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Employers Urged to Extend Enrollment Periods

• To maintain health coverage during Medicaid unwinding, the Secretaries of HHS, Labor, and Treasury have urged employers and their plan sponsors to extend special enrollment periods for group health plans beyond the 60-day minimum to ensure health coverage for workers and their dependents. The agencies also confirmed to employers that extending enrollment periods does not have any legal or regulatory barriers (Inside Health Policy, July 21).

Several States Pause Eligibility Redeterminations

• According to documents released by CMS last week, more than half a dozen states must pause procedural terminations as CMS addresses potential violations of the Medicaid renewal requirements. . The report also shows that the Biden administration has approved mitigation plans for 35 states that are required to address renewal forms, confirm Medicaid eligibility ex parte, and comply with federal requirements. Medicaid stakeholders and advocates expressed concern over CMS’ lack of enforcement, which now includes the ability to pause redeterminations or decrease state’s enhanced federal matching funds. Key highlights of the report include the following:
  • Almost half of all states (21) had some kind of issue with their renewal forms.
  • 26 states entered a mitigation plan in part because they were not conducting renewals ex parte.
  • 15 states were listed with no identified violations of federal renewal requirements.

CMS is not naming any of the states they are working with since they are working collaboratively to address the issues. However, CMS administrator, Chiquita Brooks-LaSure, stated the agency “won’t hesitate to make the information public” should these states fail to comply in the future (Inside Health Policy, July 21; CNN Politics, July 20).

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• More than three million Medicaid beneficiaries have lost their coverage so far as state agencies begin their renewals, but the exact numbers are unclear due to limited data sharing. The Center for Medicaid and CHIP Services Director, Daniel Tsai, has announced that state-level data will be released soon which includes the number of renewals initiated, disenrollments, call center volume, wait times, and abandonment rates. Currently, data collected by the Kaiser Family Foundation and others are limited to what states voluntarily release to the public. Beneficiary advocates have expressed concern over the four-month delay in data release, citing the difficulty for stakeholders to react in time and ensure that people maintain health coverage. Existing data sources have been deemed adequate by CMS, but critics argue that key information, such as age and eligibility, is still missing to fully understand the impact of Medicaid unwinding (Inside Health Policy, July 21).
• CMS audited 25 parent sponsors in 2022, covering about 30% of all Medicare Advantage (MA) and Part D contracts including special needs plans, prescription drug plans, and Medicare-Medicaid Plans (MMP). CMS identified ongoing issues with claims processing and found plans were not meeting the required medical loss ratio (MLR). CMS imposed civil monetary penalties on certain plan sponsors based on the program and financial audits. Five sponsors were temporarily suspended from enrolling new beneficiaries for not meeting the MLR for three consecutive years. CMS urged the sponsors to ensure correct provider payment amounts, beneficiary cost sharing amounts, and to review claims system monitoring. Some plans had issues with prior authorization requests, denial explanations, Health Risk Assessments, and individualized care plans, and numerous instances of inappropriate cost-sharing for Part D medications were found. In the audit report, CMS stated that this information should not be used to draw conclusions on the entire MA, Part D, and MMP programs and is not intended to reflect overall industry performance (Inside Health Policy, July 21).
• The Joint Commission has published its second round of planned accreditation standards reductions (more than 200), that are slated to be effective August 27. The second round primarily focused on performance elements for programs relating to non-hospital settings. The following non-acute programs will see cuts or consolidation to their standards:
  • Ambulatory Health Care, 31 standards (15% reduction of reviewed standards)
  • Behavioral Health Care, 20 standards (25% reduction of reviewed standards)
  • Critical Access Hospital, 23 standards (15% reduction of reviewed standards)
  • Laboratory, 64 standards (28% reduction of reviewed standards)
  • Nursing Care Center, 19 standards (26% of reviewed standards)
  • Office-based surgery, 22 standards (9% of reviewed standards)
  • Home Care, 24 standards (15% of reviewed standards) (Fierce Healthcare, July 24).
• On July 21, the Biden administration announced the creation of a permanent office, the Office of Pandemic Preparedness and Response (OPPR), that will take over the government’s response to COVID-19, monkeypox, polio, avian and human influenzas, respiratory syncytial virus (RSV), and future pathogens and biological threats. The OPPR will provide reports to Congress every two years, with a more extensive report being required every five years. The change comes after reported disagreements about where key pieces of pandemic response should reside, and as Congress works to reauthorize the Pandemic and All-Hazards Preparedness Act (PAHPA) (Inside Health Policy, July 21).
• Since 2013, Congress has voted 13 times to delay Medicaid funding cuts prescribed by the Affordable Care Act (ACA). Now, unless Congress acts by October, the federal government will cut $8 billion annually for the next three years to the Medicaid Disproportionate Share Hospital (DSH) payments program. The cuts are part of a deal brokered with the hospital industry 14 years ago when hospitals agreed to accept $155 billion in Medicare and Medicaid funding cuts over 10 years with the assumption that insuring more individuals would improve hospitals’ bottom lines. The hospital industry is once again asking for a delay to ACA Medicaid funding cuts, citing the COVID-19 pandemic and the millions of people losing Medicaid coverage through the pandemic unwinding as reasoning for the delay (KFF Health News, July 25).

