June 26, 2024 - Health Management Associates HMA Weekly Roundup – June 26, 2024 (2024)

Unlocking Solutions in the Medicaid, Medicare, and Marketplace Programs

Health Management Associates (HMA) is hosting its 2024 Fall Conference October 7−9 in Chicago, IL. Unlocking Solutions in Medicaid, Medicare, and Marketplace Programs promises to enhance your ability to navigate and shape healthcare programs and systems, focusing on improving health and well-being.

In a landscape dominated by endless video meetings, the HMA Fall Conference offers a refreshing change. Join us for an enriching experience featuring:

• Engagement with healthcare experts and thought leaders who are actively collaborating with stakeholders
• Participation in face-to-face discussions to exchange ideas and receive valuable feedback
• Opportunities to connect with peers who are committed to strengthening public programs and enhancing health outcomes

Keynote Address and Sessions

Darshak Sanghavi, MD, from the Advanced Research Projects Agency for Health (ARPA-H), will deliver the Keynote Address. He and other speakers will inspire attendees to explore innovative healthcare programs and their potential impacts on healthcare delivery, reimbursem*nt, and health outcomes.

The conference will feature a diverse array of speakers and participants, including C-suite executives from national, regional, and local health plans. Federal and state leaders joining panels will include:

• State Medicaid directors from New York, Iowa, New Mexico and Alabama
• State insurance commissioners
• Behavioral health agency officials
• State housing agencies
• Leaders from the US Interagency Council on Homelessness

The conference will include a revamped pre-conference workshop on October 7, featuring hands-on exercises and interactive sessions led by HMA leaders. Sessions will include a value-based care contracting exercise, a value-based purchasing assessment discussion for providers, tips and tricks on navigating Medicaid section 1115 demonstrations, AI applications in healthcare, and more.

The agenda and event details, including speakers confirmed to date, can be found here.

Registration

Early bird registration is open until July 31. Don’t miss this opportunity to gain actionable knowledge, forge valuable connections, and discover fresh insights and best practices. Register now to secure your spot at the forefront of healthcare innovation.

Zeroing in on Medicare Advantage Policies Set to Transform the SNP Landscape Beginning in 2025

Regulatory policy changes finalized by CMS aim to increase the percentage of dual-eligible individuals enrolled in integrated plans

This week, our In Focus section delves into important and complex regulatory policy changes that affect coverage and services for the 12.9 million individuals who are dually enrolled in both Medicare and Medicaid. These policy changes—which were finalized as part of a broader final rule that the Centers for Medicare & Medicaid Services (CMS) released on April 4, 2023—are designed to increase the percentage of dually eligible people who are enrolled in integrated Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs). The modifications will be phased in gradually, with certain provisions affecting D-SNPs starting in 2025. These adjustments forge a stronger connection between state-level policy and operational decisions, shaping the future landscape of D-SNPs.

Overview

Amid rapid growth of D-SNP plan offerings and increased enrollment of dually eligible individuals into D-SNPs, CMS has finalized an interconnected set of regulatory policy changes to increase enrollment in integrated plans while simplifying coverage and plan options for this population.

By promoting enrollment in integrated plans, CMS seeks to improve the care experience and outcomes for dually eligible individuals, with the ultimate goal of making integrated plan enrollment the standard. Integrated D-SNP plans, which consolidate Medicare and Medicaid services under one managed care organization, offer uniform consumer protections (including unified grievance and appeals process), integrated plan materials, and more coordinated care.

Key policy changes include:

• Replacing the current quarterly special enrollment period (SEP) with a monthly SEP for dually eligible and other low-income subsidy (LIS) individuals to enroll into a standalone prescription drug plan (PDP)
• Establishing a new integrated care SEP that will enable dually eligible individuals to choose an integrated D-SNP plan on a monthly basis
• Restricting enrollment in certain D-SNPs to individuals also enrolled in an affiliated Medicaid managed care organization (MCO)
• Limiting the number of D-SNPs an MA organization can offer in the same service area as an affiliated Medicaid MCO to reduce and simplify plan offerings for dually eligible individuals.

What Issue is CMS Trying to Solve?

CMS intends to make it easier for dually eligible people make enrollment decisions. Simplified plan options and more integrated care could prevent beneficiaries from inadvertently selecting plans that fail to provide the comprehensive Medicare and Medicaid benefits they need.

This shift toward aligned enrollment could improve beneficiary experiences, enhance outcomes, and streamline administrative processes for CMS. The introduction of a monthly SEP specifically for dually eligible individuals enrolled in Medicaid managed care plans underscores CMS’s commitment to facilitating enrollment in affiliated D-SNP plans throughout the year. Health Management Associates (HMA) experts expect these changes to affect the sales cycle for dual eligibles and potentially increase member satisfaction, expand access to care, and improve overall health outcomes for this population.

