Tag: State News

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PHE – More than 1 million dropped from Medicaid as states start post-pandemic purge of rolls

MM Curator summary

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.

 
 

[MM Curator Summary]: 1 million out of the 23M added= 4.3%. So far 95.7% of the Medicaid expansion aka the “PHE” remains in place. Math.

 
 

 
 

Clipped from: https://www.philasun.com/week-in-review/more-than-1-million-dropped-from-medicaid-as-states-start-post-pandemic-purge-of-rolls/

 
 

ABOVE PHOTO: Samantha Richards looks over her Medicaid papers, Friday, June 9, 2023, in Bloomington, Ind. Richards has been on Medicaid her whole life and currently works two part-time jobs as a custodian. (AP Photo/Darron Cummings)

By David A. Lieb and Andrew DeMillo

ASSOCIATED PRESS

More than 1 million people have been dropped from Medicaid in the past couple months as some states moved swiftly to halt health care coverage following the end of the coronavirus pandemic.

Most got dropped for not filling out paperwork.

Though the eligibility review is required by the federal government, President’s Joe Biden’s administration isn’t too pleased at how efficiently some other states are accomplishing the task.“Pushing through things and rushing it will lead  to eligible people — kids and families — losing coverage for some period of time,” Daniel Tsai, a top federal Medicaid official recently told reporters.

Already, about 1.5 million people have been removed from Medicaid in more than two dozen states that started the process in April or May, according to publicly available reports and data obtained by The Associated Press.

Florida has dropped several hundred thousand people, by far the most among states. The drop rate also has been particularly high in other states. For people whose cases were decided in May, around half or more got dropped in Arkansas, Idaho, Kansas, Nevada, New Hampshire, Oklahoma, South Dakota, Utah, and West Virginia.

By its own count, Arkansas has dropped more than 140,000 people from Medicaid.

The eligibility redeterminations have created headaches for Jennifer Mojica, 28, who was told in April that she no longer qualified for Medicaid because Arkansas had incorrectly determined her income was above the limit.

She got that resolved but was then told her 5-year-old son was being dropped from Medicaid because she had requested his cancellation — something that never happened, she said. Her son’s coverage has been restored, but now Mojica says she’s been told her husband no longer qualifies. The uncertainty has been frustrating, she said.

“It was like fixing one thing and then another problem came up, and they fixed it and then something else came up,” Mojica said.

Arkansas officials said they have tried to renew coverage automatically for as many people as possible and placed a special emphasis on reaching families with children. But a 2021 state law requires the post-pandemic eligibility redeterminations to be completed in six months, and the state will continue “to swiftly disenroll individuals who are no longer eligible,” the Department of Human Services said in a statement.

Arkansas Gov. Sarah Huckabee Sanders has dismissed criticism of the state’s process.

“Those who do not qualify for Medicaid are taking resources from those who need them,” Sanders said on Twitter last month. “But the pandemic is over — and we are leading the way back to normalcy.”

More than 93 million people nationwide were enrolled in Medicaid as of the most recent available data in February — up nearly one-third from the pre-pandemic total in January 2020. The rolls swelled because federal law prohibited states from removing people from Medicaid during the health emergency in exchange for providing states with increased funding.

Now that eligibility reviews have resumed, states have begun plowing through a backlog of cases to determine whether people’s income or life circumstances have changed. States have a year to complete the process. But tracking down responses from everyone has proved difficult, because some people have moved, changed contact information, or disregarded mailings about the renewal process.

Before dropping people from Medicaid, the Florida Department of Children and Families said it makes between five and 13 contact attempts, including texts, emails, and phone calls. Yet the department said 152,600 people have been non-responsive.

Their coverage could be restored retroactively, if people submit information showing their eligibility up to 90 days after their deadline.

Unlike some states, Idaho continued to evaluate people’s Medicaid eligibility during the pandemic even though it didn’t remove anyone. When the enrollment freeze ended in April, Idaho started processing those cases — dropping nearly 67,000 of the 92,000 people whose cases have been decided so far.

“I think there’s still a lot of confusion among families on what’s happening,” said Hillarie Hagen, a health policy associate at the nonprofit Idaho Voices for Children.

She added, “We’re likely to see people showing up at a doctor’s office in the coming months not knowing they’ve lost Medicaid.”

Advocates fear that many households losing coverage may include children who are actually still eligible, because Medicaid covers children at higher income levels than their parents or guardians. A report last year by the U.S. Department of Health and Human Services forecast that children would be disproportionately impacted, with more than half of those disenrolled still actually eligible.

That’s difficult to confirm, however, because the federal Centers for Medicare & Medicaid Services doesn’t require states to report a demographic breakdown of those dropped. In fact, CMS has yet to release any state-by-state data. The AP obtained data directly from states and from other groups that have been collecting it.

Medicaid recipients in numerous states have described the eligibility redetermination process as frustrating.

Julie Talamo, of Port Richey, Florida, said she called state officials every day for weeks, spending hours on hold, when she was trying to ensure her 19-year-old special-needs son, Thomas, was going to stay on Medicaid.

She knew her own coverage would end but was shocked to hear Thomas’ coverage would be whittled down to a different program that could force her family to pay $2,000 per month. Eventually, an activist put Talamo in contact with a senior state healthcare official who confirmed her son would stay on Medicaid.

“This system was designed to fail people,” Talamo said of the haphazard process.

Some states haven’t been able to complete all the eligibility determinations that are due each month. Pennsylvania reported more than 100,000 incomplete cases in both April and May. Tens of thousands of cases also remained incomplete in April or May in Arizona, Arkansas, Indiana, Iowa, New Mexico, and Ohio.

“If states are already behind in processing renewals, that’s going to snowball over time,” said Tricia Brooks, a research professor at the Georgetown University Center for Children and Families. “Once they get piles of stuff that haven’t been processed, I don’t see how they catch up easily.”

Among those still hanging in the balance is Gary Rush, 67, who said he was notified in April that he would lose Medicaid coverage. The Pittsburgh resident said he was told that his retirement accounts make him ineligible, even though he said he doesn’t draw from them. Rush appealed with the help of an advocacy group and, at a hearing this past week, was told he has until July to get rid of about $60,000 in savings.

Still, Rush said he doesn’t know what he will do if he loses coverage for his diabetes medication, which costs about $700 a month. Rush said he gets $1,100 a month from Social Security.

