Category: Curator

HHS Curator is our free research service published by our team. We read hundreds of Medicaid news items each week and highlight and summarize them for you to save you time.

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Medicaid costs, enrollment spiral in pandemic

 
 

 
 

MM Curator summary

 
 

Florida Medicaid will cost 19% more this year- but the state will have a $342M surplus because of the increased 6.2% FMAP increase for COVID. Then next year the state will have a $1.25B shortfall if the FMAP increase is not continued. No pressure.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

Clipped from: https://www.news4jax.com/news/florida/2020/12/16/medicaid-costs-enrollment-spiral-in-pandemic/

 
 

 

TALLAHASSEE, Fla. – A new forecast for Medicaid shows state economists and health officials continue to predict a jump in the number of people enrolling in the coming year — bringing a dramatic surge in the amount of money needed for the safety-net program.

In a report posted online Monday, economists projected that Medicaid costs in the current fiscal year, which started July 1, will total $31.6 billion, which is about 19 percent higher than during the 2019-2020 fiscal year. The COVID-19 pandemic, which has played a major role in increased enrollment, hit the state several months into the 2019-2020 fiscal year.

Despite the tremendous increase in enrollment and costs, the economists say Medicaid will have a $342.8 million surplus in general revenue funds this fiscal year. The projected surplus is a result of Congress’ decision to increase the federal government’s share of money this year for Medicaid, which is jointly funded by states and Washington.

Congress this spring approved a 6.2 percentage-point increase in what is known as the Federal Medical Assistance Percentage, or FMAP, a move that effectively drives up the amount of federal money going into the program and eases the burden on states.

But the $342 million current-year surplus, state economists agreed, will turn into a nearly $1.25 billion shortfall in the 2021-2022 fiscal year, “primarily caused by the end of the supplementary federal funding,” according to an executive summary of the report. That projected deficit will confront state lawmakers when they begin the annual legislative session in March and work on a budget for the 2021-2022 year.

The increased costs are driven primarily by a surge in enrollment as the COVID-19 pandemic has caused widespread job losses and new demands on the health-care system.

Florida’s Medicaid enrollment was around 3.9 million people before the pandemic. Economists, who meet as the state’s Social Services Estimating Conference, predicted enrollment of more than 4.44 million people this fiscal year, before the ranks swell to 4.588 million in 2021-2022 and then begin to subside in later years.

“As a result of the uncertainty arising from the future course of the COVID-19 pandemic and its differential effects on the economy, the conference increased total caseload in FY 2020-21 to 4,442,013 — well above the prior peak of 4,017,726 seen in FY 2016-17,” the report’s executive summary said. “Caseload then remains higher than the old peak throughout the forecast, despite its expected decline in the outer years as the unemployment rate improves.”

With Medicaid providing health coverage to poor, elderly and disabled people, enrollment is countercyclical, increasing in tough economic times and decreasing when the economy is thriving. Because Medicaid enrollment increases come during recessions when there is less tax revenue to pay for the program, it puts strains on state budgets.

With the pandemic cutting deeply into state tax collections, legislative leaders already are warning they will have to make budget cuts. The state’s Revenue Estimating Conference is scheduled to meet Friday to update overall general-revenue projections, which will be used in making budget decisions.

 
 

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1199SEIU pushing to repeal medicaid drug carve-out

MM Curator summary

 
 

Provider groups that can currently use the 340B program to redirect millions of surplus dollars are upset that this opportunity is being removed from them and given back to the state of NY itself.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Clipped from: https://www.news10.com/community/honoring-healthcare-heros/1199seiu-pushing-to-repeal-medicaid-drug-carve-out/

Pharmaceuticals in North Andover, Massachusetts on June 15, 2018. (AP Photo/Elise Amendola, file)

ALBANY, N.Y. (NEWS10) — The largest health care union in the country is joining the call to repeal “the disastrous Medicaid drug carve-out.”

Currently, the 340B program lets community programs buy medication at a deep discount while passing savings in the form of housing aid and food assistance to residents. New York plans to carve-out this Medicaid prescription drug program on April 1.

Dozens of community health groups—Save NY’s Safety Net coalition—want the Department of Health to reverse the changes to the 340B drug discount program. 1199SEIU United Healthcare Workers East (1199SEIU) has signed onto the coalition, which says the carve out changes will impact vaccine distribution and decimate service for thousands of vulnerable, underserved, and low-income New Yorkers who have been impacted the most by the pandemic.