Timeline of Regulatory Changes

Considerations for Health Plans

The impact on individual health plans hinges on state-specific approaches to dually eligible beneficiaries and D-SNPs, as well as each plan’s strategy for integrating Medicare and Medicaid services. HMA experts identified the following key factors as essential for understanding and monitoring these interconnected dynamics:

• Does the state administer managed Medicaid, and if so, does it include the dually eligible population?
• Does the Medicare D-SNP (or an affiliated/ related company) hold a state Medicaid contract that covers dually eligible individuals?
• What is the state’s vision regarding duals and D-SNPs?
• Does the state require its Medicaid contractors to offer a D-SNP?
• Does the state currently or plan to restrict D-SNPs to their Medicaid contractors?
• Is the state moving toward an exclusively aligned enrollment model?

What’s Next

The changes in D-SNPs present opportunities and risks for beneficiaries, MA and Medicaid health plans, and states. Successful navigation of these changes requires proactive planning and anticipation of forthcoming federal and state regulations. Health plans operating within the D-SNP space must actively engage with state Medicaid agencies to understand and potentially help shape this evolving environment. For example, health plan strategies may include:

• Understanding the state’s priorities and its current and planned approach to integrated care for dually eligible individuals
• Participating in and/or advocating for stakeholder meetings with the state regarding dually eligible members and D-SNPs to ensure the opportunity to shape regulations
• Developing internal integration strategies that align product design, operations, quality, clinical, and member experience capabilities for D-SNPs and Medicaid
• Strategically planning actions, such as participating in Medicaid procurements, to achieve the plan’s objectives

Connect with Us

These regulatory changes significantly affect dually eligible beneficiaries, states, and both Medicare and Medicaid health plans. Though some changes may disrupt the duals’ market, others align state objectives with plan strategies. Ultimately, dually eligible individuals with full benefits will gain the most, experiencing improved opportunities to choose suitable plans, access necessary care, and achieve optimal health outcomes and well-being.

For further insights into these upcoming changes, view the D-SNP Growth and Integration: Key Implications of the 2025 CMS Final Rule webinar, featuring the HMA team—Dara Smith ([emailprotected]), Holly Michaels Fisher ([emailprotected]), Greg Gierer ([emailprotected]), and Tim Murray ([emailprotected]). Join these and other experts at HMA’s Fall Conference to stay informed about the strategic directions plans and states are pursuing.

Alaska

Alaska Releases Coordinated Care Demonstration Project RFI. The Alaska Department of Health released on June 17, 2024, a Request for Information (RFI) to help inform the development of a possible coordinated care demonstration project for Medicaid beneficiaries. The state is seeking responses from interested vendors addressing their capabilities and readiness to implement a coordinated care demonstration project, and recommendations from the public and other interested parties. In addition to any potential statewide projects, the Department is also interested in demonstration projects that feature region- or population- specific solutions. The Department is authorized to contract with entities such as provider-led entities, managed care organizations, accountable care organizations, primary care case managers, and others to implement this potential project. Responses are due by July 18.Read More

Arizona

Arizona Receives 60 Notices of Intent to Sue Over Medicaid Provider Fraud. The Arizona Republicreported on June 15, 2024, that a group of Arizona behavioral health providers and former patients have filed 60 notices of claim against the state over behavioral health Medicaid provider fraud that targeted Native Americans. The notices of claim were filed on behalf of 38 Indigenous individuals who are former patients at Arizona behavioral health facilities and 22 behavioral health providers who were affected by the state’s actions to address fraudulent Medicaid providers. The notices of claim, which total up to $2.3 billion, allege that Arizona has unfairly punished compliant providers and has not provided necessary coordination of care for displaced patients.Read More

California

California Budget Deal Delays Healthcare Worker Minimum Wage Raise. Modern Healthcarereported on June 24, 2024, that the California Legislature delayed the healthcare worker minimum wage raise until at least October 15, as long as the state’s revenue is three percent higher than current projections suggest between July and September. If revenue is not higher, the raise may be pushed to January 2025. The minimum wage raise was supposed to begin July 1, 2024, but legislators worked with Governor Gavin Newsom to reach this budget deal as the state battles with a multi-billion dollar budget deficit.Read More

County-Run MCO Raises Provider Wages by $526.2 Million. Modern Healthcarereported on June 17, 2024, that California Medicaid-managed care organization (MCO), CalOptima Health, approved a $526.2 million increase in provider pay rates in Orange County. The funds are meant to stabilize the managed care network amid the state’s budget deficit. CalOptima, a county-run plan, will distribute the funds between July 2024 and December 2026.Read More

