Issue #160
Key Updates:
The Medicaid and CHIP Payment and Access Commission (MACPAC) met on November 2-3 to discuss topics including: improving the managed care appeals process; Medicaid primary language and limited English proficiency data collection; state and managed care plan strategies for unwinding the continuous coverage requirements; medical care advisory committees and beneficiary engagement; interview findings regarding school-based behavioral health services; comparison of states home and community-based services (HCBS); Medicaid payment policies to support the HCBS workforce; and state Medicaid contracts optimizing Medicare Advantage (MA) dual eligible special needs plans (D-SNPs) (MACPAC, November 2-3).
CMS has finalized a 3.4% reduction to the Medicare physician fee schedule. Other policies finalized in the rule are intended to promote health equity, expand access to dental services, and broaden the group of providers eligible for Medicare reimbursement (Inside Health Policy, November 2; Modern Healthcare, November 2).
Providers who are participating in the 340B drug discount program will receive $9 billion by early 2024 to compensate for payment cuts in previous years. The payments are intended to undo reimbursement cuts from 2018 to 2022 (Modern Healthcare, November 6; Modern Healthcare, November 2).
From November 1 through November 8, CMS approved 18 SPAs and has one 1115 waiver out for public comment.
- Federal Updates
Featured Content
MACPAC November Meeting
- The Medicaid and CHIP Payment and Access Commission (MACPAC) met on November 2-3 to discuss topics including: improving the managed care appeals process; Medicaid primary language and limited English proficiency data collection; state and managed care plan strategies for unwinding the continuous coverage requirements; medical care advisory committees and beneficiary engagement; interview findings regarding school-based behavioral health services; comparison of states home and community-based services (HCBS); Medicaid payment policies to support the HCBS workforce; and state Medicaid contracts optimizing Medicare Advantage (MA) dual eligible special needs plans (D-SNPs). Key takeaways from each of the agenda topics are included below (MACPAC, November 2-3).
- The Commission continued its review and discussion on denials and appeals in Medicaid managed care. The Commissioners began with a review of findings from beneficiary focus groups, and then began discussion of key challenges with the current requirements for the appeals process as well as the exploration of policy options to address these challenges.
- The Commission discussed Medicaid demographic data on primary language and limited English proficiency (LEP) information. Specifically, Commissioners discussed how data can be used to ensure language access and measure health disparities and the way language information can be collected from Medicaid enrollees.
- MACPAC staff discussed the role of medical care advisory committees (MCACs) in supporting state Medicaid agency efforts to include beneficiary views into their programs and provided an overview of the federal statute and regulations related to MCACs and proposed implementation of changes to these regulations. MACPAC staff shared key findings and challenges with beneficiary engagement on MCACs. Staff also provided suggestions on how to improve beneficiary engagement such as, CMS issuing guidance and providing technical assistance to address the challenges. (MACPAC, November 2).
- MACPAC staff provided an overview of administrative requirements for HCBS-delivered under 1915(c), 1915(i), 1915(j), and 1915(k) authorities. Staff also summarized the results of interviews with state and federal officials to assess their experiences in dealing with the administrative requirements. Staff noted that states have identified potential administrative efficiencies that could streamline program operations relating to various administrative requirements including cost-neutrality, program renewal processes and reporting and monitoring (MACPAC, November 3).
- MACPAC staff reviewed the manner in which Medicaid payment policies for HCBS are used to support HCBS direct care workers, direct support professionals, and independent providers. Staff presented preliminary findings from a review of state payment policies and interviews with national experts. The presentation included the identification of five policy issues for additional consideration:
- The data used to develop fee-for-service (FFS) rate setting.
- Budget constraints affect a state’s ability to finance HCBS rates at levels recommended during the rate-setting process.
- The use of self-directed services and managed care to pay rates that may differ from FFS.
- Policies to regulate the share of HCBS payments agencies spend on HCBS worker wages.
- Non-financial policies to increase HCBS worker recruitment and retention (MACPAC, November 3).