“Each year, Callen Lorde reaches thousands of patients who would otherwise have nowhere to receive care. I believe with all my heart we improve the health and lives of our patients who receive essential services including housing and behavioral health. All of this is at risk if we lose the income we receive from the 340b program,” said Danielle Pickering, an R.N. at Callen Lorde Community Health Center and member of the New York-based union.

The coalition says hospital facilities and health care support groups statewide have written to the Department of Health to protest the change. They also point to a report—“Why New York Should Maintain its Medicaid Pharmacy Carve-In Approach“—indicating that the change would cost over $1 billion over the next five years. Community health groups also warn that changes to the 340B drug discount program will make it harder to educate people about the vaccine and vaccinate New Yorkers from minority communities.

Vaccine hesitation continues in underserved communities

“The programs 340B helps fund are the same programs that have helped community health centers forge relationships with communities that are justifiably skeptical of the COVID vaccine. The State should be relying on those relationships to build vaccine confidence in black and brown communities, not undermining them,” said Rose Duhan, CHCANYS president and CEO.

Duhan says changing the program would destroy those relationships and cost insurers hundreds of millions, all without amounting to savings for taxpayers. “We are begging the state: abandon this ill-conceived plan,” she says.

Coalition members include:

  • African Services Committee
  • AIDS Healthcare Foundation
  • Albany Damien Center
  • Alliance for Positive Change
  • Bridging Access to Care
  • Callen-Lorde Community Health Center
  • Community Health Care Association of New York State (CHCANYS)
  • Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA)
  • Communities Advocating Emergency AIDS Relief Coalition
  • Community Health Initiatives
  • Community Healthcare Network
  • Damian Family Care Centers
  • Drug Policy Alliance
  • EngageWell IPA
  • Evergreen Health Services
  • Finger Lakes Community Health
  • Gay Men’s Health Crisis (GMHC)
  • Harlem United
  • Hispanic Health Network
  • Housing Works
  • iHealth
  • Latino Commission on AIDS
  • Legal Action Center
  • New York Immigration Coalition
  • New York #Insulin4All
  • NYS Council for Community Behavioral Healthcare
  • Planned Parenthood Empire State Acts
  • Primary Care Development Corporation (PCDC)
  • RWC-340B
  • Ryan Health
  • Sun River Health
  • The Alcoholism & Substance Abuse Providers of New York State
  • The Institute for Family Health
  • The LGBT Community Center
  • The Mental Health Association in New York State
  • The National Working Positive Coalition
  • Therapeutic Communities Association of New York (TCANY)
  • TOUCH
  • Treatment Action Group
  • Trillium Health
  • VIP Community Services

 
 

 
 

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With new model, CMS opens up home care opportunities for MCOs serving dual eligibles – Home Care Daily News – McKnight’s Senior Living

MM Curator summary

 
 

A new CMS direct contracting model will allow Medicaid health plans to provide more services in the homes of members.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

Clipped from: https://www.mcknightsseniorliving.com/home/news/home-care-daily-news/with-new-model-cms-opens-up-home-care-opportunities-for-mcos-serving-dual-eligibles/

 
 

The Centers for Medicare & Medicaid Services’ new model for 2021 enables Medicaid managed care organizations (MCOs) to allow in-home aides to promote flu vaccines, manage medical appointments, and receive training on meal preparation for clients with diabetes and other nutrition-sensitive conditions. As part of the model, beneficiaries must be concurrently enrolled in both Medicaid managed care and Medicare fee-for-service (FFS) programs.   

The model, which CMS unveiled recently, strives to encourage Medicaid MCOs to partner with providers and suppliers, and implement care coordination programs that can improve quality and reduce Medicare FFS costs for dually eligible beneficiaries — or those who receive Medicare and Medicaid.

“Beneficiaries eligible for both Medicare and Medicaid are some of our most vulnerable neighbors and friends, and the COVID-19 pandemic has made this abundantly clear,” CMS Administrator Seema Verma recently said. “For too long we have struggled to deliver acceptable outcomes for this population, but today’s model is a game changer. It represents a significant step toward addressing these longstanding issues.”

