Issue #139

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Secretary Becerra Sends Letter to Governors

• On Monday, HHS Secretary Xavier Becerra sent a letter to U.S. governors following up on a March 2023 letter regarding Medicaid redeterminations. In the June 12 letter, Secretary Becerra reminds governors of the significance to ensure Medicaid beneficiaries are not losing coverage exclusively due to administrative reasons. He urges governors to reconsider their states’ currently elected flexibilities and also urges them to consider additional policy, procedural, and renewal processes. Secretary Becerra highlights the following options based on existing flexibilities and included an additional list of other available state strategies which have been utilized:
  • Spreading out renewals for all populations over 12 months in order to provide additional time to run a smooth process and prevent systems backlog. This process will reduce the burden on individuals, families, and state eligibility systems. Additionally, this will ensure those eligible for continued coverage do not experience a gap in care and those no longer eligible transition to other sources of coverage without problems.
  • Maximizing the use of data sources, such as allowing individuals’ coverage to be renewed on the basis of their eligibility for other programs, such as SNAP and TANF. This will help decrease the need for some individuals to fill out and return a Medicaid renewal form.
  • Partnering with managed care plans and using data from the USPS to update contact information so that individuals are more likely to receive the renewal forms.

Additionally, Becerra encourages states to work with community-based organizations and other stakeholders to engage directly with Medicaid and CHIP beneficiaries and their families concerning the renewal process (HHS, June 12).

Supreme Court Ruling on Medicaid Beneficiary Lawsuits

• On June 8, the Supreme Court ruled 7-2 that patients can sue nursing homes in federal court for violating their civil rights (under Section 1983 provisions), specifically those granted by the Federal Nursing Home Reform Act (FNHRA) under Medicaid. The ruling upholds the right of private action under the FNHRA, granting nursing home residents protection from being drugged for discipline or convenience and from being transferred or discharged from the facility without notice and consent. Two lower courts affirmed the nursing home residents’ right to sue, but the Health and Hospital Corporation of Marion County appealed to the Supreme Court in November 2021. The majority opinion of the Court stated the FNHRA provisions create enforceable rights under Section 1983. Justices Clarence Thomas and Samuel Alito dissented, arguing that the FNHRA should not be enforced through Section 1983 and that it exceeds Congress’ spending power. (Inside Health Policy, June 8; Modern Healthcare, June 8).

New CMS Primary Care Model

• CMS has announced a new primary care model called Making Care Primary (MCP), set to launch in July 2024. The MCP is a three-tracked, multi-payer demonstration that will last 10.5 years. The program aims to strengthen primary care infrastructure and improve coordination with specialists, as well as providing an on-ramp for ACO participation in the future for providers who aren’t currently participating in value-based care. Participants in eight states – Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington – will receive extra funding to meet the goals of the MCP. The three different tracks correspond to participants’ experiences with value-based care and alternative payment models. Track one is reserved for participants without any prior value-based care experience and focuses on building infrastructure. Track two emphasizes coordination of care and moves to a 50/50 blend of prospective payments and fee-for-service. The third track moves to fully prospective payments and utilizes quality frameworks to improve care. The demonstration prohibits participants from being a part of an ACO at the same time, drawing the ire of the National Association of Accountable Care Organizations (NAACOS). Despite these criticisms, CMS designed the model to reach primary care providers “who are new to value-based care,” according to CMMI Director Liz Fowler (Inside Health Policy, June 8).

News

• On June 9, HHS and the Health Resources and Services Administration announced the Pediatric Specialty Loan Repayment Program, which provides eligible clinicians $100,000 if they work for at least three years in a health professional shortage area or provide care for a medically underserved population. In order to qualify for the program, clinicians must work in or be trained in a pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent behavioral healthcare. The program is the latest effort from the federal government to recruit and retain clinicians for children and adolescents in schools and underserved areas, which has been a growing area of concern over the course of the pandemic. The program application deadline for clinicians is July 20 (Modern Healthcare, June 12).

• To help people better understand data relating to the Medicaid redeterminations, the National Association of Medicaid Directors (NAMD) released a brief detailing best practices that included the following:

