Tag: State News

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Biden admin will allow TennCare’s controversial block grant, with some caveats

 
 

MM Curator summary

[MM Curator Summary]: The state will no longer have a cap on spending, and CMS will tell it how it can spend the savings, and the closed formulary is out. But let’s still call it a block grant.

 
 

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.

 
 

The Biden administration is making TennCare’s new block grant, approved under President Trump, more tenable to Democrats who fought it from the start. And TennCare officials say they’re open to alterations, though they have yet to submit a formal response.

TennCare is Tennessee’s Medicaid program that provides health insurance for 1.4 million people — mostly women, children and those with disabilities. It’s mostly funded by the federal government, and conservatives have pushed for years to get the money as a block grant with much more flexibility for states. Tennessee was the first — and only — to get such a proposal approved. But TennCare director Stephen Smith says it was never just a block of money with no strings attached.

“I don’t place a lot of importance on what this is called,” he tells WPLN News.

And now, the federal agency over Medicaid is making the state’s latest funding formula even less like a block grant.

Under the changes, outlined in a letter dated June 30, the funding model would revert to being based on how many people have TennCare coverage instead of a dollar cap. There were always caveats with the cap allowing for years with big enrollment growth, so Smith says the change is not a big deal. Also, the feds want more say-so over how the state spends the money that it saves. Smith says there’s nothing to hide.

“We reinvest back into the program to enhance benefits, enhance services and add people to the program,” Smith says, pointing out TennCare has already expanded benefits like taking thousands off a wait list for home-based care.

The new administration is totally rejecting limits on which medications patients can get, known as a closed formulary. But TennCare knew that was a possibility, which is why Smith says the drug limits still haven’t been implemented a year and a half into the new funding model.

It also behooves the state to go along with the demands because the “block grant” — if it can still be called that — is already generating savings, Smith says. But that money can’t be spent on newly approved initiatives like dental coverage-for-all until the sticking points are settled.

“This is a 10-year waiver,” Smith says. “So, it’s to our benefit to solidify this, so we can have certainty for the next eight years.”

 
 

Clipped from: https://wpln.org/post/biden-admin-will-allow-tenncares-controversial-block-grant-with-some-caveats/

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Federal audit forces New Hampshire to repay $7.9M Medicaid funds

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[MM Curator Summary]: NH is writing a check to CMS over issues with poor quality of opioid addiction treatment services- 90% of methadone clinics did not provide required followups and other care.

 
 

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.

 
 

(The Center Square) – A majority of Medicaid-funded treatments for New Hampshire opioid addicts don’t meet quality standards, according to a new audit, which will require the state to pay back nearly $8 million to the federal government.

The audit, conducted for the U.S. Department of Health and Human Services, found that more than 90% of the state’s methadone treatment programs that billed the Medicaid program for services didn’t provide the required follow-up counseling or long-term recovery plans, and in many cases didn’t require follow-up with tests for illegal drugs.

Of 100 opioid treatment cases reviewed by federal auditors, only six complied with state and federal laws, according to the report.

“These deficiencies occurred because New Hampshire did not have the resources to oversee providers and enforce the opioid treatment program requirements,” the auditors wrote in the report. “Providers said high personnel turnover, difficulty attracting and retaining personnel, and difficulty keeping patients engaged in counseling services contributed to the lack of adherence to state requirements.”

Auditors also pointed out the New Hampshire officials didn’t provide enough guidance to providers on the treatment requirements.

In a response to the audit, New Hampshire officials accepted the findings and agreed to refund $7.94 million to the federal agency. That amount covers the estimated cost for more than 350,000 Medicaid claims from 2016 to 2019, according to the audit.

Overall, state officials say drug treatment programs have suffered the same staffing shortages in personnel as other health-care sectors which has impacted care.

“New Hampshire is not unique in the difficulty health-care providers experience recruiting and retaining direct workforce,” Henry Lipman, director of the state’s Medicaid program, wrote to HHS in a response to the audit.

He said the state is working on plans to expand the health care workforce and last year convened a working group of stakeholders to work on solutions to the hiring crunch.

“Over 70 health-care thought leaders from around the state convened to identify aligned priority projects and strategies that the department is uniquely positioned to help collaboratively address,” Lipman wrote. “We believe these efforts are important to ensuring care is delivered timely and with appropriate documentation.”