Some examples of the actions MCOs and their affiliates serving as MCO-based Direct Contracting Entities (DCEs) — organizations that participate in Direct Contracting via a participation agreement with CMS — could take to better serve dually eligible beneficiaries include:

· Deploying care coordinators or in-home aides who provide Medicaid long-term services and supports to also actively promote flu vaccines, preventive screenings, evidence-based falls prevention, and diabetes management activities;

· Having care coordinators or in-home aides who provide Medicaid long term services and supports assist enrollees with managing Medicare-covered medical appointments to help reduce missed treatments;

· Training in-home aides — who often cook meals for their clients — on meal preparation for individuals with nutrition-sensitive conditions, like diabetes.

 
 

 
 

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Medicaid and CHIP enrollment grew 5.6% since last year

 
 

MM Curator summary

 
 

COVID and unemployment drove most of the 5.6% increase in the Medicaid rolls seen from July 2019 to July 2020. Early talks of a Medicaid bailout via an additional FMAP increase have begun.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

Clipped from: https://www.modernhealthcare.com/medicaid/medicaid-and-chip-enrollment-grew-56-last-year

Enrollment in Medicaid and the Children’s Health Insurance Program increased by 5.6% from July 2019 to July 2020, according to the Medicaid and CHIP Payment and Access Commission on Wednesday.

The expert panel said the economic fallout of the COVID-19 pandemic drove most of the increase. All states saw their Medicaid rolls grow except Montana and the District of Columbia, ranging from 0.2% in South Carolina to 30.2% in Idaho, which expanded its Medicaid program in 2020.

“The COVID-19 pandemic and related unemployment have major implications for Medicaid and CHIP,” MACPAC Chair Melanie Bella said in a statement.

The Families First Coronavirus Response Act temporarily raised Medicaid’s federal matching percentage—FMAP—by 6.2% until the public health emergency ends, granting states some much-needed fiscal relief. But states can’t curb eligibility, disenroll beneficiaries or raise premiums if they want the additional federal money. They also must cover all COVID-19 testing and treatment costs and can’t force local governments to pay a higher share of the state’s nonfederal Medicaid spending.

With Medicaid enrollment on the rise and tax revenue slipping thanks to the pandemic, many states are slashing their Medicaid spending to balance their budgets. They’re increasingly turning to provider rate cuts to make the numbers work. Experts say another FMAP increase could protect beneficiaries’ access to care by enabling safety-net providers to keep their doors open. But Congress seems unlikely to boost the federal match for Medicaid anytime soon.

According to MACPAC, Medicaid accounted for 9.2% of the federal budget in 2019. Medicaid and MACPAC accounted for 16.9% of national health expenditures in 2020.

More than 40% of people enrolled in Medicaid and CHIP in 2018 had family incomes less than 100% of the federal poverty, according to new MACPAC data. Enrollees were more likely to have fair or poor health than people with private coverage or no insurance.

In addition, drug rebates lowered gross drug spending by more than half in 2019. Medicaid managed care plans made up over 63% of Medicaid’s gross spending on drugs.

 
 

 
 

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U.S. Supreme Court takes Medicaid work-requirement appeal with N.C. implications | Local News | journalnow.com

 
 

MM Curator summary

 
 

North Carolina Medicaid expansion is tied to whether the state can have a work requirement, so the upcoming SCOTUS decision has a large impact on the TarHeel state.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

Clipped from: https://journalnow.com/news/local/u-s-supreme-court-takes-medicaid-work-requirement-appeal-with-n-c-implications/article_d3905850-4228-11eb-9bfb-abb4c897576c.html

 
 

One potential North Carolina path to Medicaid expansion — a controversial work requirement — has reached the U.S. Supreme Court.

Medicaid covers 2.2 million North Carolinians, with projections of expansion adding between 450,000 and 650,000 residents.

The justices are expected to review during their spring session the 3-0 D.C. Circuit Court ruling from February against work-requirement laws passed by Arkansas and New Hampshire.

The separate state cases have been consolidated by the Court.

Arkansas’ law placed a work, education and/or public service requirement on certain Medicaid recipients to qualify for benefits.

The N.C. General Assembly has not advanced a similar Medicaid-expansion work-requirement bill sponsored by Rep. Donny Lambeth, R-Forsyth, despite begrudging Democratic support.

Why? Because of intense Senate Republican opposition led by Senate leader Phil Berger, R-Rockingham.

Berger and other GOP legislative leaders claim the federal government could end its 90% match on additional administrative costs for expansion.

They also oppose an annual $758 million assessment that the state’s hospitals and health-care systems have agreed to provide to help cover the state’s 10% expense share.

However, several public-health advocates, as well as Lambeth, have said the GOP warning is unfounded.