In Indiana, Samantha Richards, 35, said she has been on Medicaid her whole life and currently works two part-time jobs as a custodian. Richards recalled receiving a letter earlier this year indicating that the pandemic-era Medicaid protection was ending. She said a local advocacy group helped her navigate the renewal process. But she remains uneasy.

“Medicaid can be a little unpredictable,” Richards said. “There is still that concern that just out of nowhere, I will either get a letter saying that we have to reapply because we missed some paperwork, or I missed a deadline, or I’m going to show up at the doctor’s office or the pharmacy and they’re going to say, ‘Your insurance didn’t go through.'”

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MH/SA- Many Medicaid patients lack access to opioid addiction treatment

MM Curator summary

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.

 
 

[MM Curator Summary]: Hey “advocates” – can we use some of that “free” Medicaid expansion money to deal with this? What’s that? Expansion money is not for the hard problems but for soft-ball rate cells only? My bad.

 
 

 
 

Clipped from: https://www.statnews.com/2023/06/23/opioid-addiction-treatment-access-2/

 
 

An estimated 82,998 people died from opioid overdoses in the U.S. last year. A new study published Friday in JAMA Health Forum drives home how lack of access to lifesaving medications could contribute to these preventable deaths.

The study is the most comprehensive Medicaid analysis of opioid addiction to date, analyzing a national claims dataset with 76 million patient data points between 2016 and 2018. Medicaid patients are already at disproportionate risk of opioid overdoses, almost four times higher than patients on commercial insurance. Correspondingly, Medicaid is one of the primary payers of opioid addiction treatment in the U.S., covering nearly 40% of adults under 65 with this chronic disease.

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“It’s a vulnerable slice of the population,” said Elizabeth Armstrong, an assistant professor of social work at the University of Maine, who was not involved with the study. “People’s socioeconomic status, as well as access to secure and stable housing, food security, mental health issues; these are all challenges that tend to cluster together.”

But insurance coverage doesn’t automatically mean that patients have access to treatments like methadone, buprenorphine, or naltrexone — the three FDA-approved medications for treating opioid addiction. Both methadone and buprenorphine activate opioid receptors at safer levels to reduce cravings and are associated with a reduced risk of death. Overall, the study found that 55% of Medicaid enrollees with opioid addiction received some medication treatment nationwide.

In New England, around 75%-80% of these patients received medication treatment. But in the majority of states in the Midwest and South, fewer than 40% of Medicaid patients diagnosed with opioid addiction received medication. “The variability suggests quality of care problems,” said Dennis McCarty, a study co-author and professor emeritus of public health at Oregon Health and Science University. “It reveals lost opportunities to intervene.”

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The authors also revealed significant disparities in treatment access within states. For example, while West Virginia as a whole had an above-average opioid addiction treatment rate of nearly 70%, treatment rates by county ranged from 23% to 82%. Right in the middle was Cabell County with a treatment rate of 64%, infamous for being the epicenter of the opioid epidemic, with 81 million prescription pain pills flooding the region over eight years. In 2018, Cabell County had the highest opioid overdose death rate in the state.

Patrick Marshalek, an associate professor of behavioral medicine and psychiatry at West Virginia University who was not involved with the study, said that while the findings are intriguing, it’s equivalent to “the first shot of a grainy video” — meaning that it’s not yet clear how to interpret some results. For example, across the study period, states varied widely in their coverage of methadone treatment, reimbursement rates, and whether or not they expanded Medicaid under the Affordable Care Act, making it difficult to directly compare state medication rates or extract lessons.

As one example, the study found that 83% of patients with opioid addiction in Maine received medication treatment — the highest rate of any state. But Armstrong thinks this may simply be because Maine hadn’t expanded Medicaid at the time, meaning that the state was insuring a much smaller patient population. “So there may have been less of a disjuncture between the population seeking treatment and the availability of treatment for that study period.”

Health economist Stephan Lindner, the lead author of this study and an associate professor of emergency medicine at Oregon Health and Science University, also noted that the research team wasn’t able to analyze race or ethnicity due to data quality concerns. But given well-known demographic disparities in opioid addiction treatment access, Armstrong suggests that Maine’s relatively homogenous population — about 94% of residents are white — could also help explain the state’s high medication rates.

The most pressing question is what can states do to close treatment disparities. “We fail people by not providing adequate treatment to people with opioid use disorder enrolled in Medicaid,” said Lindner.

Marshalek points to telemedicine as one powerful way to expand access to opioid addiction treatment, especially given that many regulatory barriers were relaxed during the Covid-19 pandemic and may soon become permanent.

Marshalek also said that West Virginia’s hub-and-spoke model serves as an example of how to expand access: Rather than expecting patients to drive hours to the main hospital in order to get medications, experts at WVU’s hub in Morgantown train doctors in primary care clinics and federally qualified health centers across the state to help them distribute opioid addiction treatment within their own communities.

On a similar note, Armstrong recommends providing opioid addiction care within school clinics and expanding access to non-students and family members, given that Medicaid already pays for school-based behavioral health services. In the long term, however, Armstrong says that the U.S. needs more people empowered to provide integrated behavioral health care, which is why she directs the Professional Opioid Workforce Response Program to train social workers in opioid addiction and create a network of providers across Maine.

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Lindner also emphasized the need for further research. By using Medicaid claims data, the study is inevitably unable to capture patients who have not interacted with the health care system. “They are flying under the radar, but, very importantly, they’re still there,” said Lindner, “and eventually they’re going to show up in the overdoses.”

Ultimately, combining various streams of data — including Medicaid claims, overdose fatalities, national surveys, and first responder data — could provide greater clarity about the human toll of opioid addiction.  From hopelessness to isolation to despair, “there’s a fire burning with this addiction epidemic,” Marshalek said, “and it’s really not that discriminating when it comes to looking for fuel.”

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OP/ED- An Idaho Without Medicaid

MM Curator summary

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.

 
 

[MM Curator Summary]: In which the opiner opines the unthinkable.

 
 

 
 

Clipped from: https://idahofreedom.org/an-idaho-without-medicaid/

 
 

 
 

 
 

Counterfactuals are hard to contemplate. What would the world be like if we never did X? Or, what if we had done Y, instead? In the classic movie, “It’s a Wonderful Life,” the main character, George Bailey, gets a glimpse of how his community would have fared had he never been born.  The experience is an eye-opener for him; it shows him his amazing influence and how he is a blessing to those around him. George learns the world is better with him in it than without him.