- MACPAC organized a panel discussion around Medicaid unwinding to discuss the approaches and adjustments states have made over the course of the process. Panelists included Amir Bassiri, Medicaid Director of New York State; Stephanie Myers, State Affairs Director of MPHA; and Cora Steinmetz, Medicaid Director of Indiana. The discussion focused on how states have been able to pivot as they have moved through the unwinding process, how states are using data in making decisions and looking at new approaches and including managed care plans in their unwinding efforts (MACPAC, November 2).
- To better understand the experience of schools and states in providing school-based behavioral health services, MACPAC conducted stakeholder interviews in five states. Notably, this work was conducted prior to CMS releasing school-based services guidance on May 18, 2023. The results of the interviews showed that states have limited data available on the effects of covering these services and stakeholders cited a lack of clear guidance from the federal government which hindered access to behavioral health and other school-based services. Stakeholders identified three major themes that create barriers to providing services in schools: access, financing, and billing and documentation. Challenges with access related to provider availability and qualifications, difficulties coordinating services, and the referral process. States were concerned about the lack of federal matching funds and random moment time study requirements. Finally, there were significant concerns about billing and documentation as it related to parental consent, medical necessity, and audits. A large topic of concern was also third-party liability that creates an administrative burden for schools. With the release of the new guidance in May, stakeholders are still analyzing the impact this will have on their programs. MACPAC plans to continue to monitor for additional guidance and publish an issue brief with more background information on Medicaid school-based services (MACPAC, November 3).
CMS Finalizes FY2024 Medicare Physician Reimbursement Rule
- CMS has finalized a 3.4% reduction to the Medicare physician fee schedule. Other policies finalized in the rule are intended to promote health equity, expand access to dental services, and broaden the group of providers eligible for Medicare reimbursement. Evaluation and management codes were also revised, with a focus on long-term care. CMS faced appeals from physician organizations such as the Medical Group Management Association and other stakeholders to prevent the 3.4% cut to the conversion factor. With the new policies, caregiver training services by various healthcare providers will be reimbursed under Medicare and new health equity codes will be used to pay for resources used by community health workers and care navigators. Related to dental services, CMS finalized policy that will allow Medicare to pay for certain dental services related to cancer treatments. CMS extended payment through December 31, 2024, for telehealth services provided by Federally Qualified Health Centers and Rural Health Clinics CMS also expanded mental and behavioral health policies, including reimbursement for a variety of behavioral health providers, such as marriage and family therapists and mental health counselors. Additionally, policies for accountable care organizations have been finalized to improve digital quality measures (Inside Health Policy, November 2; Modern Healthcare, November 2).
Providers to Receive Additional 340B Payments
- Providers who are participating in the 340B drug discount program will receive $9 billion by early 2024 to compensate for payment cuts in previous years. The payments are intended as remedy payments based on a U.S. Supreme Court decision to undo reimbursement cuts from 2018 to 2022. In the final rule, regulators lowered payments for non-drug items and services to all hospitals by $7.8 billion over a 16-year period starting in 2026. Hospital groups support the lump sum payments, but strongly oppose the cuts in other areas, stating that they might be forced to cut services as a result of lower outpatient reimbursement rates (Modern Healthcare, November 6; Modern Healthcare, November 2).
News
- The number of MA plans offering non-medical benefits has significantly increased in the last four years. In 2019, CMS allowed MA payers to offer health-related supplemental benefits which include in-home support services, adult day care, palliative care, therapeutic massage, groceries and prepared meals, non-medical transportation, and pest control services. Grocery services, with stipends of around $25 to $100 per month have seen the most rapid increase, from 101 plans offering services in 2020 to 1,475 for the 2024 plan year. Non-medical transportation services have also seen significant growth, from 88 plans to 679 for the 2024 plan year. Subsidies for housing, utilities, and personal care which are sometimes referred to as “general supports for living,” have increased from 67 plans in 2020 to 996 for the 2024 plan year. In contrast, structural home modification offerings have decreased. Aetna leads MA payers in offering grocery benefits whereas Humana leads in other categories such as meal services, transportation, and pest control (Health Payer Specialist, November 3).