Berger’s opposition carries more weight than similar Medicaid expansion scenarios in Idaho, Missouri, Nebraska and Utah because North Carolinians do not have the ability to initiate statewide ballot referendums.

As a result, there’s not much optimism that a favorable decision by the conservative-leaning U.S. Supreme Court on the work requirement would persuade senior GOP leadership to support Lambeth’s bill.

“The only potential option for any productive discussion on allowing access to Medicaid for North Carolina is some form of a work requirement,” Lambeth said.

Yet, Lambeth acknowledged that “even with that being allowed, it will be a very difficult decision for North Carolina going forward.”

Lawsuit background

The Trump administration’s Department of Health and Human Services approved changes in March 2018 to Arkansas’ Medicaid policies that allowed the state to add a work requirement for “able-bodied” individuals between ages 19 and 64.

The Affordable Care Act makes Medicaid available to households with incomes below 138% of the poverty line, or nearly $36,000 for a family of four. Arkansas’ waiver lowered the income level to qualify, thus reducing the number of eligible beneficiaries.

Residents in Arkansas and Kentucky sued U.S. DHHS in August 2018, claiming the agency acted “in an arbitrary and capricious manner” when approving the work requirements.

The three-judge appellate panel affirmed the D.C. District Court’s ruling that the agency “failed to analyze whether the (Medicaid work) demonstrations would promote the primary objective of Medicaid — to furnish medical assistance.”

Kentucky ended its Medicaid work requirement in December 2019, shortly after the election of Democratic Gov. Andy Beshear.

Lambeth had expressed confidence for several years that his Medicaid legislation — the latest version being House Bill 655 — has bipartisan support even with the work requirement.

HB655 stalled in the House Rules and Operations committee in September 2019 after Lambeth agreed to make a few changes and consider others requested by Democrats.

There are 36 states, though only Virginia in the Southeast, that have expanded their Medicaid program.

The Missouri and Oklahoma legislatures have adopted expansion, but it hasn’t been implemented.

Another path?

The 2019-20 N.C. budget stalemate hinged on Gov. Roy Cooper’s veto of the legislation, chiefly because the GOP budget does not include a form of Medicaid expansion and also contains a lower pay-rate increase for public school teachers than Cooper proposed.

Centers for Medicare and Medicaid Services has said it will not consider any Medicaid expansion waiver unless it has been passed by a state legislature.

With Cooper’s re-election and the Republicans maintaining their advantages in both chambers — Senate 28-22 and House 69-61 — there’s a significant likelihood that there could be gridlock on Medicaid expansion during the 2021-22 session.

That reality is a major reason behind a bipartisan push behind the N.C. Council on Health Care Coverage, which held its second of four scheduled meetings Friday.

Cooper and state Health Secretary Dr. Mandy Cohen are among the 44 participants that include five representatives with Triad ties: Lambeth; Sen. Joyce Krawiec, R-Forsyth; Winston-Salem businessman Don Flow, owner and chief executive of Flow Automotive Cos.; Sen. Gladys Robinson, D-Guilford; and Gene Woods, president and chief executive of Atrium Health, the not-for-profit parent of Wake Forest Baptist Medical Center.

The council features other members from the state’s health care, business and nonprofits sectors, as well as members of the Cooper administration and legislators from both sides of the political aisle.

The council focused on Medicaid expansion during the first virtual meeting on Dec. 4.

During Friday’s second meeting, some strategies discussed have conservative-backing, such as Association Health Plans for small businesses and reinsurance program.

Some are overall neutral, such as pursuing more innovation waivers through CMS.

Some are liberal leaning, such as increasing coverage for pregnant and postpartum women, and for parents with foster children. 

Also a priority: increasing access to, and coverage of, behavioral health services, in particular for individuals with intellectual and development disabilities.

“I think that there are core principles that we can agree to, like the fact that more people in North Carolina deserve health insurance,” Cooper told The Associated Press.

“This is not just purely a Medicaid expansion issue.”

Forecasts

Mark Hall, a public-health and law professor at Wake Forest University, said the Court could clarify what authority the federal government has to authorize individual-responsibility requirements for Medicaid enrollees.

 
 

 
 

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Medicaid MCOs covering dual-eligibles to join direct contracting

MM Curator summary

CMS will start allowing health plans that serve duals to participate in shared savings on the Medicare side under a new payment model (they currently can participate in shared savings on the Medicaid side). There will be 2 types of applications accepted: professional (with 50% of shared savings and losses) and the global (the plan is fully at-risk).