Is government medical welfare –  Medicaid — like George Bailey? Is Idaho’s world better with Medicaid in it? Let’s do a similar thought experiment. What would Idaho be like if we did not participate in Medicaid — one of the most expensive and least effective welfare programs ever devised? 

We must first recognize that programs (Medicaid) are costly, but people (George Bailey) are productive.  Most people produce more than they consume, while the government must feed off the productive sector to survive. The prosperity of a free people creates the capacity–and the incentives–for people to produce and then help their fellow man. The parasitic nature of government lacks the capacity on its own to promote the general welfare and therefore requires compulsory taxation. Thus, government programs, by their nature, are inferior to people.

The Idaho Freedom Foundation has extensively chronicled the beast and the burden that President Johnson’s Great Society program of Medicaid has become for Idaho.  As of 2023, 432,804 individuals are on Medicaid rolls, according to the Idaho Department of Health and Welfare, and the Legislature has appropriated a total Medicaid budget of nearly $4.68 billion for the coming fiscal year. We spend more than $10,000 per year for each person on Medicaid. Medicaid is enormous, with coverage exceeding 22% of Idaho’s population and consuming over 32% of government spending. The program  has been in place since 1966 and has done nothing to solve long-term poverty issues in the state.

No federal law  requires Idaho, or any state for that matter, to administer a Medicaid program. It’s completely optional. The last state to join Medicaid was Arizona, which did so in the 1980s. It’s clear that getting rid of the Medicaid behemoth would save the state (and the nation) billions of dollars from the start.  We will hear the cries immediately: “You don’t care about people, about kids. They will be dying in the streets for lack of health insurance assistance and the health care coming with it.” Is this a truly serious concern, though?

For a close comparison, The Washington Post reported in 2012 on how the U.S. might work without Medicare, a separate program for old age health insurance assistance.  Remember, the report spoke to the cost of medical insurance for seniors (Medicare), not for the poor (Medicaid).The Post report focused on two concerns. One was that medical care and insurance will become exceedingly expensive for those on fixed incomes. The other was that the elderly, more than other demographic groups,  need more health care because of their old age and its related health problems.   

The two concerns of seniors  — the cost for those on fixed incomes and the increased need for health care — don’t necessarily exist for many in the Medicaid population, who have more work opportunities and who have fewer health problems because of their younger age (and we could still manage to help the disabled and children without requiring the full Medicaid bureaucracy). 

Ending Medicaid is much less problematic than ending Medicare. Seniors do have more limitations on their ability to earn income, and they do have more health care needs. Top that with the fact that seniors have paid Medicare taxes their entire lives, and there are compelling philosophical problems with ending Medicare, at least as it applies to people who have been taxed for the program their whole lives. Some seniors do receive indigent support through Medicaid now (about 27,000), but ending Medicaid could include other options for them such as a more robust Medicare system for long term care and/or more family and community care responsibilities for their well-being.  In short, there are far fewer obstacles to ending Medicaid.

Prior to 1965, and the advent of state-run health insurance for the poor, medical insurance and care came largely from state policies via public assistance but more directly from communities and churches. There is scant evidence of “people dying in the streets for lack of health insurance or healthcare.” Quite the opposite, America has a history of being one of the most charitable countries on the planet.

According to the Charities Aid Foundation annual report,
World Giving Index 2022, the U.S. is the third most charitable country overall. We are in the top ten of all countries in the report’s three main measures of charity: helping a stranger, donating money, and volunteering time.  Imagine the charitable waterfalls that would be created if billions of dollars in Idaho were returned to individuals (from government) stoking their proclivities to help others. Churches, medical centers, communities, families, and individual benefactors would be better equipped to exercise their generosity and caring for others. Those private entities existed before Medicaid came into being. Where are they now? 

Let’s not forget how government “caring” often crowds out private charity. Knowing a government program exists, can make us complacent in helping others. We don’t leave our friends and neighbors to die in the streets. Instead we respond to incentives and to what our resources limit us to. Many of us will probably be more willing and ready to help when we know there isn’t a government safety net — in other words, when the caring responsibilities fall on us rather than a government program. 

We can only imagine the love, care and  personal sacrifice that would come when the charity falls to the private sector. Health foundations, community care centers, and church affiliated programs already exist. There is human dignity in helping others through voluntary donations and time sacrifice. Those virtues are squelched  when government bureaucracies commandeer our private responsibilities, but they are magnified when people are free to rise  to the occasion.

It’s not hard to imagine the true good for Idaho families that would come from ending or severely cutting the broken Medicaid system. Families could keep more of their tax dollars, shop for the best private insurance and health care, and see lower health care costs. Free from the state burden of Medicaid, Idaho could reduce taxes by more than  $1 billion per year.  Carefully crafted, that might mean cutting all Idaho property taxes or individual income taxes in half, permanently.It could mean ending corporate income taxes. Or cutting sales taxes as well as eliminating the sales tax on groceries.

With such a boost in disposable income, combined with more economic freedom, families could be more charitable toward their communities and each other in providing personal assistance. In all this, government in Idaho would be limited to its proper role.  And, restoring the competitive, private health insurance market will lead to lower costs and better service than the insulated, monopolized, government insurance program. 

Those searching for the best healthcare alternatives won’t be shunted into government cookie-cutter programs ill suited-for innovation and choice. Reverting to private health insurance and healthcare, individuals are sure to have more options and more freedom than they would under federal/state health insurance programs. 

The Idaho Freedom Foundation sees virtue in private action, in human caring, and in the liberty and dignity coming from personal sacrifice. Impersonal and coercive government programs and bureaus cannot develop virtue, and a government bureau is a poor and expensive substitute for the personal touch of friends caring for friends. The world needs more George Bailey and less Medicaid.  Let’s give liberty and love a try for a change.

Ronald M. Nate, senior policy fellow at the Idaho Freedom Foundation, is an economics professor at BYU-Idaho, holds a Ph.D. in economics from the University of Connecticut, and is a former state representative for Idaho Legislative District 34.
Ph. 208-403-3609

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MCO NEWS (KS)- Blue KC, partners will compete for $3.9B Kansas Medicaid contract

MM Curator summary

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.

 
 

[MM Curator Summary]: After about 2 years of delay drama, the MCO contract political game is starting back up.

 
 

 
 

Clipped from: https://www.bizjournals.com/kansascity/news/2023/06/27/blue-cross-blue-shield-kc-kansas-medicaid-contract.html

 
 

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Healthy Blue Kansas, a new entrant to the Kansas health care market, plans to compete for $3.9 billion in KanCare contracts later this year.