- On November 2, House Republicans on the House Oversight and Accountability Committee sent a letter to FDA Commissioner Rober Califf informing him that they are investigating the FDA’s efforts to prevent and mitigate drug shortages. The letter stated that the FDA has failed to address supply chain issues and that CMS’ new ability to engage in drug price negotiation will make the problem worse. The committee highlighted that 128 drugs are currently listed as in shortage, including many that treat life-threatening conditions like cancer. The committee sent the letter the same day CMS announced it would not implement a requirement for hospitals to keep a buffer stock of critical drugs on hand through its 2024 outpatient payment rule. However, CMS is still considering the issue and will address it through a separate rulemaking. This is the second congressional investigation the FDA is currently facing (Inside Health Policy, November 3).
- On November 7, CMS released additional guidance for states to improve the monitoring and oversight of managed care in Medicaid and CHIP. This CMS informational bulletin (CIB) is the third in a series of guidance documents released by CMS around these topics. The guidance includes additional updates and reminders for the web-based reporting portal and other reporting requirements for managed care. The CIB also provides updates on CMS’ process for the review and approval of managed care contracts, rate certifications, and state directed payments. Finally, the CIB announces the release of new technical assistance toolkits.
- Managed Care Reporting Requirements
- States are required to submit various reports to CMS relating to their managed care programs. These reports will now be collected through the web-based portal known as the Medicaid Data Collection Tool (MDCT-MCR), which streamlines the submission process and allows for structured data analysis. This tool will collect both MCPAR and MLR reports from the states.
- The MDCT-MCR system is intended to help CMS identify areas that need improvement and provides targeted technical assistance to help states comply with managed care statutory and regulatory requirements.
- Only authorized state employees can access the portal. States that are ready to submit their MLR Summary Report through the online portal can do so immediately. It will be required to submit these MLR Summary Reports through the MDCT-MCR for rate periods beginning on or after July 1, 2024.
- The Network Adequacy and Access Assurances Report (NAAAR) will be collected through the MDCT-MCR in the future but is not available now. Until the system is available, states should submit their Excel template of the report to CMS.
- CMS Review of Managed Care Contracts, Rate Certifications, and State Directed Payments
- Previously, CMS outlined process improvements to CMS’ review of contracts and rate certifications and a CIB was issued that outlined revisions to the submission process. CMS has expressed they are still experiencing delays in the state submission of complete Medicaid managed care contracts, rate certifications, and state directed payment preprints. As a result, CMS includes guidance on these topics in this CIB.
- CMS is outlining new minimum documentation standards that must be met for CMS to review a managed care contract submission. This will be implemented in two phases to allow states time to comply. Phase 1 will begin for any managed care contract effective on or after July 1, 2024. Phase 2 will begin for managed care contracts effective on or after July 1, 2025.
- Regarding Medicaid rate certifications, CMS notes the rate certification must include both the letter or attestation from the actuary that certifies the rates are actuarily sound and meets applicable Federal requirements and all supporting documentation to the letter or attestation. This includes the actuarial report, other reports, letters, memorandums, other communications, and other workbooks or data.
- CMS notes state directed payment preprints must be completed in full, and all information must be provided only in the fillable sections of the preprint and addendum tables with no additional markings or comments. CMS requests that the states use the addendum tables when possible and avoid using separate supporting documentation. CMS strongly recommends that states submit preprints that require written prior approval at least 90 calendar days before the start of the applicable rating period.
- For each State directed payment, the risk-based managed care contracts must include a description of providers entitled to payment, how the payment is authorized, how the state is directing the plans to pay providers, and any reporting requirements the MCOs must meet to show compliance.
- Technical Assistance Toolkits for States
- CMS has developed a series of technical assistance toolkits to assist the states in complying with managed care standards and regulations and to improve state monitoring and oversight of their managed care programs.
- These toolkits cover various topics, including Medicaid managed care plan transitions, tribal protections in Medicaid and CHIP managed care, and validating Medicaid managed care encounter data.
- Additionally, CMS has released program integrity toolkits on the following topics: addressing compliance program requirements; prompt referrals of potential fraud, waste, or abuse; treatment of overpayments and recoveries; and payment suspensions based on credible allegations of fraud (CMS, November 7).