Legislature Keeps In-Home Support Benefits for Immigrants in Fiscal 2025 Budget. KFF Health Newsreported on June 14, 2024, that the California Legislature passed a fiscal 2025 budget that keeps nearly $95 million in funding for in-home care services for disabled and older low-income immigrants. In Governor Gavin Newsom’s proposed budget, these services were cut indefinitely as the state faces a $45 billion budget deficit. Lawmakers also rejected the governor’s proposal to cut $300 million from public health agencies.Read More

District of Columbia

District of Columbia Submits 1115 Behavioral Health Transformation Demonstration Renewal Request. The Centers for Medicare & Medicaid Services announced on June 6, 2024, that the District of Columbia has submitted a section 1115 waiver renewal request for its Behavioral Health Transformation demonstration, which would address several social determinants of health and rename the demonstration Whole-Person Care Transformation. The renewal will continue allowing Medicaid reimbursem*nts for institutions for mental diseases for individuals with substance use disorders and serious mental illness. The proposal seeks to add initiatives for justice-involved individuals including for Medicaid services up to 90-days pre-release, health-related social needs services, and housing supports and nutrition supports. The federal public comment period will be open through July 24.Read More

Florida

Florida Awards Two Incumbents With Statewide Medicaid Prepaid Dental Program Contracts. The Florida Agency for Health Care Administration announced on June 17, 2024, its intent to award statewide Medicaid Prepaid Dental Program contracts to incumbents Liberty Dental Plan of Florida and DentaQuest of Florida. Contracts will run from the execution date through December 31, 2030. Incumbent MCNA Dental and new bidder Avesis were not awarded contracts.Read More

Florida Spends 54 Percent Less on Emergency Medicaid Services for Undocumented Immigrants in 2024. Politicoreported on June 23, 2024, that Florida has spent $67 million on the state’s Emergency Medical Assistance Medicaid program for undocumented immigrants in fiscal 2024, a 54 percent decrease from the $148.4 million spent in fiscal 2023. The federally-required program mostly covers costs associated with pregnancy and birth. The decrease in Medicaid expenditures comes just one year after Governor Ron DeSantis signed a bill requiring hospitals that provide Medicaid to ask patients about immigration status when they come in for emergency treatment, though patients are not required to answer. That law went into effect in July 2023.Read More

Governor Signs Fiscal 2025 Budget. Florida Politicsreported on June 13, 2024, that Florida Governor Ron DeSantis signed the $116.5 billion dollar budget plan for fiscal 2025, which includes a $247.8 million increase in Medicaid funding for the state’s nursing homes. The budget also includes funding for the Live Healthy Act, which the governor signed in March. The act aims to boost the state’s healthcare workforce and improve access to mental and maternal health. DeSantisvetoed$750,000 lawmakers had included for the Agency for Health Care Administration (AHCA) to conduct a study evaluating how health care data is being used. He also vetoed $1 million meant for AHCA to evaluate Medicaid payment transactions reported for the Achieved Savings Rebate Program.Read More

Florida Disenrolls 36,000 Medicaid Beneficiaries During April Redeterminations. Health News Floridareported on June 14, 2024, that Florida has disenrolled approximately 36,000 Medicaid beneficiaries following redeterminations in April 2024. The state had 4.4 million Medicaid beneficiaries enrolled in May, which is down from 4.5 million in April 2024.Read More

Georgia

Georgia Governor Appoints Caylee Noggle to Lead Study of Medicaid Expansion. The Atlanta Journal-Constitutionreported on June 13, 2024, that Georgia Governor Brian Kemp has appointed Caylee Noggle, the president and CEO of the Georgia Hospital Association, to lead a panel of eight other health policy experts in evaluating the potential impact of expansion in the state. Noggle was also the former commissioner of the Georgia Department of Community Health.Read More

Idaho

Idaho Behavioral Healthcare Contractor Hires Former State Government Employees. The Idaho Capital Sunreported on June 18, 2024, that the awardee of the $1.2 billion Idaho Behavioral Health Plan contract, Magellan of Idaho, hired three former state government employees. The Idaho Department of Administration found no wrongdoing in the health plan solicitation or Magellan hiring’s.Read More