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Clipped from: https://www.modernhealthcare.com/payment/medicaid-mcos-covering-dual-eligibles-join-direct-contracting

CMS’ Center for Medicare and Medicaid Innovation will allow Medicaid managed care organizations serving beneficiaries dually eligible for Medicaid and Medicare to take part in its new direct contracting model, the agency said Thursday.

It’s the first payment model to enable Medicaid MCOs to coordinate and manage care for beneficiaries enrolled in both Medicaid managed care and Medicare fee-for-service coverage, according to CMMI. The agency wants to encourage Medicaid MCOs to coordinate care to lower Medicare fee-for-service costs by allowing them to take part in direct contracting’s global and professional options.

The professional track offers participants 50% shared savings/shared losses, while the global track puts participants fully at-risk.

“CMS believes that dually eligible individuals can benefit from more integrated systems of care that meet all of their needs — primary, acute, long-term, behavioral, and social — in a high quality, cost-effective manner. This new opportunity to participate in direct contracting creates the incentives and flexibilities for Medicaid MCOs to better integrate care for these beneficiaries,” CMS said in a statement.

Medicaid MCOs with dually eligible beneficiaries currently have no incentive to coordinate care to lower Medicare costs, CMS said. That’s because current savings from managed care investments in Medicaid services that reduce acute care utilization benefit Medicare, not Medicaid MCOs.

The agency suggested Medicaid MCOs and their affiliates could improve care and lower costs for dual eligibles by connecting them with high-value primary care providers, targeting care coordination to high-cost beneficiaries and better coordinating long-term services and supports, among other strategies and tactics.

CMMI plans to start accepting applications for all professional and global participants early next year, including MCO-based direct contracting entities.

Unlike other direct contracting entities, CMS will only use enrollment-based alignment to assign beneficiaries to MCO-based entities. It won’t use claims-based or voluntary alignment.

In addition, entities that don’t name participating or preferred providers won’t have to enter capitation-based arrangements. But if they do, they can use those payments to support population health.

For example, an MCO-based entity could enter “value-based payment arrangements with its downstream (providers) or to invest in healthcare management tools, such as innovative healthcare technologies (e.g., remote monitoring),” CMS said in a fact sheet.

According to CMS, CMMI will make sure MCO-based direct contracting entities align with states’ plans to better serve dually eligible beneficiaries by requiring them to get a letter of support from their state Medicaid agency to participate in the model.

“CMS will track both Medicare and Medicaid expenditures in order to ensure there is no cost-shifting from Medicare to Medicaid or vice versa,” CMS said in a statement.

Direct contracting is an evolution of CMS’ accountable care models and offers new waivers, beneficiary engagement tools and other flexibilities. Experts say its professional and global tracks favor new entrants over existing ACOs. CMMI has been on a tear in recent weeks, debuting its geographic option for direct contracting earlier this month. The geographic option created new ways for health plans to participate in direct contracting, just like this latest annoucement. Some stakeholders aren’t enthusiastic about the recent focus on insurers.

“We urge the Innovation Center to … put back the provider emphasis into this model. Specifically, to ensure ACOs and providers who are already focused on value-based care have an equitable opportunity to be successful in the professional and global options,” the National Association of ACOs said in a letter to CMS on Wednesday.

 
 

 
 

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HHS Proposes New Prior Authorization Rules for Medicaid, CHIP and Certain Marketplace Plans – Manatt, Phelps & Phillips, LLP

MM Curator summary

 
 

A new federal DHS rule will require payers to implement technology that reduces complexity and delays associated with prior authorizations in Medicaid, CHIP and exchange coverage. This rule also would add new requirements and clarifications related to the Interoperability Rule finalized in May 2020.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

Clipped from: https://www.manatt.com/insights/newsletters/manatt-on-health/hhs-proposes-new-prior-authorization-rules-for-med

 
 

On December 10, the U.S. Department of Health & Human Services (HHS) released a Proposed Rule with the goal of “making the prior authorization process less burdensome for payers and providers, and in turn, avoiding care delays for patients.” In addition, HHS proposes to build on the Interoperability Rule released in May 2020 by significantly expanding the circumstances under which healthcare payers must make data available in a standardized fashion via Application Programming Interfaces (APIs). (See here for Manatt’s June 2020 white paper on consumer digital health privacy, which addresses these API requirements and other issues.)