- Managed Care Reporting Requirements
Federal Legislation
- On November 2, CMS finalized a 3.4% cut to pay under the physician fee schedule just hours after leaders of the Senate Finance Committee released draft legislation to mitigate 1.25% of that cut and extend the alternative pay model bonuses beyond 2023. The proposed legislation would also delay the $8 billion per year reduction to Medicaid Disproportionate Share Hospital payments for two years. Last year, lawmakers eased 2.5% of the 2023 Medicare physician fee schedule conversion factor cuts, and 1.25% of the expected cuts for 2024, resulting in 2% of the cut to kick in this past January 1. (Inside Health Policy, November 2).
Federal Studies and Reports
- New data from the Leapfrog Group, a nonprofit organization dedicated to quality, safety, and transparency in the health system, revealed hospital-acquired infection rates fell at health systems across the country last year after increases amid the pandemic. This new data demonstrates that hospitals are reducing the rate of infections and the surge in infections that occurred during the pandemic were partly due to shortages in protective equipment and staff. However, there were declines in several measures of patient experience across the industry, which could be due to ongoing labor challenges and workforce burnout (Axios, November 6).
- The Medicaid and CHIP Payment and Access Commission (MACPAC) met on November 2-3 to discuss topics including: improving the managed care appeals process; Medicaid primary language and limited English proficiency data collection; state and managed care plan strategies for unwinding the continuous coverage requirements; medical care advisory committees and beneficiary engagement; interview findings regarding school-based behavioral health services; comparison of states home and community-based services (HCBS); Medicaid payment policies to support the HCBS workforce; and state Medicaid contracts optimizing Medicare Advantage (MA) dual eligible special needs plans (D-SNPs). Key takeaways from each of the agenda topics are included below (MACPAC, November 2-3).
- State Updates
Waivers
- Section 1115
- Wyoming
- On October 25, Wyoming submitted a new 1115 waiver demonstration request to provide home and community-based services to individuals over the age of 65 who are currently ineligible for Medicaid. The goal of this demonstration is to prevent or delay future institutional level of care for this population. The federal public comment period is open from November 8 through December 8, 2023. Comments can be submitted here.
- Wyoming
SPAs
- Administrative SPAs
- North Dakota (ND-23-0025, effective August 1, 2023): Updates the Designees for State Plan submissions.
- Payment SPAs
- Colorado (CO-23-0024, effective July 1, 2023): Increases the maximum daily coverage rates by 3% for long term home health and for acute home health services.
- Colorado (CO-23-0034, effective July 26, 2023): Adds a supplemental payment for Class I nursing facility providers that admit residents directly from the Colorado Department of Corrections who are released on parole or due to compassionate care or medical release.
- Illinois (IL-23-0026, effective August 1, 2023): Updates Enhanced Ambulatory Patient Groups (EAPG).
- Nebraska (NE-23-0008, effective July 1, 2023): Updates the rate methodology for nursing facility and ICF-DD rates for state fiscal year 2024.
- New Jersey (NJ-23-0011, effective July 1, 2023): Updates the fee schedule rate for Private Duty Nursing.
- New Jersey (NJ-23-0012, effective July 1, 2023): Updates the fee schedule rates for Personal Care Assistant (PCA) services.
- New Jersey (NJ-23-0018, effective July 1, 2023): Updates the fee schedule rates for Family Planning Services.
- New Jersey (NJ-23-0021, effective July 1, 2023): Updates the fee schedule rates for Behavioral Health services.
- New Jersey (NJ-23-0022, effective September 1, 2023): Updates the fee schedule rates for NJ Integrated Care for Kids (InCK).
- Washington (WA-23-0034, effective July 1, 2023): Updates the ambulance transportation quality assurance fee expiration date from June 30, 2024 to June 30, 2028.
- Services SPAs
- Alabama (AL-23-0013, effective October 1, 2023): Clarifies that the state covers and reimburses approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).
- California (CA-23-0024, effective November 1, 2023): Adds Coordinated Family Supports services as a state plan home and community-based service..
- Illinois (IL-23-0029, effective January 1, 2024): Increases reimbursement rates for speech therapy services, physical therapy services, and occupational therapy services; adds speech-language pathology assistants, physical therapy assistants, and occupational therapy assistants as providers.