Indiana

Indiana Medicaid, CHIP, HIP Premiums to Return July 1. The Indiana Capital Chroniclereported on June 24, 2024, that beneficiaries of the Healthy Indiana Plan (HIP), the Children’s Health Insurance Plan (CHIP), and Medworks will have to pay premiums for the first time since Indiana waived cost-sharing requirements at the start of the COVID-19 pandemic. Premium costs, which restart July 1, for the three programs range from $1 to $187 for single enrollees. Cost-sharing, known in Indiana as POWER Accounts, will also restart on July 1.Read More

Kansas

Kansas Faces Protests from Aetna, CareSource Over KanCare Awards. Health Payer Specialistreported on June 26, 2024, that CVS/Aetna and CareSource have filed protests over the KanCare Medicaid capitated managed care procurement after failing to win a contract. CareSoure has accused its competitors of underbidding the contract. Contracts went to incumbents Centene/Sunflower Health Plan and UnitedHealthcare, and non-incumbent Elevance/Healthy Blue. A final administrative decision on the protests is expected by mid-July.Read More

Kansas Extends Medicaid to Cover Doula Services. KCLYreported on June 25, 2024, that Kansas will expand its Medicaid coverage to include doula services, beginning July 1. Services covered include community-based doulas, prenatal doulas, labor and birth doulas, and postpartum doulas.Read More

Massachusetts

Massachusetts Extends Waystar MMIS Contract Through June 2025. The Executive Office of Health and Human Services of the Commonwealth of Massachusetts announced on June 24, 2024, that it is extending its Medicaid Management Information System (MMIS) contract for certain Centers for Medicare & Medicaid Services (CMS) data exchange services with Waystar through June 30, 2025. Waystar supports 24 inbound and outbound data exchange interfaces with CMS. The state will conduct data exchange services directly with CMS through an in-house solution, beginning July 1, 2025.

Massachusetts Awards Medicaid Dental Program TPA Contract to BeneCare Dental Plans. BeneCare Dental Plans announced on May 8, 2024, that it has been awarded a contract to provide statewide Third-Party Administrator (TPA) services for the MassHealth Dental Program, which provides dental care to approximately 2 million Medicaid beneficiaries. Contract implementation begins July 1, 2024, and will run for three years with up to seven renewal option years. Incumbent DentaQuest was not awarded a contract.Read More

Michigan

Michigan Disenrolls 12,402 Medicaid Beneficiaries During May Redeterminations. The Michigan Department of Health and Human Services announced on June 24, 2024, that it has disenrolled 12,402 Medicaid beneficiaries during May redeterminations, of those 1,954 were due to procedural reasons. The state renewed Medicaid coverage for 141,992 beneficiaries, with 1,842,038 million people having coverage renewed to date. The state still has 94,723 pending eligibility cases for May.Read More

Missouri

Missouri Legislature Passes Legislation Enforcing 340B Discounted Drug Distribution to Contract Pharmacies. Modern Healthcarereported on June 26, 2024, that the Missouri Legislature has passedlegislation requiring pharmaceutical manufacturers to supply discounted drugs under the 340B program to pharmacies that contract with hospitals, federally qualified health centers, and other 340B-covered providers. Missouri would be the eighth state to enact a 340B contract pharmacy law if the legislation is signed by Governor Mike Parson.Read More

Montana

Montana Governor Urged to Increase DPHHS Staffing, Increase Funding in 2027 Biennial Budget Proposal. The Daily Montananreported on June 24, 2024, that national and state organizations are requesting Montana Governor Greg Gianforte to add staff to the state Department of Public Health and Human Services (DPHHS) and modernize safety net services in the 2027 biennial budget proposal. In a letter sent by 66 organizations, it partially faults DPHHS understaffing with procedural delays during Medicaid redeterminations and the difficult application process for safety net services.Read More

Nebraska

Nebraska Faces Lawsuit Over Terminating Medicaid Beneficiaries. WOWTreported on June 12, 2024, that Nebraska has disenrolled more than 109,000 Medicaid beneficiaries during redeterminations through April 2024, with at least 22,000 being unlawfully terminated. Non-profit Nebraska Appleseed filed a lawsuit against the state over the adequacy of Medicaid ineligibility notices that they allege violates the due process clause of the 14th amendment. The state has nearly 50,000 pending Medicaid eligibility cases.Read More

Nevada

Nevada Receives Approval for Dental Benefit Demonstration for Adults with Diabetes. The Centers for Medicare and Medicaid Services announced on June 21, 2024, that it has approved Nevada’s section 1115 Whole Mouth Whole Body Connection for Adults with Diabetes demonstration, effective through June 30, 2029. The demonstration will allow the state to offer a limited dental benefit package to non-pregnant diabetic adults who are enrolled in Medicaid. The benefits, provided through a network of Federally Qualified Health Centers and Tribal Health Centers, include diagnostic and preventative, restorative, endodontic, and periodontic dental services.Read More

