–state government owned nursing facilities in Hillsborough County from Proportionate Share Incentive Adjustment 1 (which uses a resource utilization group–based methodology) to Proportionate Share Incentive Adjustment 2 (which uses a cost-based methodology) for payment purposes. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Ohio (OH-23-0009, 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.
  • Texas (TX-23-0010, 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.
  • Texas (TX-23-0002, effective March 1, 2022): Amends the methodology for retention payments to providers delivering HCBS attendant and nursing services through the provider agency and consumer directed services option in the following state plan services: Community Attendant Services program; Primary Home Care program; day activity and health services; Community first choice (CFC) personal assistance services and CFC habilitation services; 1915(i) Home and Community-Based Services–Adult Mental Health Program; and personal care services. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Vermont (VT-23-0013, effective March 11, 2021): Implements mandatory coverage and reimbursement of COVID-19 vaccines and administration, testing, and treatment benefits as required by section 9811 of the American Rescue Plan Act.
  • West Virginia (WV-23-0004, 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.
  • West Virginia (WV-23-0006, effective July 1, 2022): Increases rates for certain Home- and Community-Based Services. This SPA increases rates for personal care services and behavioral health services by 70% for the period ending March 31, 2023.
  • Wyoming (WY-23-0006, 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.
• Eligibility SPAs
  • Kentucky (KY-23-0004, effective January 1, 2023): Adopts changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
  • Virginia (VA-23-0004, effective January 1, 2023): Disregards certain resources for various eligibility groups covered under the state plan.
  • New Hampshire (NH-23-0030, effective January 1, 2023): Updates the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
• Payment SPAs
  • Arizona (AZ-22-0011, effective September 30, 2022): Provides state fiscal year 2023 Graduate Medical Education payment pools for new programs or expanded positions that began on or after July 1, 2020.
  • Arizona (AZ-23-0002, effective January 1, 2023): Updates nursing facility rates.
  • Colorado (CO-22-0017, effective July 1, 2022): Implements supplemental payments to nursing facilities based on discharges and staff wages.
  • Florida (FL-22-0002, effective January 1, 2022): Updates physician-administered drug reimbursement, over-the-counter drug coverage, and current age restrictions on existing vaccination language that includes coverage of certain vaccines to individuals that reside in institutions.
  • Florida (FL-22-0011, effective July 1, 2022): Updates language regarding payments within the outpatient hospital reimbursement methodology.
  • Illinois (IL-22-0024, effective July 1, 2022): Establishes outpatient hospital reimbursement rates for medical forensic examinations.
  • Iowa (IA-23-0002, effective January 1, 2023): Implements an inpatient hospital psychiatric intensive care per diem rate.
  • Michigan (MI-23-0009, effective May 12, 2023): Updates payment rates for Home Help and Personal Care services.
  • Minnesota (MN-23-0007, effective July 1, 2023): Updates the rates for Intensive Behavioral Health Services.
  • Missouri (MO-23-0001, effective February 1, 2023): Adds a value-based supplemental payment for Home and Community Based Personal Care Providers.
  • Montana (MT-23-0003, effective April 1, 2023): Updates the date of the fee schedule for state plan services on the Introduction Page.
  • Nebraska (NE-23-0003, effective January 1, 2023): Implements a provider rate increase for basic Personal Assistance Services.
  • Virginia (VA-23-0002, effective January 1, 2023): Updates sections of the state plan that pertain to the Program of All-Inclusive Care for the Elderly (PACE).
• Services SPAs
  • Colorado (CO-22-0039-A, effective July 1, 2022): Sets coverage limits for long-term and acute home health.
  • Illinois (IL-23-0006, effective January 1, 2023): Allows pharmacists to provide patient care services related to HIV pre-exposure prophylaxis and HIV post-exposure prophylaxis.
  • Kansas (KS-23-0013, effective January 25, 2023): Removes outdated language regarding the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver from the Medication Assisted Treatment provider qualifications.
  • New Jersey (NJ-23-0003, effective January 1, 2023): Expands the criteria for allowable providers of Developmental, Individual Differences, and Relationship-based (DIR)/Autism Services.
  • New York (NY-21-0067, effective May 12, 2023): Allows the remote delivery of Crisis Services for Individuals with Intellectual and/or Developmental Disabilities (CSIDD) through telephonic or other technology in accordance with State, Federal, and Health Insurance Portability and Accountability Act (HIPAA) requirements. Other technology means any two­ way, real-time communication technology that meets HIPAA requirements.

News

• Starting May 1, the Commonwealth of Virginia will start processing Medicaid disenrollments as part of the nationwide ongoing “Medicaid unwinding” process. An estimated 400,000 Virginia residents are expected to lose their Medicaid coverage during the unwinding process (MSN, April 30).
• Three abortion providers in Montana are suing the state over the new rule that restricts the coverage of abortion while on Medicaid. The new rule took effect on May 1, and providers are asking the Lewis and Clark District Court to temporarily suspend the rule before access is restricted. The (as set forth in the notice of public hearing) adds new requirements for individuals seeking pregnancy termination through Medicaid coverage, including proof that they have a physical illness that would be exacerbated by pregnancy and a prior authorization requirement before a pregnancy termination procedure is performed. The rule also prohibits coverage for abortions performed by nurse practitioners or physician assistants. The court has not yet taken action on the providers’ request (Montana Public Radio, April 30).
• New Hampshire began planning for Medicaid redeterminations in July 2020, with efforts such as a massive public awareness campaign last year to encourage enrollees to voluntarily start the process early. The state then sent out friendly reminders printed on pink paper before switching to more urgent yellow notices to provide a frame of reference for providers and others who come into contact with enrollees. Additionally, the state Medicaid agency has been working with advocacy groups, the insurance department, and federally funded health care navigators to steer individuals into other coverage. In March of 2023, the state assessed eligibility for 21,000 people, with 70% deemed no longer eligible for Medicaid. Of those, 56% were referred to the federal marketplace plans. Since New Hampshire’s initial focus was on individuals who had not used their benefits in the past year, were no longer in touch with the department, or were known to no longer qualify, the state expects the number of ineligible members to drop in the coming months. Children, individuals in long-term care, and other vulnerable populations will be New Hampshire’s focus later in the unwinding process (S. News, April 28).