He wrote that the state has ordered Medicaid funded opioid treatment providers to conduct reviews of their programs and submit their findings next month.

But Lipman disagreed with claims in the audit that opioid treatment services are being rendered by “clinically unqualified personnel.”

“We are committed to working with OTP providers and Managed Care Organizations to ensure OTPs are available to provide critical treatment services which meet New Hampshire’s high standards of care,” he wrote in his response.

 
 

Clipped from: https://www.washingtonexaminer.com/news/audit-forces-new-hampshire-to-repay-medicaid-funds

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Medicaid program did not recover $292M in overpayments

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[MM Curator Summary]: NY MCOs did not run third-party liability ops like they should have.

 
 

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.

 
 

Lax oversight led to $292 million in overpayments from the state Medicaid program to never be recovered by New York officials, state Comptroller Tom DiNapoli’s office found in an audit released Wednesday. 

The payments were part of pharmacy claims, covering instances in which Medicaid has paid medical bills a third-party insurer should have covered, but was never clawed back. 

Both the state Department of Health as well as the Office of the Medicaid Inspector General should have done a more thorough job to ensure the payments were recovered, DiNapoli’s audit concluded. 

“Medicaid is essential for millions of New Yorkers, but the program needs to ensure that funding is only used for appropriate costs for those who need it,” DiNapoli said. “This is my office’s latest audit to uncover weaknesses in the Medicaid system’s oversight. These potentially unnecessary payments likely contributed to significant waste and a missed opportunity to recover the nearly $300 million in questionable payments. DOH should recoup any overpayments and take steps to better protect taxpayers from costly billing mistakes.”

The Medicaid program is considered a payer of “last resort.” If a recipient has third-party insurance coverage, those benefits should be exhausted first before Medicaid funds are used. 

DiNapoli’s audit covered October 2015 and May 2020, finding prescription drug claims that were paid by Medicaid managed care plans for which third party cairrers were not being billed. 

The comptroller’s office recommended state health officials review Medicaid payments made on behalf of those who have third party health insurance and assess pharmacy claims that were billed to those carriers. The audit also proposed an assessment of third-party liability recovery for managed care pharmacy services. 

 
 

Clipped from: https://www.ny1.com/nyc/all-boroughs/ny-state-of-politics/2022/07/13/audit–new-york-medicaid-program-did-not-recover–292m-in-overpayments

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Nearly 200K disabled Texans are waiting for help, some for a decade

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[MM Curator Summary]: Texas has 6 different waivers for HCBS, and hundreds of thousands of people are waiting to get services on them. But sure, lets expand Medicaid to much healthier members first.

 
 

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.

 
 

 
 

An open bible sits next to Chase Brown’s computer in his bedroom in his home south of Spring Branch. Brown spends a lot of time studying his bible and wants to become a minister. Employment training provided through a Medicaid waiver program, which use state and federal funds to get people care in the community instead of in an institution, could help him achieve that goal, but he has been waiting 11 years and counting for those services. 

Mark Mulligan, Houston Chronicle / Staff photographer

Texas has six Medicaid waiver programs for people with disabilities, which allow the state to use a combination of state and Medicaid funds for services to keep residents living in the community instead of in hospitals or nursing homes.

Services covered by these programs include personal care like dressing or bathing, therapies and short-term relief for caregivers, known as respite care.

About 170,000 people are waiting for access to one or more of these programs. While each program has its own waitlist, residents often add their name to more than one program list to give more opportunities to get care more quickly.

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The six programs are as follows, and the data is as of March:

  • Home and Community-based Services: provides services and supports to children and adults with an intellectual disability or a related condition who live in their own home, a family members’ home or a group home with no more than four people.
    Enrollment: 29,665    
    Waitlist: 108,838
  • Texas Home Living: provides services to children and adults with an intellectual disability or related condition while they live in their own home or a family’s home
    Enrollment: 3,965    
    Waitlist: 96,893
  • Community Living Assistance and Support Services: provides home and community services to children and adults with an intellectual disability or a related condition, such as cerebral palsy and spina bifida, that occurred before age 22.  
    Enrollment: 6,021    
    Waitlist: 78,259
  • Deaf Blind with Multiple Disabilities: provides services to children and adults who are deaf-blind or have a related condition that leads to deaf-blindness and have another disability.
    Enrollment: 313    
    Waitlist: 1,239
  • Medically Dependent Children Program: Provides services to children and adults who are 20 or younger nad are medically fragile as an alternative to a nursing facility.
    Enrollment: 5,689    
    Waitlist: 7,650
  • STAR+PLUS Home and Community Based Services: provides services for adults 21 and older to keep them out of a nursing home and in their community.
    Enrollment: 62,738    
    Waitlist: 19723

To add your name to the waiting list for the Home and Community-based Services or Texas Home Living programs, contact your Local Intellectual or Developmental Disability Authority. Their contact information can be found here. For the other four programs, call 1-877-438-5658.