Russell Gray | KCBJ

After a multiyear delay, one of the Kansas City area’s biggest insurers is readying to make a run at a giant contract to manage the state of Kansas’ Medicaid program.

First announced in November 2021, Healthy Blue Kansas intends to bid this fall on $3.9 billion contracts that will determine which insurance companies oversee KanCare.

Blue Cross and Blue Shield of Kansas City, along with its partners Topeka-based Blue Cross and Blue Shield of Kansas and Anthem Partnership Holding Co. LLC, a subsidiary of St. Louis-based Elevance Health Inc. (NYSE: ELV), hired Bryan Baier as the president of Healthy Blue Kansas in May.

“Bryan is recognized throughout the industry as a trusted leader who brings to Healthy Blue an extensive knowledge of Medicaid and the important role it plays in the lives and well-being of Kansans,” Dr. Greg Sweat, chief health officer at Blue KC, said in a May release. “Under Bryan’s leadership, Healthy Blue will build and expand on our commitment to working with community-based organizations across the state to improve the health of Kansas communities.”

 
 

 
 

Bryan Baier became president of Healthy Blue Kansas in May.

Healthy Blue Kansas

According to the release, Baier has more than 20 years of experience in regulatory, compliance and legislative advocacy with Medicaid managed care organizations (MCOs). Baier and Healthy Blue will be based in Topeka

“By partnering with the KanCare program, care providers and community-based organizations across the state, Healthy Blue is eager for the chance to coordinate the care and critical support services that will enable individuals to live healthy and productive lives,” Baier said in the release.

Aetna, Sunflower Health Plan and United HealthCare are the current contractors for the state’s Medicaid program, which was first privatized under former Gov. Sam Brownback in 2012. KanCare serves 415,000 individuals.

The request for proposals for KanCare are expected to be issued in September, a Elevance Health spokesman said. Once awarded, Gov. Laura Kelly‘s administration indicates that the contracts would take effect Jan. 1, 2025.

Elevance Health, formerly Anthem Inc., has approximately 50 workers living in the Kansas City area. It has more than 100,000 employees across the U.S.

As of June 2022, Blue KC had 1,632 employees — almost all of which worked in the immediate Kansas City area.

According to its website, Blue Cross and Blue Shield of Kansas has 1,610 employees. It serves all counties in Kansas except Johnson and Wyandotte, which Blue KC serves.

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OP/ED- Texas Was Right to Reject Medicaid Expansion

MM Curator summary

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.

 
 

[MM Curator Summary]: In which the heretic says the heretical.

 
 

 
 

Clipped from: https://www.independent.org/news/article.asp?id=14586

 
 

What does Texas understand that other states don’t?

With the recent addition of North Carolina and South Dakota, 40 states have now opted to expand Medicaid coverage. Texas legislators ignored the lure of “easy money” from Washington and nixed the idea again. Who’s right?

Texas Medical Association lobbyists told state legislators that expanding Medicaid eligibility would reduce the number of uninsured by half, producing $5.4 billion a year in federal matching funds in exchange for $650 million a year in new state spending.

It’s the same bill of goods that lobbyists in other states used to pitch Medicaid expansion. But the numbers don’t add up.

According to calculations by the Foundation for Government Accountability, expansion states forecast that their total Medicaid enrollment would increase by about 6.5 million. As of 2022, the actual increase stood at 16.7 million.

Medicaid costs have also significantly exceeded forecasts. In 2012, the Department of Health and Human Services predicted annual costs would average $4,000 per person. By 2018, the actual costs were 50% higher: $6,100 per person.

Medicaid expansion, encouraged by the Affordable Care Act, has helped reduce the percentage of uninsured, lowering it from 17.8% in 2010 to 10.9% by 2019. But supply didn’t rise to meet the increased demand.

Instead, the overall number of annual physician visits decreased from an average of 332 per 100 people in 2010 to 276 per 100 in 2018.

The small uptick in physician visits among low-income patients was offset by small reductions among the rest of the population.

Expanding Medicaid to the relatively healthy might make sense if it improved general health. But there is little evidence it does. In Oregon, for example, a first-of-its-kind controlled trial tracked individuals who applied for Medicaid through a lottery.

After two years, there was no discernible difference in the health of coverage winners and losers.

Health outcomes aside, the Texas medical establishment apparently was hoping the added $5.4 billion in Medicaid matching payments from Washington would improve the bottom line. That was wishful thinking.

Medicaid reimbursement rates are generally lower than both commercial insurance payments and total provider costs.

Research shows that lower-income working-age people often substitute Medicaid for existing private coverage, which typically requires out-of-pocket cash payments for co-pays and deductibles. This reduces providers’ overall compensation.

Below-cost payments may be manageable when Medicaid covers a relatively small portion of the population, but when Medicaid replaces private payers for large portions of the population, the combination of below-cost payments, reduced commercial insurance payments, and increased regulatory costs, invariably exceeds the savings providers realize from providing less uncompensated care.

A 2020 analysis of IRS filings for 2,253 nonprofit hospitals in expansion and nonexpansion states confirms this. The analysis showed that Medicaid expansion reduced reported uncompensated-care costs by an average of $1.11 million between 2012 and 2016.

But it also increased average losses, largely due to reduced income from commercial insurance and below-cost Medicaid reimbursements, by $1.63 million.

For Texas lawmakers, the fight over Medicaid expansion couldn’t have come at a more opportune time: As state health care providers were grappling with the extraordinary staffing and financial burdens caused by the federal government’s unprecedented tolerance of illegal immigration.

This certainly helped focus their attention, as did the testimony of Dr. Robert Trenschel, president and CEO of Arizona’s Yuma Regional Medical Center, who told Congress earlier this year that providing uncompensated care for migrants cost his hospital $26 million in 2022 (helping to produce an operating loss of $14.2 million, according to HMP Metrics.)

The influx of migrants also has been “crowding out Yuma’s residents, competing for beds in the emergency room or forcing delays in elective surgery,” according to news reports. Complicating the problem are persistent staffing shortages. Staff, not physical beds, is the binding constraint for most hospitals. Yuma Regional is licensed for 406 beds, but at the pay rates it can afford, it usually staffs only 250 to 270 beds.

Texas border hospitals face similar problems. Medicaid expansion would have only exacerbated them.

To their credit, Texas lawmakers saw through the false economics of Medicaid expansion.

