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Redetermination Continues

• More than 1.5 million Americans have lost Medicaid coverage, and this number is projected to rise as nine more states begin their Medicaid redetermination process in July. Disenrollment numbers vary across states with Florida still maintaining the highest number of dropped enrollees in the country at 303,000. Across all states approximately 71% of people lost coverage due to procedural reasons such as incomplete paperwork. Some states are pausing or delaying disenrollments to allow more time for outreach. There are concerns about the number of children losing Medicaid coverage, with children accounting for over one-third of disenrollments in five states. Only Oregon has not yet started its redetermination process, scheduled to begin in October. The Kaiser Family Foundation estimates that 8-24 million people could ultimately lose Medicaid coverage during the redetermination process. (Health Payer Specialist, June 30)

Home Health Medicare Payments

• Home health providers are criticizing CMS for its proposed pay cuts to the home health pay system. CMS, in its efforts to revamp the payment system, proposed a 2.2% cut for home health pay in 2024. The cut is a combination of three factors: 2.7% proposed home health payment update, 0.2% increase from an update to the fixed-dollar loss ratio, and 5.1% cut from the Patient-Driven Groupings Model. Provider groups have been critical of the cut saying that home health providers could lose $18 billion over 10 years. (Inside Health Policy, June 30)

Drug Price Negotiation Guidance

• On June 30, CMS issued final guidance on its Medicare drug price negotiation program, offering some insight into how CMS could defend itself in litigation drug makers and industry groups have filed against the program. CMS officials commented on the guidance saying the manufacturers of selected drugs will not have a price forced upon them and instead will participate in voluntary, collaborative negotiations. These statements negate industry arguments that CMS intends to impose prices unilaterally and in violation of drug manufacturers’ constitutional rights. The four separate lawsuits have variations of overlapping arguments including Congress violating the separation of powers and nondelegation provisions in the Constitution by allowing CMS to design the program as well as due process violations by limiting administrative and judicial review of determinations made by CMS. (Inside Health Policy, June 30)

News

• Industry associations across various healthcare settings have raised concerns over the proposed 2.8% Medicare payment increase proposed by CMS for fiscal year 2024. Organizations like the American Hospital Association (AHA) and the Federation of American Hospitals (Federation) criticize CMS’ market basket update for failing to consider escalating costs, including rising drug, equipment, and supply prices, as well as higher labor expenses. The AHA and the Federation have requested CMS to provide a 5.8% reimbursement increase in fiscal year 2024. Additionally, industry representatives requested CMS to slow down changes to quality reporting and value-based payment programs, making adoption of these non-mandatory. (Modern Healthcare, July 3)
• The U.S. Supreme Court’s June 29 decision on the barring of affirmative action in university and college admissions was a disappointment for the Biden administration and many medical education institutions. The Association of American Medical Colleges (AAMC) expressed disapproval of the Supreme Court’s decision noting “the decision demonstrates a lack of understanding of the critical benefits of racial and ethnic diversity in educational settings and a failure to recognize the urgent need to address health inequities in our country.” HHS also weighed in noting that health equity initiatives are hampered with a shortage of Black and Latino providers. (Inside Health Policy, June 29)

Federal Studies and Reports

• In a study released on June 16, researchers at Georgetown University found that one in six women between ages 18-44 in Alabama lack health insurance and face multiple barriers to good health. Additionally, the state had the third-highest maternal mortality rate between 2018 and 2020. During this time, there were 36 deaths per 100,000 live births, almost 16 additional deaths per 100,000 live births when compared to the national average maternal mortality rate. Researchers believe that Medicaid expansion in Alabama will have a significant impact on maternal health. In states that have expanded Medicaid, there are lower rates of both maternal and infant mortality. While Alabama legislators took an important step and expanded postpartum coverage from 60 days to 12 months, Medicaid expansion would further demonstrate a commitment to maternal and child health in the state. (MSN, July 2; Georgetown University, June 16)

Waivers

• 1915(c) Appendix K
  • Montana
    • Effective July 1, 2023, the State will implement rate increases approved by the state legislature for Montana Big Sky Home and Community Based (HCBS) Waiver, HCBS for Individuals with Developmental Disabilities (IDD) Waiver, and Severe and Disabling Mental Illness (SDMI) Waiver.
  • Connecticut
    • Effective February 1, 2023, the State is amending how funds from Section 9817 of the American Rescue Plan are issued for incentive-based outcome payments and enhanced rate increase for the identified providers within the Comprehensive Supports Waiver, Individual and Family Support Waiver, and Employment and Day Supports Waiver.

