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CMS finalizes rule for greater pricing flexibility for Medicaid drug purchases

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CMS has begun the process to define value based purchasing arrangements for drugs in the Medicaid program, with a focus on the value delivered by a drug to the individual patient. One key change to regs is to allow manufacturers the ability to report multiple best prices.

 
 

 
 

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.benefitspro.com/2020/12/23/cms-finalizes-rule-for-greater-pricing-flexibility-for-medicaid-drug-purchases/

New value-based pricing approaches could save up to $228 million in federal and state dollars through 2025.

 
 

 
 

The final rule codifies a broad definition of VBP, which can better align pricing and payment to observed or expected evidence and/or outcomes-based measures in a targeted population. (Image: Shutterstock)

States, private payers and manufacturers now have more flexibility to enter into value-based purchasing (VBP) arrangements for prescription drugs under Medicaid. The Centers for Medicare & Medicaid Services on Monday finalized regulatory changes to modernize Medicaid prescription drug purchasing and drive payment innovation.

“Rules on prescription drug rebates and related reporting requirements have not been updated in thirty years and are thwarting innovative payment models in the private sector,” CMS Administrator Seema Verma said. “Medicaid’s outdated rules have consistently stymied the ability of payers and manufacturers to negotiate drug reimbursement methods based on the actual outcome of the treatment. A new generation of approaches to payment methods is needed to allow the market the room to adapt to these types of curative treatments while ensuring that public programs like Medicaid remain sustainable and continue to receive their statutorily required discounts.”

Related: Drug pricing legislation and the impact on self-insurers’ pharmacy spend

Under current regulations, prescription drug manufacturers face challenges accounting for VBP arrangements in their Medicaid best price reporting to CMS. This has the unintended consequence of hindering providers, insurers and prescription drug manufacturers in their efforts to develop innovative payment models for new drug therapies and other innovative treatments. Current regulations also discourage payers and manufacturers from designing new payment arrangements based on the value their product may provide.

With the new flexibilities under this final rule, manufacturers are expected to be more willing to negotiate with payers, including Medicaid, with
drug pricing being driven by the value of their drug to the individual patient.
New genetic-based treatments initially may be expensive but in the long run offer significant value to the patient and payer.

Payers will be able to negotiate prices with manufacturers for these genetic-based treatments based upon outcomes and evidence-based measures such as reduced hospitalizations, lab visits and physician office visits, ensuring that if such measures fail to support the value of a drug, the payer is not held accountable for the full price.

The final rule codifies a broad definition of VBP, which can better align pricing and payment to observed or expected evidence and/or outcomes-based measures in a targeted population. The final rule also allows manufacturers to report multiple best prices instead of a single best price when offering their VBP arrangements to all states. By making these changes, effective in January 2022, CMS hopes to encourage VBP arrangements and negotiations to help make new, innovative therapies more available to all patients. As a result, it is estimated that these new

VBP approaches could save up to $228 million in federal and state dollars through 2025. Basing payment on the effectiveness of a given therapy can foster innovation in the treatments that are most beneficial to patients, while reducing overall health-care spending and hospital visits. When payers are positioned to be stronger negotiators with drug manufacturers, Medicaid beneficiaries will benefit from better access to prescription medications.

 
 

 
 

 
 

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D.C. Medicaid contract awards violated procurement rules, judge says

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A judge has ruled that the latest round of DC MCO contract awards must be re-evaluated.

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.washingtonpost.com/local/dc-politics/judge-says-dc-violated-law-in-awarding-three-lucrative-medicaid-contracts/2020/12/16/4000ba38-3f41-11eb-9453-fc36ba051781_story.html

D.C. Mayor Muriel E. Bowser (D) speaks at a ceremony in November. (Bill O’Leary/The Washington Post)

The D.C. government violated procurement laws when it awarded three of its largest contracts this summer — totaling $1.5 billion for three companies to manage health care for Medicaid recipients, a D.C. Contract Appeals Board judge ruled.

The city must reassess the contracts that govern which insurance plans are available to hundreds of thousands of poor Washingtonians, Judge Nicholas A. Majett said in his order. The decision could mean tens of thousands are forced to change health plans, some for the second time in a year.