Even if expanding eligibility cost “only” $650 million per year, they understood that the same $650 million could be used to defray some of the costs imposed on hospitals, physician practices, and Texas citizens by the unprecedented level of immigration.

Or it could be used to improve care for those already covered by Medicaid. Some 114,000 developmentally and intellectually disabled Texans enrolled in Texas Medicaid have spent years on waiting lists for home- and community-based care they were promised but never received.

Shouldn’t public money be used to meet existing needs such as these before it’s spent on new benefits for healthy, able-bodied adults?

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MCOS- Iowa Medicaid contract triggers legal action over alleged conflicts of interest

MM Curator summary

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.

 
 

[MM Curator Summary]: In which an extensively documented set of concerns about the way the state made its MCO award decision is discussed. TL/DR- Lucy, you got some splainin’ to do.

 
 

Clipped from: https://iowacapitaldispatch.com/2023/06/13/iowa-medicaid-contract-triggers-legal-action-over-alleged-conflicts-of-interest/

 
 

The state of Iowa is accused of conflicts of interest in hiring a company that soon will begin managing the state’s billion-dollar Medicaid program. (Photo illustration via Canva)

With Iowa’s newest Medicaid managed-care provider set to begin work in less than three weeks, the state is now being accused of conflicts of interest in hiring the company.

A civil petition filed in Polk County District Court alleges Iowa’s newest Medicaid managed-care provider, Molina Healthcare of Iowa, was selected last fall in part because its CEO, Jennifer Vermeer, is Iowa’s former Medicaid director.

Vermeer, the petition claims, “worked closely over time” with those who played a key role in hiring her company to help deliver billions of dollars’ worth of Medicaid-funded health care services to almost 800,000 Iowans.

Molina is expected to begin working in Iowa on July 1.

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The petition was filed recently by CareSource Iowa Co., an Ohio-based nonprofit Medicaid managed-care company that failed to win the Iowa contract.

CareSource now seeks judicial review of the Iowa Department of Health and Human Services’ decision to hire Molina over CareSource, alleging the competitive bidding process used by DHHS produced an “unfair, biased result” that resulted in the hiring of “the only bidder that hired as its CEO a longtime colleague/supervisor” of state workers tasked with evaluating the bidders.

The petition notes that Molina earned 98% of the available points handed out during the evaluation process — a score that “even DHHS’s top witnesses admitted was shockingly high” and which CareSource argues “was no coincidence and demonstrates unfair bias” on the part of DHHS.

In court filings, DHHS has admitted to many of the factual claims made by CareSource, but has denied any bias or wrongdoing.

Bid evaluators allegedly lacked experience 

The hiring process that sparked the petition dates back to May 2021, when DHHS published a notice of its intent to solicit proposals from companies to manage Iowa’s Medicaid program. At the time, DHHS said it planned to select “up to four” companies for the work.

DHHS’s written solicitation for proposals did not disclose the specific evaluation criteria to be used in selecting the winning companies, and instead said only that DHHS would conduct a “comprehensive, fair and impartial evaluation.”

CareSource says it “invested millions of dollars and thousands of hours in learning about Iowa Medicaid’s needs and preparing an extensive and detailed proposal” to submit.

Each of the five members of DHHS’s evaluation committee independently reviewed each of the proposals submitted by five bidders: CareSource, Molina, UCare Iowa, Aetna Health of Iowa, and an incumbent Iowa Medicaid managed-care provider, Amerigroup.

According to CareSource, none of the evaluators compared any features of the proposals to any of the competing proposals, nor did they compare the proposals to the specific evaluation criteria or any other objective scoring methods.

The five evaluators eventually met to engage in scoring the bids through a pro

cess of consensus – although, according to Care Source, “there is no documentation of the reasoning justifying the consensus scores assigned to the various proposals.”

CareSource alleges the evaluation committee was comprised of DHHS staffers who “had spare time to devote to the evaluation process,” but didn’t necessarily have the expertise the job required.

“The disparity of the evaluators’ levels of experience with Medicaid managed care contracts was striking,” CareSource alleges. One evaluator, Jennifer Steenblock, had more than 30 years of experience specifically in Medicaid, but was the only member of Iowa’s Medicaid Leadership Team to assist with the evaluations.

A second evaluator had worked at Iowa Medicaid for only nine months at the time, while a third had no experience with Medicaid managed care oversight and helped run a state-run, long-term care facility that was the focus of a U.S. Department of Justice investigation.The remaining two evaluators had some management experience within DHHS but lacked “substantial experience with Medicaid managed care,” CareSource alleges.

Questions raised about conflicts of interest

While two of the five evaluators allegedly individually contacted the state’s procurement officer to raise concerns about their potential or perceived conflicts of interest due to their close working relationship with Amerigroup, these same evaluators would later testify that they “were told not to worry” about the issue, the petition claims.

Two other evaluators identified potential conflicts of interest on DHHS-supplied disclosure forms but, according to CareSource, there was no follow-up by DHS and the two were never asked if they could set aside any bias or personal opinions they might have.

The most qualified evaluator, Steenblock, had worked closely with Molina’s CEO, Vermeer, when Vermeer served as Iowa’s Medicaid director and when she later consulted for Iowa Medicaid, CareSource alleges in its petition to the court.

CareSource also claims that documents produced by DHHS demonstrate that the department’s “leadership was concerned Amerigroup would pursue litigation if not selected for an managed care organization contract.”

In the end, Molina was the top-scoring bidder, followed by Amerigroup and then CareSource. Rather than award all three of the companies a contract, DHHS Director Kelly Garcia opted to award only two contracts — one for Molina and one for Amerigroup.

Separately, Iowa Total Care has a managed care contract with Iowa that is expected to run through 2025. Together, the three companies are expected to manage the Medicaid program that each year provides $7 billion worth of health care services to 788,000 low-income or disabled Iowans.

According to the petition, Garcia later testified that her decision to hire Molina was based solely on the points awarded by the evaluators. According to CareSource, Garcia was “surprised and concerned by Molina’s extraordinarily high score,” but didn’t go back to the evaluation committee to investigate the basis for the score.

Withheld documents allegedly contradict testimony 

Last September, CareSource filed a formal request to have DHHS reconsider its decision, but the request was denied. CareSource then filed an administrative appeal, sought documents from DHHS and deposed the five evaluators and Garcia.

An administrative law judge held a hearing over several days last November and eventually issued a decision denying CareSource’s appeal.