Alex Stuckey is an investigative reporter with the Houston Chronicle. She can be reached at alex.stuckey@chron.com or Twitter.com/alexdstuckey.

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Written By

Alex Stuckey

Reach Alex on

Alex Stuckey is an investigative reporter for the Houston Chronicle. She is a 2017 Pulitzer Prize and 2022 Livingston Award winner. She also received the Charles E. Green Award for Star Reporter of the Year in 2022.

Since graduating college in 2012, journalism has taken her to five different states, where she’s covered a nuclear research facility, the Missouri Legislature, the mishandling of sexual assault reports at colleges and universities and even NASA. Her reporting throughout the years has put two people in prison, resulted in federal investigations at higher education institutions and overhauled broken policies at the state and local level.

She loves falling down information rabbit holes, playing in spreadsheets and listening to Gilmore Girls on repeat at work.

When she’s off the clock, you can usually find her playing with her dogs, Waffle and Moby, curled up on the couch with a good book or on her yoga mat.

 
 

Clipped from: https://www.houstonchronicle.com/news/investigations/in-crisis/article/Here-are-the-six-Medicaid-waiver-programs-17301957.php

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KS- Gubernatorial candidates at odds on approach to Medicaid expansion in Kansas

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[MM Curator Summary]: Those pesky politicians want to tie work requirements to expansion for able-bodied adults who can work and don’t meet the normal low-income requirements.

 
 

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.

 
 

 
 

Derek Schmidt, a Republican gubernatorial candidate for governor, would not support Medicaid expansion in its current proposed form, said Katie Sawyer, his running mate, during a candidate forum in June.

TIM CARPENTER/KANSAS REFLECTOR

TOPEKA – Katie Sawyer, Republican gubernatorial candidate Derek Schmidt’s running mate, said neither she nor the attorney general would support Medicaid expansion in its current proposed form.

Sawyer made the remarks at a candidate forum in Salina the last weekend of June in response to a question from an audience member who asked if Schmidt would support a plan to expand KanCare, the state-run Medicaid program. The audience member also questioned former Gov. Sam Brownback’s stance against expansion, arguing the state lost billions of dollars by not expanding.

“I can’t speak to what Gov. Brownback did,” Sawyer said. “What I will say pretty clearly is, as it stands right now in its current proposed form, Derek Schmidt would not be supportive of expanding Medicaid.”

 
 

CJ Grover, campaign manager for Schmidt, said the attorney general could not support current proposals because they would assist able-bodied Kansans without children without a work requirement. No matter who is governor, Grover said he did not believe the Legislature was likely to pass Medicaid expansion.

Overall, he said Schmidt considers himself an “open-minded skeptic” on the issue.

“Should the Legislature one day reconsider and decide to advance a proposal, there are requirements AG Schmidt believes must be met,” Grover said. “First, the state share of the expansion cost must be honestly paid for, second there must be a work or job training requirement to ensure expansion is not a welfare program but instead a way to help able-bodied Kansans who are working to support themselves, and third there must be a clear and enforceable prohibition of any taxpayer funding for abortion coverage.”

According to the most recent Kansas Health Institute estimates, expansion in January 2023 would lead to 148,000 newly enrolled Kansans. Nearly 88,000 adults who currently fall in the “Medicaid coverage gap” would gain coverage if Medicaid were to expand.

The April estimates indicate an increase of 36% from the pre-pandemic monthly average KanCare enrollment, but only a 1.4% increase in spending. In addition, KHI estimated that the American Rescue Plan Act would create $418 million in savings for Kansas over two years if KanCare were expanded to low-income adults.

“None of the non-expansion states have adopted expansion since ARPA was enacted,” the brief notes in conclusion. “In the meantime, Kansans who remain in the coverage gap have few alternatives for comprehensive affordable health insurance.”