1. States are engaging in unprecedented levels of outreach to existing Medicaid members.
   • Prior to the start of redeterminations, states were running digital, mail and text campaigns urging current enrollees to make sure contact information is up-to-date. State call centers and managed care plans are now answering current members’ calls and providing outreach to unresponsive members. States are required to look at internal data and do everything possible to automatically reenroll members who have not provided the necessary paperwork, which is helping more people. Additionally, states are partnering with community-based organizations, providers, hospitals, and health insurance plans to make sure that no one is missed.
2. How states opted to prioritize the order of Medicaid members undergoing eligibility checks in any given month dramatically impacts the numbers from that state.
   • Certain states have started the redetermination process with individuals they anticipate are now ineligible. Other states are aligning their work to parallel typical redetermination rates and timelines over the year which makes it difficult to assess broader trends.
3. Procedural terminations (e.g., people being removed from Medicaid for administrative reasons including non-response to Medicaid agencies) are one important metric to measure unwinding success, but it is not one that can be understood based on a single number.
   • Early data cannot capture what these initial rates mean yet and reducing it to one global number ignores the reality that there are many different scenarios at play. For instance, individuals that have become ineligible for Medicaid are obtaining coverage through their employers, federal, or state marketplace plans and have opted not to respond to redetermination requests.
4. States are required to observe extensive procedural protections for people at risk of losing coverage.
   • All states are required to ensure member protections, including the types of outreach required, fair hearing processes, and a new 90-day reconsideration period that provides for coverage reinstatement.
5. Medicaid is always open for new enrollment or reenrollment.
   • Unlike private insurance which has limited, open enrollment periods with few exceptions for qualifying life events, Medicaid is always available for those who need it and meet coverage qualifications (National Association of Medicaid Directors, June 12).

• HHS Secretary Xavier Becerra testified before Congress stating that keeping $5 billion for next generations of COVID-19 vaccine development is critical for having the country prepared for a new strain of the virus or another disease. The Secretary further warned that smaller funding would only extend the timeline for developing the vaccine. The debt ceiling deal between the Biden administration and Congressional Republicans includes a $5 billion allocation for funding next generation COVID-19 vaccine development however, the funding is far less in magnitude than was available for Operation Warp Speed (Inside Health Policy, June 8).

Waivers

• Section 1115
  • Arkansas
    • On June 2, 2023, Arkansas requested to amend their Arkansas Health and Opportunity for Me (ARHOME) demonstration to provide additional supports to underemployed and unemployed adults in ARHOME. Beneficiaries who are not progressing toward improved health and economic independence will be provided the opportunity to receive focused care coordination services through the assistance of a Success Coach. The proposed amendment also seeks to expand Success Life360 HOME eligibility. The federal public comment period will be open from June 14 through July 14, 2023.
  • Kentucky
    • On May 31, 2023, Kentucky submitted an amendment to the KY HEALTH demonstration requesting authority to reimburse medically necessary short-term inpatient treatment services within settings that qualify as institutions for mental diseases (IMDs) for Medicaid-eligible adults with serious mental illness (SMI). Additionally, the state is requesting authority to implement a recuperative care pilot program for adult beneficiaries who are homeless or at risk of homelessness and need additional medical support and care coordination. The federal public comment period will be open from June 14 through July 14, 2023.
• 1915(c) Appendix K
  • Utah
    • Effective January 27, 2020 through six months after the end of the public health emergency (PHE). The amendments to various home- and community-based services (HCBS) waivers that the state has requested are additive to those previously approved. Effective April 1, 2022, the State will update its calculation of payment revisions to providers utilizing section 9817 of the American Rescue Plan funds. The state will also delay its submission of evidentiary package(s) and its collection of data for performance measures other than those identified for health and welfare assurances.