On March 24, DHHS allegedly advised CareSource that it had discovered in its own offices three binders of procurement-related materials belonging to one of the evaluators, Brandi Archibald, that had not been turned over to CareSource in response to prior requests for such information.

The newly disclosed documents included handwritten notes on the proposals submitted by Molina, Amerigroup, and CareSource and “were squarely covered by CareSource’s September 2022 public records request” to DHHS, the petition alleges. The state agency admits the records “were merely sitting on a shelf in DHHS’s own offices,” according to the petition. The records allegedly contradict testimony by Archibald that she took no notes during her review of the bid proposals.

After the discovery of those records, CareSource asked DHHS to conduct another sweep of its offices to ensure no other relevant materials were missed. In April, DHHS turned over “still more evaluator materials it had failed to produce in response to the public records request,” the petition alleges.

This second batch of newly discovered records include handwritten notes from another evaluator who had testified that he took no notes, as well as extensive, typed notes prepared by Steenblock, the petition alleges.

Molina has been sanctioned by states, feds

CareSource is now asking that a district court judge review DHHS’s decision, reverse that decision, and order the department to either add CareSource as a third winning bidder or begin a new evaluation process, using a “fresh slate of unbiased and properly trained evaluators who are instructed to compare the proposals as required by Iowa law.”

A hearing on the matter is scheduled for Oct. 20. Amerigroup and Molina have each been granted the right to intervene and be heard in the case.

In recent years, Molina has had problems with state and federal regulators.

Last June, the state of California took enforcement action against Molina Healthcare of California and imposed a $1 million fine against the company for its failure to acknowledge and resolve 29,124 provider disputes between September 2017 and September 2018.

Days later, Molina Healthcare and its previously owned subsidiary, Pathways of Massachusetts, agreed to pay $4.6 million for alleged violations of the False Claims Act. Federal officials had alleged that Molina owned and operated a group of mental health centers that improperly submitted claims for reimbursement while failing to properly license and supervise mental health center staff.

In 2019, the Molina of Texas was fined $500,000 by regulators in Texas who alleged the company had been unable to pay beneficiaries’ claims on time. That penalty was imposed one year after the company agreed to settle allegations of late payments by paying a combined total of $7.7 million to the Texas Department of Insurance and various health care providers in the state.

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EXPANSION- NC will get $1 billion Medicaid expansion ‘bonus,’ but there’s disagreement on how to spend it

MM Curator summary

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.

 
 

[MM Curator Summary]: How do we split the loot?

 
 

Clipped from: https://www.bpr.org/2023-06-14/nc-billion-medicaid-expansion-bonus-disagreement-spend

 
 

The decision by North Carolina lawmakers to expand Medicaid will come with a billion dollars of new federal funds for the state. But the House and Senate disagree on how to spend the money.

The billion-dollar allocation from the federal government is called a “signing bonus” for expanding the government health care program to hundreds of thousands of people. It’s an incentive from Washington to convince more states to expand Medicaid.

Gov. Roy Cooper and leading House Republicans think the billion dollars should be used to fix the state’s troubled mental healthcare system. Supporters of the plan, including Ashish George with the National Alliance on Mental Illness, say the federal money creates a rare opportunity.

“I think it’s the best shot we’ve had in many, many years,” George said.

A state House bill calls for about a quarter of the money to go toward increasing Medicaid reimbursement rates to mental health providers.

Health and Human Services Secretary Kody Kinsley says the current reimbursement rates are too low, and that makes it hard to keep enough mental health professionals in North Carolina.

“If you can’t get an increased rate, or if you can’t get a rate that will sustain your business, you won’t stay in business in any place,” Kinsley said. “This is really stark, and I want to make this clear: Medicaid has not increased its behavioral health rates since 2012.”

The House plan also includes $50 million to help mental health practitioners pay back student loans. And it would fund a variety of new mental health care facilities.

Rep. Donny Lambeth, R-Forsyth, developed the House plan. He says hundreds of patients are stuck daily in emergency rooms waiting for treatment beds to come available at mental health facilities.

“We have a once-in-a-generation opportunity to strengthen our care,” Lambeth said. “Thus, the focus will be on opening more care options, providing incentives to staff more beds.”

Senate leaders want to spend ‘bonus’ on new children’s hospital, health sciences training

But Senate leaders want to take a different approach to spending the billion-dollar fund. Their budget directs the money to a wider variety of health care projects, including new hospital construction and new health sciences training facilities at community colleges and universities.

 
 

WUNC Politics

The WUNC Politics Podcast is a free-flowing discussion of what we’re hearing in the back hallways of the General Assembly and on the campaign trail across North Carolina.

Senate leader Phil Berger says he recognizes the state’s mental health crisis, but he’s not sure a one-time infusion of money can fix it.

“There is some concern as to whether or not just throwing a lot of money at a particular problem is actually going to move the needle that much, and maybe if there are other things in the health space that we can actually have some impact on with some of those dollars, it’s probably better to do that,” Berger said.

The biggest project in the Senate’s proposal is a hundred million dollars for a new UNC children’s hospital, which will include a mental health component.

Sen. Ralph Hise, R-Mitchell, says the children’s hospital is in need of an expansion.

“A lot of young kids are having to travel to Atlanta and Pennsylvania to get high-end children’s services and we hope to be able to offer that here,” he said.

The Senate plan also includes $40 million in incentives to entice more health care providers to locate in rural areas of the state. And it includes funding to help keep rural hospitals from closing.

Senators also want to build new community college health sciences buildings in smaller counties like Caldwell, Robeson and Pamlico. The goal is to train more health care providers in those areas.

Working on a compromise

Budget writers from the House and the Senate are now working to negotiate a compromise plan for the final budget. Kinsley says he’s hearing support from both chambers for mental health, but there’s disagreement on whether to use the Medicaid expansion money or other funding sources. He argues that while the backlog of mental health needs looks costly, it can ultimately save the state money.

“What I try to remind folks is that, you know, when you spend money on behavioral health, you drive down costs in the short and long term in a number of other buckets, right?” Kinsley said. “You drive down costs in incarceration costs and jail-based costs, you drive down costs for physical health controls. We know that people that have their behavioral health issues managed, their costs for diabetes and other chronic diseases decrease. You drive down costs around homelessness and other social services.”

Kinsley added: “Investing in behavioral health is not just about finding more money to spend, it is about spending that money first, because the payoff is huge in a number of other places.”

The final budget agreement will likely be released in the coming weeks.