KHI estimates include indirect effects of expansion enrollment for children and currently eligible adults.

Alliance for a Healthy Kansas estimates the state has lost out on over $5.6 billion without expansion and 150,000 Kansans fall in the Medicaid gap.

Proponents of expansion also highlight concerns with rural hospital closures. Since 2005, nine rural hospitals in the state have closed, and of the 105 rural hospitals in Kansas 75 are currently running at a loss and are vulnerable to closure, according to a Center for Health Care Quality and Payment Reform study.

Madison Andrus, a campaign spokeswoman for Gov. Laura Kelly, said the governor would continue to strongly support expansion.

“It will expand quality health care for 150,000 hardworking Kansans and create 23,000 jobs,” Andrus said. “That’s good for rural Kansas, good for the Kansas economy, and good for Kansas health care workers – and it will remain a top priority in her second term.”

 
 

Clipped from: https://www.derbyinformer.com/news/area_news/gubernatorial-candidates-at-odds-on-approach-to-medicaid-expansion-in-kansas/article_2dccaac4-fc9c-11ec-8d17-ffe35c5ca232.html

 
 

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State budget goes to Gov. Cooper

MM Curator summary

[MM Curator Summary]: The Good Guvn’r has to decide whether his year’s long fight for Medicaid expansion is worth throwing the whole state in disarray.

 
 

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.

 
 

 
 

Gov. Roy Cooper will now have to decide whether to veto the budget, which does not include Medicaid expansion. Cory Vaillancourt photo

Both chambers of the North Carolina General Assembly approved the state’s $28 billion fiscal year 2022-23 budget last week, but as Gov. Roy Cooper nears the halfway point of his final term, he’ll now have to decide whether or not to veto the proposal, which does not include what’s become his signature issue — Medicaid expansion.

“North Carolina is emerging from the pandemic stronger than before, and we will sustain that only if we invest in a strong foundation for our people: A quality education, good jobs and infrastructure, and access to affordable healthcare,” Cooper said  in a May 11 press release attached to his own budget proposal, which included Medicaid expansion. 

The House and the Senate each passed their own proposals for expansion, but ultimately could not agree on which to advance. 

Expansion aside, the proposed budget  represents a 7.2% increase from the previous biennium, increasing the rainy-day fund’s balance to nearly $5 billion and setting aside an additional $1 billion in anticipation of a recession. 

State employees will see a 3.5% pay increase, teachers 4.2% and non-certified public school employees either 4% or a raise to $15 an hour, whichever is greater. Entry-level teachers will also see an increase in starting salary. Overall, education spending is up nearly 7%. 

In the wake of the mass shooting at Robb Elementary School in Uvalde, Texas, North Carolina legislators pushed for a dramatic increase in school safety spending, including an additional $32 million in grants to support safety equipment and training as well as students in crisis. School resource officer spending will increase by more than $40 million, and an additional $15 million has been earmarked for elementary and middle school SROs. 

A series of threats to the state’s Historically Black Colleges and Universities this past February, including Fayetteville State University and Winston-Salem State University, prompted an additional $5 million in funding for cybersecurity and bomb threat prep at the state’s HCBUs. 

More than $880 million has been set aside for water and wastewater infrastructure projects, alongside $250 million to cover possible project cost overruns due to inflation. There’s also a small $5 million increase in the GREAT grants program for rural broadband. 

One element of Cooper’s proposed budget did make it into the General Assembly’s proposal, a $1 million appropriation to the Economic Development Partnership of North Carolina to identify megasites that could host advanced manufacturing facilities. 

Public safety spending is also on the rise, increasing nearly 4% over the last budget. An additional 13 magistrates, 11 assistant district attorneys and more than 130 judicial support and clerk positions will be funded if the budget’s approved. 

On the local level, there was much anticipation over how much state funding Haywood County and the Town of Canton would receive to aid in the recovery from historic flooding  that took place in August, 2021. 

The scale of the damage was initially estimated at more than $300 million, including private property. The Town of Canton suffered catastrophic losses to major infrastructure including police, fire and town hall. 

Given the town’s relatively small annual budget, replacing the multi-million-dollar facilities would have resulted in substantial property tax increases, however Haywood County’s Rep. Mark Pless said in a release that he’d worked to secure more than $23 million. 

At least $8 million will go toward repairing damaged buildings and the town’s playground. The appropriation is separate from a $9 million previous allotment intended for repair of water infrastructure damaged un the flood. 