Federal Regulation

• With only a few days remaining before the congressional August recess, lobbyists expect the House Ways & Means Committee to take up their version of a hospital transparency, pharmacy benefit manager (PBM) reform, and hospital site-neutral pay reform package as early as next week. Many House committees and the Senate Health and Finance committees, have been working on a series of overlapping policies on site-neutral pay, PBM reforms, hospital and insurer transparency, delay of Medicaid Disproportionate Share Hospital pay cuts, and more that are set to expire at the end of September. The House Ways & Means Committee’s late entry into the debate could push back on movement for the multi-pronged health care package this year. Additionally, since the House Ways & Means Committee is drafting its own legislation, it is unclear what will be included or whether the package will be bipartisan. (Inside Health Policy, July 21)

Waivers

• 1915(c) Appendix K
  • Michigan
    • Effective May 11, 2023, the state is ending the flexibility which allows for level of care determination extensions and the ability to conduct these assessments virtually. Additionally, the state is ending the flexibility that suspended the collection of data for performance measures and the option to not comply with the HCBS setting requirement to allow waiver participants to have visitors at any time.

SPAs

• COVID-19 SPAs
  • Ohio (OH-23-0018, effective May 12, 2023): Extends the premium suspension for the Medicaid Buy-In for Workers with Disabilities (MBIWD) group originally approved in Disaster Relief SPA OH-22-0013.
• Administrative SPAs
  • Wyoming (WY-23-0007, effective April 1, 2023): Updates requirements for Third Party Liability, Payment of Claims and Identifying Liable Resources.
• Services SPAs
  • Arkansas (AR-22-0020, effective November 1, 2022): Adds Therapeutic Communities to the Arkansas Adult Behavioral Health Service for Community Independence (ABSCI) Program.
  • California (CA-22-0043, effective January 1, 2023): Adds qualifying community-based mobile crisis intervention services authorized by Section 9813 of the American Rescue Plan as rehabilitative mental health and substance use disorder services.
  • Kentucky (KY-23-0016, effective October 1, 2023): Adds twenty-three hour crisis observation stabilization service; updates the definition for Crisis Intervention Services and Residential Crisis Stabilization Service; and changes Mobile Crisis to Community Mobile Crisis Intervention services and updates the definition.
  • Wisconsin (WI-23-0012, effective April 1, 2023): Adds coverage of stand-alone vaccine counseling services.
• Payment SPAs
  • Colorado (CO-23-0019, effective July 1, 2023): Establishes a 3.0% across-the-board rate increase for specific services, and targeted rate increases and rate rebalances, per state statute.
  • Colorado (CO-23-0020, effective July 1, 2023): Establishes a 3.0% rate increase for outpatient hospital services, per state statute.
  • Kansas (KS-23-0027, effective July 1, 2023): Sets laboratory reimbursement rates to be between 85% and 100% of Medicare rates.
  • Louisiana (LA-23-0005, effective July 20, 2023): Establishes an alternative payment methodology (APM) reimbursement methodology for Federally Qualified Health Centers (FQHCs) that provides an add-on payment of $30 per encounter, in addition to the Prospective Payment System (PPS) rate on file for the same date of service.
  • South Carolina (SC-23-0003, effective April 1, 2023): Updates the base year used to determine payment rates under the Average Commercial Rate (ACR) methodology for the Supplemental Teaching Physician (STP) Payment Program.
• Eligibility SPAs
  • New Jersey (NJ-23-0009, effective April 1, 2023): Amends the current asset limit and deeming rules for the Ticket to Work eligibility group and adopts the Work Incentives eligibility group with no asset limit for employed individuals 65 years of age and older with a disability determination and countable income up to 250% of the FPL.

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