 
 

 
 

 
 

 
 

 
 

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PROVIDERS- Montana governor boosts Medicaid payments for health care providers by hundreds of millions

MM Curator summary

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.

 
 

[MM Curator Summary]: The pretend Medicaid math is out for Montana this year.

 
 

Clipped from: https://montanafreepress.org/2023/06/14/montana-governor-boosts-medicaid-payments-for-health-care-providers-by-hundreds-of-millions/

 
 

Gov. Greg Gianforte gives his State of the State address in the state House chamber on Wednesday, Jan. 25, 2023. Credit: Samuel Wilson / Bozeman Daily Chronicle

Gov. Greg Gianforte on Wednesday announced signing the state’s roughly $14.3 billion primary budget bill, creating a roadmap for funding state government for the next two years and substantially increasing reimbursement rates for health care providers who care for Medicaid patients. 

In a press release Wednesday afternoon, the governor’s office touted many aspects included in House Bill 2, including income and property tax cuts, investments in state infrastructure, boosts to affordable childcare and housing programs, and a “historic” increase to Medicaid provider rates. 

” Any one of these accomplishments would be historic on its own. Taken together, we’ve passed one of the most transformational budgets in state history,” Gianforte said.

The governor’s deputy communications director, Brooke Stroyke, later confirmed that Gianforte approved the Medicaid rate increases as passed by the Legislature, despite a suggestion in May from House Majority Leader Steve Fitzpatrick, R-Great Falls, to cut $15 million from the overall rate increases. The most recently available analysis of the final rates from the Legislative Fiscal Division calculated an increase of $339.4 million in combined state and federal funds over fiscal years 2024 and 2025. 

Advocates for behavioral health providers and other impacted services heralded the governor’s announcement. 

“Montana’s mental health system and our citizens who rely on it desperately needed better reimbursements,” said Matt Kuntz, director of NAMI Montana, a mental health advocacy group, in a Wednesday text message. “It’s wonderful to have them pass.” 

The fight over how much to increase Medicaid reimbursements for certain types of providers dominated much of the 2023 Legislature. Republicans and Democrats, responding to a recently commissioned study that found the state underpays behavioral health, developmental disabilities and senior and long-term care providers, pushed to close that gap beyond what Gianforte’s budget originally proposed, though to different degrees.

While Democrats and providers sought to raise rates to meet the benchmarks identified in the 2022 study, some Republicans were wary of releasing a sudden flood of funding into that sector of the health care industry. Other members of the party, including the health budget subcommittee chair, Rep. Bob Keenan, R-Bigfork, supported record increases to rates but raised concerns that the surge in funds suggested by Democrats and service providers would put rates on the chopping block during future budget shortfalls.  

Health care providers, many of whom testified to lawmakers that Medicaid patients make up the majority of their caseloads, insisted that fully funding the rates identified in the study was the only way to prevent further closures of health care providers. At least 11 nursing homes shuttered around the state in 2021 and 2022, a trend also seen at local group homes and behavioral health services. In addition to inflation and a pervasive strain on direct-service providers during the pandemic, providers often pointed to inadequate Medicaid reimbursement rates as a leading cause of the closures. 

Throughout the course of the session, bipartisan support for funding for rate increases eventually brought levels up to those in the contracted study. Providers slated to receive the largest rate increases said Wednesday that the governor’s approval signaled less financial strain in the years ahead.

“The provider rate increase combined with our temporary county tax levy that we are receiving will allow us some more time to continue caring for our own community members that built and maintained our towns and that they will not have to relocate due to a closure,” said Wes Thompson, administrator at Valley View Home, a nursing home in Glasgow. “Stabilization in long-term care is not met with this rate increase but it’s a starting point that is so desperately needed due to Montana’s growing elderly population.”

The roughly month-long delay between the session’s conclusion and the governor’s approval of the budget created anxiety among many in the health care fields. In recent weeks, Democrats accused Gianforte’s office of holding provider rates and other high-profile bills hostage while legislators debated whether to override his vetoes of bipartisan reforms to the state psychiatric hospital in Warm Springs and the child welfare system. Two out of three of those override efforts were successful — lawmakers fell seven votes short of turning the child welfare reform into law. 

Members of both parties endorsed the final rates approved by Gianforte. 

“Good to see that’s checked off the list,” Keenan said in a Wednesday statement. 

Democrats celebrated the news as well while taking credit for their role in the result.

“This session, Montana Democrats finally convinced Republicans to invest in our community health care providers, and Montana’s seniors and working families will at last have a better shot at getting the care they need close to home,” said Rep. Mary Caferro, D-Helena in an emailed Democratic press release. 

The fiscal year begins July 1. 

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RX- Inflationary Rebates for Generic Drugs Offset Medicaid Spending

MM Curator summary

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.

 
 

[MM Curator Summary]: Good luck figuring out this nonsense. Will drug costs go down? Why did they go up? Stop asking those questions and believe the official “we have a clue what we are doing” line from HHS.

 
 

 
 

Clipped from: https://healthpayerintelligence.com/news/inflationary-rebates-for-generic-drugs-offset-medicaid-spending

Inflationary rebates for generic drugs totaled between 2 and 12 percent of the $53.6 billion Medicaid spent on the drugs between 2017 and 2020.

 
 

Source: Getty Images

 
 

By Victoria Bailey

June 14, 2023 – Inflationary rebates for generic drugs helped offset Medicaid spending from 2017 to 2020, but additional policies are needed to improve generic competition, according to a study published in Health Affairs.

Competition from generic drugs helps reduce spending on expensive brand-name drugs. Between 2014 and 2017, one in five generic drugs doubled in price over one year, leading to $1.5 billion of excess Medicaid spending.

The Bipartisan Budget Act of 2015 extended inflationary rebates under the Medicaid Drug Rebate Program to generic drugs starting in 2017 to help limit Medicaid spending when drug prices increase. Before this, generic drugs were subject to a baseline rebate of 13 percent of the average manufacturer price (AMP).

Researchers used Medicaid State Drug Utilization and CMS data to assess the economic impact of Medicaid inflationary rebates for generic drugs between 2017 and 2020.

They looked at three different drug price measures: AMP or the average price paid by pharmacies that purchase the drug directly from a manufacturer, the National Average Drug Acquisition Cost (NADAC) or the price paid by independent and chain retail pharmacies, and the average spending per unit reimbursed by state Medicaid programs.