Another $5 million is set for use on debris removal, mostly outside the town’s municipal boundaries. 

Yet another $5 million has been lined up to help farmers affected by the flood, which came just as many summer crops were ripening in the fields; famously, thousands upon thousands of green peppers littered streets and riverbanks from just south of Canton through Clyde. The money will be administered through the state’s Agricultural Crop Loss Program. 

There’s also another $5 million for bridges and roads destroyed in the flooding. The funding is earmarked for private roads and bridges not covered by previous reimbursements from the Federal Emergency Management Agency. 

Unrelated to the flood, an additional $5 million was appropriated to a separate crop loss program for a freeze that affected crops last April, and $150,000 has been allotted for baseball and softball facilities in Bethel. 

As part of the state’s overall public safety spending, Pless said that some of the funding would result in an additional assistant district attorney for the 43rd prosecutorial district as well as another assistant clerk for the Superior Court in Haywood. Since 2020, the judicial system has been hobbled by a backlog of cases due to COVID-19 shutdowns in the court system. 

Pless also secured $3 million for a wastewater treatment plant in Yancey County. 

“Our office is pleased with the appropriations for these important projects and positions,” said Pless. “We have been working hard this session to listen to the needs of the district and secure funding based on those needs and suggestions. While we did not secure all of our requests, we will continue to advocate for them in future budgets.” 

 
 

Clipped from: https://www.smokymountainnews.com/news/item/33909-state-budget-goes-to-gov-cooper

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Maryland Man Charged With Defrauding Medicaid in Scheme Involving Personal Care Services

 
 

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[MM Curator Summary]: Joe Tamjong stole $733,405 by submitting fake claims, including multiple times he was out of the country.

 
 

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.

 
 

 
 

Defendant Accused of Submitting Over $700,000 in Fraudulent Claims

            WASHINGTON – Joseph Tamjong, 50, of Lanham, Maryland, was arrested today after being charged in federal court with defrauding the D.C. Medicaid program out of hundreds of thousands of dollars. 

            The announcement was made by U.S. Attorney Matthew M. Graves, Wayne A. Jacobs, Special Agent in Charge of the FBI Washington Field Office’s Criminal Division, Maureen R. Dixon, Special Agent in Charge of the U.S. Department of Health and Human Services’ Office of Inspector General for the region that includes Washington, D.C., and Daniel W. Lucas, Inspector General for the District of Columbia.

            Tamjong was charged in a criminal complaint with health care fraud and health care false statements. He is to make his initial appearance later today in the U.S. District Court for the District of Columbia.

            According to charging documents, between approximately December 2014 and the present, Tamjong has been employed as personal care aide and/or a participant-directed worker to provide personal care aide services to District of Columbia residents who need assistance performing activities of daily living, such as getting in and out of bed, bathing, dressing, and eating. Tamjong is alleged to have submitted false timesheets claiming that he provided such services when in fact he did not, including when he was traveling outside the United States on eight different trips. Charging documents allege that between December 2014 and February 2022, Medicaid issued payments totaling approximately $733,405 for personal care aide services that Tamjong purportedly provided as a personal care aide or participant-directed worker.

            A complaint is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law.

            Today’s arrest marks a continued effort by the FBI, the Department of Health and Human Services’ Office of Inspector General, the District of Columbia’s Office of the Inspector General’s Medicaid Fraud Control Unit, and the U.S. Attorney’s Office to investigate and prosecute individuals who defraud the D.C. Medicaid program.  Since August 2018, 11 former personal care aides have pleaded guilty to defrauding Medicaid in the United States District Court for the District of Columbia. Six of those aides were sentenced to 13 months in prison; a seventh was sentenced to serve 15 months. An eleventh, Susan Tingwei—a licensed attorney—is scheduled to be sentenced on July 11, 2022.

            The government urges the public to provide tips and assistance to stop health care fraud. If you have information about individuals committing health care fraud, please call the Department of Health and Human Services’ Office of Inspector General hotline at (800) HHSTIPS [(800) 447-8477] or the D.C. Office of the Inspector General at (800) 724-TIPS [(800) 274-8477].

            This case is being prosecuted by Assistant U.S. Attorney Kondi Kleinman, with assistance from Paralegal Specialist Michon Tart.