The Proposed Rule would apply to the following “impacted payers”:

  • Medicaid and CHIP programs, including both fee-for-service programs and managed care plans.
  • Qualified health plans offered on the Federally Facilitated Exchanges (FFE QHPs). Unlike the Interoperability Rule, the Proposed Rule would not affect Medicare Advantage plans or commercial plans offered on State-Based Exchanges.

If finalized, the Proposed Rule would take effect in 2023, and could require impacted payers to make significant updates to their existing technology and prior authorization procedures.

HHS has solicited public comments on all aspects of the Proposed Rule, and also on a variety of other issues related to prior authorization procedures. Comments are due by January 4, 2021. This timeline is significantly shorter than is typical for proposed rules, and suggests that the Trump Administration may be hoping to finalize the rule before President Trump leaves office.

What Are the Proposed Rules Regarding Prior Authorization?

If finalized as proposed, the following requirements would apply starting in 2023 with respect to prior authorization procedures for all services except prescription drugs. HHS has proposed to allow exemptions or extensions, however, for impacted payers that meet certain requirements.

  • Electronic requests and responses. Medicaid, CHIP and FFE QHPs would be required to implement APIs that: (1) allow providers to identify in advance each payer’s prior authorization requirements, including the list of services that require prior authorization and the documentation needed to request it; and (2) offer a HIPAA-compliant mechanism for providers to electronically send prior authorization requests and receive responses through the provider’s electronic health record (EHR) platform.
  • Tighter time frames. Medicaid and CHIP (but not FFE QHPs) would be subject to stricter time frames for responding to prior authorization requests. Specifically, Medicaid and CHIP payers would be required to provide notice of prior authorization decisions:
     

 
 

  • For expedited decisions, no later than 72 hours after receiving a request (consistent with existing standards for Medicaid managed care and CHIP);
  • For standard decisions, no later than seven days after receiving a request (down from the current limit of 14 days in Medicaid managed care and CHIP).
  • Reasons for denials. When denying prior authorization, Medicaid, CHIP and FFE QHPs would be required to provide a specific reason for the denial (e.g., a determination that necessary documents were missing, the service was not medically necessary or the patient has exceeded applicable service limits).
  • Increased transparency.
     

 
 

  • Information on pending and approved prior authorization requests would need to be made available to patients and providers through the Patient and Provider Access APIs (described below).
  • Impacted payers would be required to publish certain prior authorization data, including the list of services that are subject to prior authorization, the payer’s average and median response times for prior authorization requests, and the percentage of requests that were denied or approved, as well as information on appeals and extensions of time.

How Does the Proposed Rule Interact With the May 2020 Interoperability Rule?

  • Enhanced Requirements for the Patient Access API. The Interoperability Rule requires payers to make various types of clinical, claims and encounter data available to patients through a “Patient Access API.” The Proposed Rule would add new requirements for these Patient Access APIs, which are generally consistent with HHS’s existing guidance regarding API development and procedures for vetting the security of third-party apps that patients might use to access their data. In addition, the rule would require impacted payers to report quarterly on certain metrics regarding API data requests.
  • Two New APIs for Data Exchange. Over and above the Patient Access API, HHS proposes to require that Medicaid, CHIP and FFE QHPs implement a Payer-to-Payer API to facilitate data transfers when a patient switches payers, and a Provider Access API that allows providers to access data on their patients in real time.

Conclusion

HHS is proposing to enhance the ability for patients and providers to access payer-held data and to communicate with payers about prior authorization. These proposals would, however, require new compliance activities for Medicaid and CHIP programs as well as commercial plans offered on the Federally Facilitated Exchanges. Stakeholders interested in expressing their views on these proposals should be sure to submit their comments before the January 4, 2021 deadline.

 
 

 
 

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As pandemic tears through Louisiana’s economy, Medicaid enrollment surges by 208,000 | Legislature | theadvocate.com

MM Curator summary

 
 

COVID has driven a dramatic surge in Louisiana Medicaid enrollment, but the current DHS Director says 160,000 members are ineligible.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Clipped from: https://www.theadvocate.com/baton_rouge/news/politics/legislature/article_0dbc69f6-417f-11eb-b1ad-779ea34243b4.html

 
 

 
 