Deputy Mayor for Health and Human Services Wayne Turnage said in an interview Wednesday that he would seek a solution that would allow as many beneficiaries to keep their current health plans as possible: “The goal of the administration is to make sure that we do not have to move the beneficiaries yet again. We will do all that we can to prevent that from happening, and I believe we will be successful.”

Majett ruled that all beneficiaries may stay on their current plans through the end of September 2021.

The administration of D.C. Mayor Muriel E. Bowser (D) decided earlier this year to move a larger number of Medicaid recipients in the city onto what is known as a managed-care plan, where a private insurance company provides health insurance to Medicaid recipients.

Three providers won contracts to offer those plans: MedStar, AmeriHealth and CareFirst. Amerigroup, a company that previously provided managed-care plans for the city but lost out on this bid, challenged the decision.

Majett ruled in Amerigroup’s favor this month, with Chief Administrative Judge Marc D. Loud Sr. concurring. The Dec. 1 ruling was unsealed Tuesday.

Under District procurement law, companies that bid on city contracts are scored on a point system. Of the seven companies that bid on the Medicaid contract, according to Majett’s ruling, the three contract recipients scored the highest, followed by Amerigroup.

But Majett found that MedStar did not include information about its leadership that was supposed to be in its bid, and that the company submitted performance evaluations pertaining to two previous contracts when it should have submitted three.

MedStar should have scored lower under the law, and Amerigroup should have scored higher, Majett wrote, concluding that Amerigroup was judged more harshly than MedStar for weaknesses in its responses.

Turnage said Wednesday that the Department of Health Care Finance would respond to the ruling. Asked whether he would consider keeping just two providers, AmeriHealth and CareFirst, given the judge’s finding that MedStar was unfairly ranked, Turnage said, “I don’t want to speak in hypotheticals.”

The lucrative Medicaid contracts have been overturned in similar fashion before, most recently in 2017.

 
 

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2020 MACStats Released by MACPAC

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The first MacPac data book with T-MSIS data is now available.

   
 

   
 

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.jdsupra.com/legalnews/2020-macstats-released-by-macpac-51897/

   
 

On December 16, 2020, the Medicaid and CHIP Payment and Access Commission (MACPAC) released its annual MACStats: Medicaid and CHIP Data Book for 2020.  This document contains a wealth of information about the Medicaid and CHIP programs and it is the primary source of information about these two important public health insurance programs.  You can access MACStats here.

This is the first MACStats to derive information from the Transformed Medicaid Statistical Information System (T-MSIS).  CMS has worked with states for many years to transform the prior Medicaid Statistical Information System.  The new data set contains enhanced information about Medicaid eligibility; beneficiary and provider enrollment; service utilization; claims and managed care data; and expenditure data for the two programs.  As CMS noted in March of 2019, “access to high-quality, timely data is essential for ensuring robust monitoring and oversight of the Medicaid and CHIP programs.”  The T-MSIS data set contains that quality and timely data.

Want to know how many people were ever enrolled in Medicaid or CHIP in 2018?  The answer is 96.1 million, or 29.3% of the U.S. population (see Exhibit 1, page 3).  Want to know how much Florida Medicaid spent on disproportionate share hospital payments in 2019?  The answer is $236.8 million (see Exhibit 24, page 63).  Want to know how much the state of Maine spent on Medicaid benefits in 2019?  The answer is $2.9 billion (See Exhibit 23, page 60).  Want to know how much Massachusetts received in § 1115 waiver payments in 2019?  The answer is $831.2 million (see Exhibit 24, page 63).  Ever wondered what percentage of Wyoming residents receive their Medicaid benefits through managed care?  The answer is a minuscule 0.2%, as opposed to Tennessee’s 91.8%.  (see Exhibit 29, page 78).

All this and more is available in MACPAC’s helpful, detailed and thoughtful analysis of the Medicaid an CHIP programs.  The MACStats guidebook is a key data source for those who care about these important public health programs.

   
 


    

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Medicaid costs, enrollment spiral in pandemic

 
 

 
 

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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

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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

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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

 
 

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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

 
 

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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

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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

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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.