 
 

Clipped from: https://www.justice.gov/usao-dc/pr/maryland-man-charged-defrauding-medicaid-scheme-involving-personal-care-services

 
 

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FL- State awards seven-year, $140M Medicaid IT contract

MM Curator summary

[MM Curator Summary]: Congrats to Automated Health Systems for the win to implement the unified operations center.

 
 

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.

 
 

 
 

Florida is going with Automated Health Systems (AHS) to handle a multiyear, $140 million IT contract involving the state’s massive Medicaid program.

The Agency for Health Care Administration (AHCA) initially awarded the contract to AHS earlier this month. The company’s competitors had until June 27 to submit written notice to the agency if they wanted to challenge the decision.

AHCA did not respond to Florida Politics’ requests for information regarding challenges. But the agency did receive informal notices of appeal from vendors. However, a formal challenge wasn’t filed by the June 27 deadline and the website shows the bid is closed.

Immediate attempts to contact AHS for a comment were unsuccessful.

The contract could be for up to a ten-year period. The underlying contract is for a seven-year stint, but the invitation to negotiate (ITN) allows the state to enter into a three-year renewal. If the contract is renewed, the ITN makes clear that it is the agency’s policy to reduce the overall payment amount by “at least” 5% “unless it would affect the level and quality of services.”

 
 

The $140 million ITN was one of three the state has advertised as it moves ahead with remodeling the Florida Medicaid Management Information System, known as FMMIS, from a singular system into a modular one instead. The new system is called Florida Health Care Connections, or FX.

The contract with AHS centers around what is known as the unified operations center (UOC), which is responsible for all interactions between the agency and stakeholders, a group that includes customers, providers, vendors, other state agencies and others. 

The UOC is responsible for management and tracking of outbound communications, and printing, fulfilling and mailing (including standard and electronic mail) information of any type as approved by the agency on a scheduled and an ad-hoc basis.

The UOC also provides historic and real-time analytic capabilities to understand issues, trends and opportunities to inform decision-making and improve the interaction with customers, health care providers and managed care plans.

Meanwhile, the agency again pushed back the timeline to award a seven-year, $33 million contract for a provider services module. That decision was supposed to be announced June 30, but it has been pushed back to later this fall.

 
 

According to state documents, the provider services module will electronically capture, validate and process provider enrollment applications (initial and renewal), including an automated screening and monitoring component to support state and federal requirements.

The third ITN the agency will award is for so-called core systems and is expected to be worth $154.5 million.

 
 

Clipped from: https://floridapolitics.com/archives/536480-state-awards-seven-year-140m-medicaid-it-contract/

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Washington State plan aimed to lower Medicaid pharmacy payments is rescinded

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[MM Curator Summary]: The state will not be allowed to set rates for dispensing fees pharmacists can charge, even though a state plan amendment was approved to do just that.

 
 

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.

 
 

 
 

Washington State Pharmacy Association | Jul 6, 2022 | Washington

CMS rescinded approval of a Washington State Medicaid amendment that aimed to dramatically lower pharmacy reimbursement rates.

 
 

 
 

The Washington State Pharmacy Association (WSPA), the National Community Pharmacists Association (NCPA), and the National Association of Chain Drug Stores (NACDS) voiced support for the CMS decision that they say will help maintain reliable patient access to care and pharmacy viability in Washington. 

“Pharmacies provide essential care and access to medications,” WSPA CEO Jenny Arnold said. “Adequate reimbursement for safe patient care is essential. Our pharmacies should not have to choose between taking care of their patients and keeping their doors open, so we are relieved by this outcome.”

On Jan. 19, 2021, the last day of the Trump administration, the acting CMS administrator approved a plan to reimburse pharmacies for Medicaid patients far below the actual cost of dispensing prescriptions. The decision was a sharp departure from CMS’ previous position, which was that the state’s reimbursement was unlawful primarily because it failed to consider the cost of dispensing. 

WSPA, NCPA, and NACDS sued CMS, accusing CMS of violating its own rules. As a result, the Department of Justice—which represented CMS in the case—filed a motion to remand the matter back to CMS, agreeing with the pharmacy groups that the final decision approving the amendment was unsupported by the administrative record before CMS and would not survive the legal challenge. 

“This is a win for patients and pharmacies not only in Washington, but around the country,” NCPA CEO Brian Douglas Hoey said. “Unfair pharmacy reimbursement rates must not stand. We are celebrating the outcome of this fight and will continue working to protect essential health care services provided by pharmacy teams.”