SPAs

• COVID-19 SPAs
  • Alabama (AL-23-0006, effective May 12, 2023): Allows the state to temporarily extend the increased nursing facility per diem rate through June 30, 2023, originally approved in Disaster Relief SPA TN 22-0014.
  • District of Columbia (DC-23-0005, effective May 12, 2023): Authorizes temporary extensions of the following: an increase to the personal needs allowance for certain beneficiaries, a delay in rebasing rates for federally qualified health centers and specialty hospitals, reimbursement rate increases for certain facilities and services, and modifications to the District’s health home program, originally approved in Disaster Relief SPAs 20-0001, 21-0020, 22-0010, and 23-0001.
  • Iowa (IA-23-0010, effective May 12, 2023): Allows the state to temporarily extend the suspension for all co-payments and premiums for all Medicaid enrollees until June 1, 2024, originally approved in Disaster Relief SPA IA-20-0008.
  • Minnesota (MN-23-0011, effective March 11, 2021): Authorizes coverage and reimbursement of COVID-19 vaccines and vaccine administration, coverage, and reimbursement of services for the treatment and prevention of COVID-19, including conditions that may seriously complicate the treatment of COVID-19.
  • Missouri (MO-23-0012, effective May 12, 2023): Authorizes a temporary extension of the requirement for Registered Behavior Technicians to have a credential if they have completed all training but are unable to test due to COVID-19-related test center closure or related delays, originally approved in Disaster Relief SPA 20-0021.
  • Ohio (OH-23-0011, effective March 11, 2021): Authorizes coverage of mandatory benefits of COVID-19 vaccines, diagnostic and screening tests, and treatment, specialized equipment and therapies, and preventive therapies in accordance with the requirements of Section 9811 of the American Rescue Plan Act (ARP).
  • Ohio (OH-23-0014, effective May 12, 2023): Authorizes the State to permanently extend the Reasonable Opportunity Period for non-citizens who are making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the verification process. During the COVID-19 pandemic, the State elected to allow an extension through Disaster Relief SPA 20-012.
  • Oregon (OR-23-0018, effective May 12, 2023): Authorizes an extension without modifications of the 5% rate increase to rate for nursing facilities, assisted living facilities, residential care facilities from May 12 through June 30, 2023.
• Eligibility SPAs
  • Louisiana (LA-23-0004, effective January 1, 2023): Authorizes 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.
  • Ohio (OH-23-0007, effective January 1, 2023): Updates post-eligibility treatment of income exclusions in accordance with the Stephen Beck Jr. Achieving a Better Life Experience (ABLE) and recently passed State legislation.
  • Oregon (OR-23-0012, effective April 1, 2023): Authorizes changes to when benefits are provided by the state. Once the reasonable opportunity is provided, the agency furnishes benefits on the first day of the month of application.
  • Puerto Rico (PR-23-0002, effective January 1, 2023): Authorizes 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 L. No 115-217, section 1002.
• Payment SPAs
  • California (CA-23-0003, effective January 1, 2023): Updates the reimbursement methodology for Durable Medical Equipment.
  • Connecticut (CT-23-0010, effective March 1, 2023): Authorizes a new reimbursement methodology for continuous glucose monitors (CGMs) when provided by a pharmacy.
  • Connecticut (CT-23-0008, effective January 1, 2023): Authorizes a rate increase for self-directed Personal Care Attendant (PCA) services within the Community First Choice benefit.
  • Georgia (GA-22-0009, effective July 1, 2022): Authorizes updates to the nursing home reimbursement rates to the 2020 nursing home cost reports. The SPA also updates the calculation of the Property and Related Net Per Diem by increasing the rate for construction cost for nursing facilities.
  • Louisiana (LA-23-0010, effective July 1, 2023): Authorizes amendments to Early and Periodic Screening Diagnostic and Treatment dental services to link services to the Louisiana Medicaid fee schedule.
  • Maine (ME-23-0001, effective January 1, 2023): Updates the reimbursement methodology for Durable Medical Equipment and medical supplies.
  • Maryland (MD-23-002, effective January 1, 2023): Authorizes emergency service transporters to provide treatment in place and in mobile integrated health services under the supervision of a physician. Treatment in place will be reimbursed at a rate of $150 and mobile integrated health services will reimburse at a rate of $150 per event.
  • Michigan (MI-23-0006, effective May 12, 2023): Authorizes payment for qualifying audio-only telemedicine visits.
  • New York (NY-22-0080-A, effective July 1, 2022): Authorizes an increase in the inpatient hospital per-diem rate of reimbursement for extended observation bed (EOB) services in hospital-based comprehensive psychiatric emergency programs (CPEP), subsequent to a CPEP full or triage and referral visit and where the beneficiary remains in the CPEP for longer than 24 hours.
  • Utah (UT-23-0009, effective July 1, 2023): Updates pricing for Durable Medical Equipment and medical supplies.
• Services SPAs
  • Louisiana (LA-23-0008, effective May 20, 2023): Authorizes amendments to the Home Health Program to increase the number of medical professionals that can order home health services.
  • New York (NY-23-0006, effective March 1, 2023): Provides for 12 months of extended postpartum coverage to individuals who were eligible and enrolled under the Medicaid state plan during their pregnancies (including during a period of retroactive eligibility).
  • North Carolina (NC-23-0006, effective April 1, 2023): Authorizes Medicaid to reimburse for Opioid Treatment Program (OTP) services provided to individuals with an Opioid Use Disorder by allowing for bundled payment rates consistent with Medicare.

News

• On June 10, North Carolina Governor Roy Cooper signed a bill into law that allows Blue Cross and Blue Shield, the state’s leading health insurance provider, and Delta Dental to transfer money, property, and other investments from their existing hospital service companies to new shell companies run by the same executive leadership. Blue Cross believes the reorganization will allow for more flexibility to compete with for-profit companies and expand services to more communities. The law requires the holding company to invest in entities that promote affordability and caps the amount of assets the insurer can transfer to the holding company at 25% (AP News, June 10).
• More than 700,000 people across 14 states have been disenrolled from Medicaid, with a significant percentage of those people losing coverage due to procedural reasons. Indiana and West Virginia have the highest percentage of disenrollments due to procedural reasons, at 89% respectively. Florida, Arkansas, and New Hampshire all have high rates of disenrollments for procedural reasons with, Florida having the highest number of people disenrolled at nearly 250,000 losing coverage. Arkansas is next with over 140,000 people losing coverage in the state. CMS has advised states to take their time during the disenrollment period to avoid eligible individuals and families losing health coverage. Between April and June, 19 states initiated disenrollments, while 22 more states started the process in June. The Kaiser Family Foundation estimates that 8 to 24 million people could ultimately be disenrolled (Health Payer Specialist, June 12).