Culture Aid Nola distributes 10,000 pounds of food to New Orleans residents at Our Lady Star of the Sea church, 1835 St Roch Ave. Monday, May 4, 2020. CAN is no-barrier aid, meaning no paperwork or ID is required to access resources. Culture Aid Nola has distributed just under 40,000 meals since forming at the end of March in response to the COVID-19 crisis. CAN works with local businesses, city council members and non-profits to provide direct food relief , medicaid access navigation, reliable verified health information, aid navigation and other services. CAN also anticipates opening its 4th weekly food pantry soon, which will enable us to serve over 6,500 meals per week. (Photo by David Grunfeld, NOLA.com, The Times-Picayune | The New Orleans Advocate)

 

In February, weeks before Louisiana would discover its first case of COVID-19, the Louisiana Department of Health sent out letters to 24,000 Medicaid recipients, warning they would be kicked off the rolls if they didn’t respond and prove they qualify for the program.

The letters were part of a stricter eligibility system installed a year earlier, which checked the wages of all enrollees every few months, and required them to prove they didn’t make too much money to qualify. As a result, enrollment fell and remained consistently lower than before.

The pandemic prompted a complete turnaround.

After seeing enrollment in the government health insurance program drop by about 3% from 2018 to 2019, the pandemic and coronavirus response legislation passed by Congress caused a spike in Louisiana’s Medicaid population. The number of people covered by the program surged by more than 208,000 from November 2019 to November 2020. That’s a jump of about 13%.

In all, nearly 1.8 million people in Louisiana – about 39% of the state’s 4.6 million residents – were receiving Medicaid as of last month. 

The increase in Medicaid expansion, a part of the Affordable Care Act that Gov. John Bel Edwards put in place shortly after taking office in 2016, was even more dramatic. The number of people receiving insurance from expansion jumped by 116,128, a 25% increase. Expansion covers adults who make up to 138% of the federal poverty line. That’s up to $1,468 monthly for an individual or $3,013 a month for a family of four.

 
 

Medicaid rolls soar in Louisiana: Federal rules prevented the state from kicking people off the rolls, leading to a 13% surge during the pandemic. 

The spike in claims further reveals the scope of the pandemic’s toll on people across the state, many of whom turned to the government health insurance after being laid off.

“We know very well when the economy goes south the demand for public services increases,” said Jan Moller, head of the Louisiana Budget Project. “It’s perfectly understandable and rational that more people would qualify for coverage.”

“This is exactly what the safety net is designed to do, is to pick people up and give them something as basic as health care access at a very uncertain time.”

An historic number of Louisiana residents lost their jobs this year, as the pandemic and government restrictions hammered employers. Moller noted thousands of people dropped out of the labor force entirely, many because they had to take care of children at home with schools closed or shifted online. It’s also possible healthy people who previously qualified for Medicaid because of their low incomes signed up because the pandemic highlighted the importance of having health coverage.

 

Congress in the spring passed legislation that gave Louisiana and other states more money to pay for their share of Medicaid. The Families First Coronavirus Response Act increased the federal match rate by 6.2% for Medicaid, not including the expansion group. That generated about $283 million in savings to the state general fund in the fiscal year that ended this summer, according to state Sen. Sharon Hewitt’s office. Hewitt, a Slidell Republican, chairs the Medicaid Forecasting Panel.

In the current fiscal year, the savings totaled $440 million. The state Legislature used much of the money to pay for other spending priorities, like the state’s bankrupt unemployment trust fund.

In exchange for the windfall, Congress told states they can’t kick people off Medicaid during the pandemic, unless recipients move, die, or request a voluntary termination of their coverage, according to the Kaiser Family Foundation.

 
 

That meant the state suspended the stricter wage verification program, which critics said kicked many people off the program simply because they didn’t fill out paperwork more frequently. Republicans who have hammered the Health Department for what they say is fraud in the state’s program have said the stricter checks are a safeguard against people gaming the system.

Tara LeBlanc, interim executive director of Medicaid at the Louisiana Department of Health, said approximately 160,000 people being covered by Medicaid are ineligible. The agency is working with the feds on how to “end coverage” for people once the federal public health emergency ends.

“Individuals who are ineligible are expected to undergo a post eligibility review,” LeBlanc said in a statement. “It will take approximately six months to conduct the post eligibility review and catch up on suspended renewals.”

Hewitt, the chair of the Senate Republican delegation, said Medicaid was designed as a safety net for people who need health coverage during tough financial times.

“I can’t think of a more challenging financial climate or a bigger need for health care resources for our families than the current COVID pandemic,” she said. “Once this public health emergency is over and we get our people back to work, I look forward to working with the Department of Health to identify those individuals who may have needed Medicaid in 2020, but now have employer-sponsored insurance or are able to purchase health insurance on their own.”