SPAs

• COVID-19 SPAs
  • American Samoa (AS-23-0001, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • Arkansas (AR-23-0013, effective May 12, 2023): Extends Brief Emotional/Behavioral Assessment Screening payments originally approved in AR-23-0004.
  • Georgia (GA-23-0004, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • Illinois (IL-23-0018, effective March 11, 2021): Authorizes the coverage of COVID-19 treatment as mandated by Section 9811 of the American Rescue Plan.
  • Illinois (IL-23-0019, effective March 11, 2021): Authorizes the coverage of COVID-19 testing as mandated by Section 9811 of the American Rescue Plan.
  • Illinois (IL-23-0020, effective March 11, 2021): Authorizes the coverage of COVID-19 vaccines and vaccine administration as mandated by Section 9811 of the American Rescue Plan.
  • Louisiana (LA-23-0018, effective May 12, 2023): Extends certain COVID-19 disaster relief provisions governing long-term personal care services currently authorized under LA-20-0004.
  • Louisiana (LA-23-0023, effective May 12, 2023): Extends provisions governing direct wage floor and workforce retention bonus payments to long-term personal care providers as originally approved in LA-22-0031.
  • Maine (ME-23-0004-A, effective January 1, 2023): Rescinds the temporary policies in Section 7.4 Medicaid Disaster Relief for the National Emergency.
  • Maine (ME-23-0005-A, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • Massachusetts (MA-23-0028, effective January 25, 2021): Updates payment methodology for nursing facilities. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • Massachusetts (MA-23-0029, effective May 12, 2023): Extends payment methodologies included in MA-23-0027 for Adult Foster Care and Continuous Skilled Nursing. This time-limited COVID-19 SPA terminated on June 30, 2023.
  • Nebraska (NE-23-0005, effective May 12, 2023): Extends the suspension of premiums and cost-sharing provisions as originally approved in Disaster Relief SPAs NE-20-0010, NE-20-0011, and NE-20-0014.
  • New York (NY-20-0081, effective July 1, 2020): Increases the rates for Psychiatric Residential Treatment Facilities (PRTF). This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • New York (NY-21-0054, effective April 1, 2021): Increases rates for State Plan Services including Children and Family Treatment and Support Services (CFTSS). This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • New York (NY-21-0072, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • New York (NY-21-0073, effective October 1, 2021): Adds rehabilitative reintegration services to help beneficiaries with behavioral health problems to function in the community. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • New York (NY-21-0074, effective February 1, 2021): Expands the list of qualified providers for both Rehabilitative Preventive Residential Treatment (PRT) services and Rehabilitative Residential Treatment services. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • New York (NY-21-0075, effective March 1, 2020): Adds coverage for the administration of the influenza vaccine, performed by Medicaid-enrolled Emergency Medical Technicians and Paramedics. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • Northern Mariana Islands (MP-23-0004, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • Northern Mariana Islands (MP-23-0005, effective May 12, 2023): Extends the increased eligibility income limit to 180% of the SSI Federal Benefit Rate as originally approved in MP-20-0001-B. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
  • Oklahoma (OK-23-0010, effective March 11, 2021): Authorizes the coverage and reimbursement of COVID-19 testing, vaccine and vaccine administration, and treatment as mandated by Section 9811 of the American Rescue Plan.
  • Pennsylvania (PA-22-0037, effective March 1, 2020): Provides lump sum supplemental payments to NEMT providers for the period beginning July 1, 2022, through April 30, 2023. This SPA also waives signature requirements for the dispensing of prescription drugs. This time-limited COVID-19 SPA terminated at the end of the public health emergency.
• Services SPAs
  • New York (NY-22-0026, effective April 1, 2022): Expands access to crisis intervention services previously available only to 1115 waiver populations and authorizes crisis intervention services provided in crisis stabilization centers to both adults and children under the state plan.
• Payment SPAs
  • Florida (FL-22-0012, effective July 1, 2022): Authorizes an ICF rate increase and updates buy-back provisions. Additionally, this SPA adds funding for a new level of reimbursement for clients who have severe behavioral needs, increases funding to providers to raise wages of direct care employees to at least $15 per hour, and makes technical and editorial changes.
  • Illinois (IL-23-0023, effective July 1, 2023): Increases the rate for early intervention services.
  • Texas (TX-23-0012, effective April 1, 2023): Updates the physicians’ and other practitioners’ fee schedules.
• Administrative SPAs
  • Washington (WA-23-0024, effective April 1, 2023): Reflects the appointment of Dr. Charissa Fotinos as the state’s Medicaid Director for the Washington State Health Care Authority.

News

• California began its redetermination process last week, sending out the first round of disenrollment notices to beneficiaries throughout the state whose original coverage began in April of the year they signed up for Medi-Cal. There are 7 million people enrolled, and the state has yet to determine how many individuals will lose coverage once redeterminations are complete. However, according to a University of California Berkeley study, it is estimated that 1.8 to 2 million people will leave Medi-Cal because of either employer-sponsored insurance coverage or subsidized plan coverage on Covered California, the state’s Affordable Care Act (ACA) exchange. The state appropriated $146 million for a multimedia, in-person, social media, and print campaign to remind people to update their information and reapply for coverage. Additionally, managed care plans are working with the state as “coverage ambassadors,” outreaching to members of their plans and reminding them to recertify. (Health Payer Specialist, June 30)
• Several states are implementing new healthcare measures to increase control over prices, benefits, and prior authorization. Illinois is transitioning from a federally facilitated health insurance marketplace to a state facilitated marketplace by 2025. This will enable the state to have more control over insurance prices by allowing state regulators to reject or modify proposed increases for health insurance plans sold on the exchange. In Washington, the D.C. Council is advancing a bill that would partially cover infertility treatment costs for Medicaid enrollees. Currently no state offers Medicaid coverage for infertility treatments but D.C. hopes to cover this benefit by 2024. Legislators in Wyoming are proposing rules on prior authorization but health insurers in the state are expressing concerns about sharing denial information and response time requirements. (Health Payer Specialist, June 30)
• New York’s health equity law went into effect on June 22. It requires health care organizations seeking state approval of service changes in the state to submit an independent report on their project’s expected impact on health disparities and access to care. The law is the first of its kind in the United States. Health departments in other states like California, North Carolina, Ohio, Oregon, and Washington have equity-focused templates for evaluating projects, however, there is no legislative mandate that applicants submit an independent equity-focused review. (, July 5)
• Minnesota is extending the Medicaid renewal deadline from July to August 1 to give recipients more time to complete and submit their paperwork to maintain coverage. President Biden has urged states to slow down their Medicaid unwinding and Minnesota’s original deadline already placed them among the last group of states to begin redeterminations after the end of the pandemic. So far, Minnesota has processed over 60,000 individuals out of the expected 1.5 million who will need to renew over the next year. (The Associated Press, June 30)