Researchers obtained spending and utilization data for 33,656 national drug codes (NCDs) between 2017 and 2020. The median Medicaid reimbursement per prescription was $18. Total Medicaid generic drug spending over the four years was $53.6 billion, ranging from $2.9 billion to $4.1 billion per quarter.

AMP estimates were available in at least one quarter for 20,353 generic NDCs, representing $29.8 billion of gross generic drug spending. NADAC values were available for 27,583 NDCs, accounting for $43.2 billion of generic drug spending.

The percentage of generic drugs with non-zero inflationary rebates in each quarter across the study period ranged from 14 percent to 33 percent. Around half of the drugs owed inflationary rebates when they were calculated using AMPs (46 percent) and average Medicaid reimbursement (51 percent). A third of drugs had inflationary rebates when NADACs were used for calculations.

Inflationary rebates calculated using AMPs totaled $516 million between 2017 and 2020, offsetting 1.7 percent of the $29.8 billion pre-rebate Medicaid spending on generic drugs. In comparison, the baseline rebates of 13 percent of AMP totaled $1.7 billion or 5.7 percent of spending.

When using NADAC values, the total inflationary rebates were $1.5 billion, representing 3.5 percent of the $43.2 million in Medicaid spending. The baseline rebates totaled $3.5 billion or 8.2 percent of spending.

When using average Medicaid reimbursement prices, inflationary rebates totaled $6.5 billion or 12.1 percent of spending, while baseline rebates were $7.0 billion or 13 percent of spending.

Rebates were higher for drugs that were not orally administered, the study found. Using average Medicaid reimbursement, orally administered drugs accounted for 68 percent of drugs with rebates but only 30 percent of the total rebate amount. Meanwhile, injected drugs accounted for only 18 percent of drugs with rebates and 61 percent of the rebate amount.

Rebates were also concentrated among drugs with the highest use and prices. When using average Medicaid reimbursement to calculate rebates, drugs with 5,000 or more prescriptions per quarter accounted for 14 percent of rebated drugs but 67 percent of rebates. Drugs costing Medicaid $50 per prescription or more accounted for 28 percent of rebated drugs but 78 percent of total rebates.

The study findings suggest that some generic manufacturers continued to raise drug prices despite Medicaid implementing inflationary rebates in 2017.

“This may be because Medicaid represented only 10 percent of the prescription drug market, so Medicaid rebates were more than offset by higher revenue from private insurers and Medicare, which were not subject to inflationary rebates,” researchers wrote.

The Inflation Reduction Act of 2022 implemented similar inflationary rebates in Medicare, but it may still not be enough to stop manufacturers from raising prices.

“Inflationary rebates do not address the root causes of market failures that lead to rising generic prices, and it will be important for policymakers to ensure that the implementation of inflationary rebates now across both Medicare and Medicaid does not lead to market exits and shortages of essential generic drugs,” the study stated.

Future initiatives should target drugs with little or no generics, as prices are lower when more generic options are available.

 
 

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RX- 340 B Medicaid MCO Duplicate Discount Confusion and HHS

MM Curator summary

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.

 
 

[MM Curator Summary]: MCOs will have to add a field to the drug claims they manage under proposed CMS rules. The new field will make it easier for manufacturers to not get dinged having to offer discounts on drugs twice.

 
 

 
 

Clipped from: https://www.natlawreview.com/article/hhs-takes-steps-to-resolve-340-b-medicaid-mco-duplicate-discount-confusion

On May 26, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed an update to the Medicaid Drug Rebate Program (MDRP) rules, which includes provisions aimed at preventing 340B duplicate discounts on claims billed to Medicaid managed care organizations (MCOs). Duplicate discounts arise when both 340B discounts and Medicaid rebates are provided by a manufacturer for the same drug. Although drug manufacturers that participate in Medicaid are required to provide discounts on 340B drugs under the 340B Drug Pricing Program and are also required to provide state Medicaid programs with rebates under the MDRP on drugs dispensed to Medicaid beneficiaries, including Medicaid MCO enrollees, manufacturers are not required to provide both a 340B discount and a Medicaid rebate under the MDRP for the same drug.

IN DEPTH

Because the relevant statutory provisions do not clearly articulate whether the state Medicaid program, the Medicaid MCO or the 340B-participating provider (covered entity) is responsible for ensuring that duplicate discounts do not occur for Medicaid MCO claims, there currently is no uniform system for identifying Medicaid MCO claims for 340B drugs. In the years since Medicaid MCO drugs became eligible for rebates under the MDRP, the US Department of Health and Human Services (HHS) has generally encouraged the relevant stakeholders and affected parties to work together to develop a solution. To date, that has not occurred. It appears that HHS may finally be stepping in to develop, or at least work towards, a solution.

Under the proposed rule, CMS would modify the standard Medicaid MCO contract requirements to require Medicaid MCOs that provide coverage of covered outpatient drugs to use unique, Medicaid-specific codes and group numbers on beneficiary insurance cards. The use of these identifiers would assist state Medicaid programs, MCOs and 340B covered entities to identify Medicaid MCO claims that might not otherwise be readily apparent as Medicaid MCO claims. Currently it is not uncommon for Medicaid MCOs to use the same group identifiers as claims for patients with private insurance. If implemented as proposed, the various stakeholders could more efficiently develop additional tools to identify such claims as being for 340B drugs or to exclude such claims for being filled using 340B drugs. CMS indicated that this change would allow the MDRP to run more efficiently, and would be helpful to all parties by ensuring that Medicaid rebates and 340B discounts are being provided appropriately. CMS proposed that this new requirement be implemented into Medicaid MCO contracts no later than the next rating period, following the effective date of the final rule adopting this provision.

While the proposed rule would provide an important tool to assist in the development of additional policies to prevent duplicate discounts on Medicaid MCO claims, it would not itself effectuate a full solution. The proposed rule also does not address the ongoing concern among 340B covered entities that state Medicaid programs or Medicaid MCOs could expand 340B “carve out” requirements or reduce reimbursement rates on 340B drugs dispensed to Medicaid MCO enrollees, thereby removing the opportunity for 340B covered entities to obtain the benefit that Congress intended for them to receive through the 340B Program—i.e., generating revenue from 340B drug sales to enable 340B covered entities to provide and expand services in their communities.

CMS solicited comments on the proposed change by July 25, 2023, and specifically requested comments regarding the implementation timeframe and operational issues that may arise from requiring the inclusion of unique Medicaid identifiers on Medicaid MCO beneficiary identification cards.