 

Between mid-March and late October of this year, 71,848 people approved for Medicaid were in a household of someone making unemployment claims because of the pandemic, according to Hewitt’s office.

Enrollment trends for another piece of the Affordable Care Act, the individual exchange where people who don’t qualify for Medicaid or receive coverage from an employer can buy health insurance, is less clear.

Becky Mowbray, a spokesperson for the Louisiana Department of Insurance, said in an email new enrollments are down and renewals are significantly up so far, which is consistent with COVID-19-related job losses triggering special enrollment periods for people and increasing enrollment. But full data that captures the bulk of the individual exchange population, those who renew automatically, isn’t available yet.

 

Data from the U.S. Centers for Medicare and Medicaid Services shows enrollment through five weeks was roughly on par with the same time period last year in Louisiana. In 2020, the number of people signing up for insurance through the individual exchange fell to its lowest point on record for a second straight year, as Republicans sued to toss the Affordable Care Act.

Moller said he’s “extremely concerned” about what happens when the public health emergency ends and potentially hundreds of thousands of people receiving Medicaid in Louisiana will likely be disenrolled from the program.

“We want to make sure it’s done in the most orderly careful fashion possible and they don’t just dump tens or hundreds of thousands of Medicaid beneficiaries off the rolls” because of paperwork issues, he said.

 
 

 
 

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A year in, Idaho is paying more for new Medicaid enrollees with expensive conditions… | Eye on Boise | idahopress.com

MM Curator summary

Idaho Medicaid expansion will cost the state 50% more than projected this year and 100% more than next year, compared to the cost estimates used to decide on expanding.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

Clipped from: https://www.idahopress.com/eyeonboise/a-year-in-idaho-is-paying-more-for-new-medicaid-enrollees-with-expensive-conditions/article_c52fafa6-0618-54df-8366-308de850dff6.html

The struggle of delayed care leading to costlier and worse conditions rings true for many of roughly 94,000 Idahoans, many of them working poor, who are now covered by Medicaid expansion, write Post Register reporters Nathan Brown and Kyle Pfannenstiel. The cost of Medicaid expansion, which is paid 90% by the federal government and 10% by the state, is coming in higher than expected.

This will create a headache for lawmakers who must decide next year how to pay for a program that will cost the state tens of millions more than they originally thought, and has provided some vindication to conservatives such as Rep. Barbara Ehardt, R-Idaho Falls, who warned before expansion that it would cost more than projected, pointing to the experience of other states.

Ehardt said lawmakers need to control costs moving forward and earmark a revenue stream for Medicaid expansion so they don’t have to scramble for funding every year.

“I definitely feel that it needs to be a dedicated source,” she said.

Higher per-patient spending appears to be driving costs. There were 94,000 people enrolled in expanded Medicaid in November, just a few percent higher than the 91,000 the actuarial firm Milliman Inc. projected in 2018. But many of those people were uninsured for a long time and are now finally accessing care for conditions that have worsened due to lack of affordable preventive care.

“I think there has always been a kind of acknowledgment that the Medicaid expansion population might have pent-up demand,” said Alex Adams, head of the state’s Division of Financial Management.

A state-commissioned 2018 report on the costs and savings of Medicaid expansion projected it would cost the state $41.9 million this year and $44.6 million next year. The new estimates are $67 million this year and the agency’s budget request for next year is $84 million, Adams said, numbers that would also increase the federal share by hundreds of millions from the report’s projections of $370.1 million and $394.9 million, respectively. Gov. Brad Little will unveil his Fiscal Year 2022 budget proposal next month when the legislative session starts on Jan. 11.

“It would be premature to say what the governor’s recommendation might be, but we’re certainly looking at all options,” Adams said.

One thing that could help is that due to the coronavirus pandemic, the federal government is paying 76% of the cost of traditional Medicaid rather than 70% as it had been before. Adams said this savings to the state could be used to cover some of the additional costs of expansion, although he said this isn’t a long-term solution.

Another is that Idaho, unlike many states, is collecting more revenue than expected and has a good deal of savings despite the coronavirus pandemic.

You can read Brown and Pfannenstiel’s full story here at postregister.com (it originally ran in the Post Register on Dec. 10), or pick up today’s Sunday/Monday edition of the Idaho Press; it’s on the front page.