- Illinois (IL-23-0039, effective July 1, 2023): Updates the professional qualifications for technicians delivering Adaptive Behavior Support services to Medicaid beneficiaries diagnosed with autism spectrum disorder.
- Iowa (IA-23-0016, effective January 1, 2024): Provides a temporary modification to the end date of co-payment and premium suspensions for Hawki and Medicaid for Employed People with Disabilities (MEPD) enrollees as originally approved in Disaster Relief SPA IA-23-0010.
- Kansas (KS-23-0035, effective October 1, 2023): Adds Children Behavioral Interventionist (CBI) Services to assist in preventing hospital or institutional treatment.
- New Hampshire (NH-23-0005, effective October 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).
News
- According to the 2023 Kansas Speaks public opinion survey conducted by the Docking Institute of Public Affairs at Fort Hays State University, approximately 70% of Kansans support or strongly support expanding Medicaid, which includes a majority of respondents from each political party. Additionally, approximately 65% of Kansans believe that those who obtain health insurance as a result of Medicaid expansion deserve that benefit and that expansion would help rural hospitals remain open (The Wichita Eagle, November 5).
- Michigan’s Medicaid managed care contract process has officially launched, with bids due by January 1, 2024. Currently, no date has been set to announce the winning bidders. The awarded contracts are set to begin in October 2024 and run for five years with three one-year extensions possible following the end of the contract. Bids will be evaluated on a point system, with a significant emphasis on “narrative submission” and value-based payment arrangements with community-based organizations. Michigan has 10 Medicaid regions, each requiring at least two contracted providers, except for one sparsely populated region where only one provider is required. The current contracts are valued at $15.2 billion annually, and the new contracts are expected to be worth over $80 billion through the new contract period. The bidding process coincides with the ongoing Medicaid redetermination process where 270,600 people have been disenrolled in Michigan, with 465,600 having renewed coverage (Health Payer Specialist, November 6).
- Walmart is growing its presence in the healthcare sector with an expanded partnership with Centene subsidiary, Ambetter Health. The joint venture would be with Ambetter’s Sunshine Health, a plan offered on Florida’s exchange, and Orlando Health, a network of community and specialty hospitals throughout Florida. The collaboration is an extension of an existing relationship between Walmart Health and Ambetter Health that started in early 2023 when the two companies began collaborating on how to increase awareness of the Medicaid redetermination process (Health Payer Specialist, November 3).
- Section 1115
- Private Sector Updates
News
- Premiums for employer-sponsored health insurance in 2023 are 7% higher on average than in 2022, reaching $23,968, causing financial challenges for various stakeholders. The healthcare industry is facing pricing pressures due to higher labor costs, staffing issues, and the ongoing impact of the COVID-19 pandemic. Providers are demanding higher reimbursement to cover their increased costs, leading to negotiations and disputes with insurance carriers. Standoffs between payers and providers have increased, with 18 disputes remaining unresolved out of 74 counted in 2023. As a result of the ongoing negotiations, some employers cannot provide complete provider network lists to their employees. To combat this, employers are adopting cost containment strategies, including narrower provider networks and limits on prescription drug coverage, while expanding mental health benefits. On the other side, health insurance companies are working to explore ways to make healthcare more accessible and convenient, such as eliminating referral requirements for specialists (Modern Healthcare, November 7).
- Sellers Dorsey Updates
- The latest MassHealth Medicaid and CHIP Section 1115 waiver demonstration is currently approved through December 31, 2027, and has been central to the Commonwealth of Massachusetts’ goals of achieving universal healthcare coverage. The Commonwealth submitted an amendment on October 16, 2023 to further the overall goals of the demonstration. In case you didn’t have time to read the entire amendment, Sellers Dorsey summarized everything you need to know. We cover key changes and expansions, budget neutrality, waiver evaluation and more. Click here to download our summary.
Contact Us
Ready to make a bigger impact?
Discover how Sellers Dorsey can help.
Explore Careers at Sellers Dorsey
Bring your authenticity and passion to work every day.
Join a dedicated team committed to making a difference.