CMS reconsidered the Jan. 19, 2021, decision and determined that the amendment—which would have reimbursed pharmacies of all sizes well-below cost—would be disapproved. Specifically, CMS determined that the amendment is inconsistent with the requirement that “States have a State plan that provides such methods and procedures to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available to the general population of the geographic area.” 

CMS also found that the amendment was inconsistent with federal regulations “which provide that payments for drugs are to be based on combined examination of the ingredient cost of the drug and a professional dispensing fee.” 

“Pharmacies have a vital role to play in health care delivery, and CMS’ decision will go a long way in helping to ensure that the most vulnerable Americans continue to have access to the pharmacy-based services they rely on and expect,” NACDS President and CEO Steven C. Anderson said. “We commend CMS for doing the hard but necessary work to reverse its approval of Washington State’s flawed pharmacy reimbursement plan, which has for many years jeopardized the ability of pharmacies to meet patients’ health and wellness needs. This is not only a victory for Washington pharmacies and their patients, but also for pharmacies and the vulnerable patients they serve across the nation.”

This press release was provided by the Washington State Pharmacy Association.

Clipped from: https://stateofreform.com/featured/2022/07/cms-rescinds-approval-of-amendment-aimed-to-lower-pharmacy-reimbursement-rates/

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CMS wants Tennessee to change Trump-approved Medicaid block grant plan

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[MM Curator Summary]: Biden HHS now wants to un-approve the TN waiver that allows the state to deliver on value-based care.

 
 

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.

 
 

 
 

Jason Kempin via Getty Images

Dive Brief:

  • The Biden administration is asking Tennessee to make fundamental changes to its plan to create a Medicaid block grant program in the state.
  • The state’s controversial Medicaid plan was approved in the final days of the Trump administration. But the CMS held a federal public comment period through September that resulted in “significant concerns” for regulators about whether Tennessee’s policy promotes the objectives of Medicaid, according to a new letter to the director of TennCare, Tennessee’s Medicaid program.
  • The letter sent Thursday requests that Tennessee submit a new financing and budget neutrality model based on a traditional per member per month cap, instead of an aggregate cap, among other modifications.

Dive Insight:

Tennessee took a notable step to realize a long-held conservative goal in early 2021, when the Trump administration greenlit a waiver allowing the state to use a modified block grant in its Medicaid program.

Under the 10-year waiver, Tennessee receives a lump sum of money annually from the federal government. Tennessee can keep up to 55% of any amount spent below the funding cap and reinvest it in other programs, giving it significant power over how it spends federal dollars.

The waiver also allowed the state to create its own commercial-style formulary of covered prescription drugs without federal approval, and granted it authority to negotiate directly with drug manufacturers.

Tennessee said the waiver would allow it to spend money and be more flexible with benefits. But researchers said that capping federal funding — along with codifying incentives to spend below the cap — could result in the state restricting benefits to achieve savings, threatening low-income beneficiaries’ healthcare quality and access.

In an opinion piece published in The Tennessean in September, Karen Camper, a Democratic member of the state’s House of Representatives, called on the CMS to rescind the waiver entirely.

“Not rescinding the waiver undermines President Joe Biden’s health equity agenda, and marginalized Tennesseans will be the first to feel its negative impact. Setting a precedent with a program that wouldn’t need to be renegotiated for another 10 years is reckless and irresponsible,” Camper argued.

The CMS is now requesting that Tennessee make major changes to the proposal. Along with urging the state to find an alternative to its aggregate cap, federal regulators want Tennessee to modify its Medicaid terms and conditions to clarify that the state can’t cut benefits or coverage without amending its demonstration.

The agency also asked Tennessee to remove expenditure authority for pharmacy and associated pharmacy flexibilities from the demonstration. Additionally, Tennessee should include a request in the demonstration amendment for expenditure authority for state reinvestments to support with any savings, such as adult dental care or enhanced home services, the CMS said.

“Making these adjustments would significantly mitigate CMS concerns,” the letter says. The CMS requested Tennessee amend its demonstration by Aug. 30.

Oklahoma also tried for a block grant during the Trump administration, but later rescinded its waiver application.

 
 

Clipped from: https://www.healthcaredive.com/news/cms-tennessee-make-changes-medicaid-block-grant/626462/