New York

New York Releases Fiscal Intermediary Services for Consumer Directed Personal Assistance Program RFP. The New York State Department of Health released on June 17, 2024, a request for proposals (RFP) for a single statewide fiscal intermediary services vendor for the Consumer Directed Personal Assistance Program, which provides daily living or skilled nursing services to chronically ill or physically disabled individuals with a medical need. Proposals are due August 2, 2024. The contract is anticipated to begin October 1, 2024, and will run for five years.Read More

New York Appeals Court Reaffirms that 70 Percent of Nursing Home Revenue Must Go to Patient Care. Crain’s New York Businessreported on June 24, 2024, that a New York state appeals court upheld a 2021 law that requires nursing homes to direct 70 percent of their revenue into patient care. A legal challenge was brought forth by 130 nursing homes that argued the state overstepped its authority by mandating minimum spending. However, the court found that the law ensures all nursing homes meet the minimum standard of patient care, a state objective.Read More

New York City Awards $10.3 million in Funding to Expand Supportive Housing. Crain’s New York Businessreported on June 20, 2024, that New York City awarded $10.3 million to two housing and human services providers to expand supportive housing for people experiencing or at risk of homelessness. The contracts were awarded to nonprofits Midtown West-based Urban Pathways and Flatiron-based Phipps Neighborhoods; both give residents access to tailored services like medical and mental health care, job training, and skill-building.Read More

Oregon

Oregon Awards Contract to Acentra to Help Implement Medicaid HRSNs. Acentra Health announced on June 13, 2024, that the Oregon Health Authority (OHA) awarded the company a contract to help carry out a portion of the state’s Medicaid Section 1115 health-related social needs (HRSN) demonstration.Read More

Oregon Disenrolls 221,958 Medicaid Beneficiaries During Unwinding. The Oregon Health Authority (OHA) announced on June 25, 2024, that it disenrolled 221,958 beneficiaries during the post-pandemic Medicaid unwinding between April 2023 and June 18, 2024. OHA reduced coverage for 10,949 beneficiaries and renewed coverage for 1,097,801 beneficiaries. OHA updated its ONE Eligibility system in May to improve the renewal process for its members, which will affect the final round of redeterminations that began earlier this month.Read More

Pennsylvania

Pennsylvania to Submit LTC Demonstration Amendment Requests in September 2024. The Pennsylvania Department of Human Services, Office of Long-term Living, announced on June 18, 2024, that it will be submitting separate amendments to the Centers for Medicare & Medicaid Services for two of the state’s 1915(c) programs, the Omnibus Budget Reconciliation Act (OBRA) home and community-based services (HCBS) demonstration and theCommunity HealthChoices(CHC) demonstration. CHC is the state’s managed long term services and supports program. The state seeks to amend the service definitions for benefits counseling, employment skills development, home adaptations. The OBRA proposal also amends the definition of personal emergency response system while the CHC amendment revises the telecare service definition. The amendments also propose to allow teleservices for cognitive rehabilitation and counseling services. The public comment period for both proposals will run through July 14.Read More

Texas

Texas Releases Medicaid, CHIP EQRO RFP. The Texas Health and Human Services Commission (HHSC) released on June 12, 2024, a request for proposals (RFP) for a Medicaid and Children’s Health Insurance Program (CHIP) External Quality Review Organization (EQRO) vendor. The selected organization will conduct External Quality Review of its contracted MCOs, PAHPs, and Prepaid Inpatient Health Plans (PIHPs). Proposals are due July 29, and awards will be announced in January 2025. The anticipated contract start date is September 2025, and contracts will run for four years with one two-year renewal option.Read More

Virginia

Virginia Medicaid Study Finds Dual Eligible Members Have Greater Satisfaction in D-SNPs. William & Mary Newsreported on June 10, 2024, that highly integrated Dual Eligible Special Needs Plans (HIDE-SNPs) can help members enrolled in both Medicaid and Medicare achieve higher levels of customer satisfaction and improve health outcomes, according to a study funded by the Virginia Department of Medical Assistance Services (DMAS). Researchers found D-SNPs allow for better care coordination because the customer’s Medicare and Medicaid benefits are handled by the same private insurer. The full study will be published in the health policy journal JAMA Health Forum in June 2024.Read More

Washington

Washington Opens Apple Health Expansion Registration for Undocumented Adults. The Chroniclereported on June 20, 2024, that registration has opened for Apple Health Expansion, which provides healthcare coverage with no out-of-pocket costs or copays to undocumented adults in Washington, beginning July 1. Services covered include primary and specialty care, emergency visits, dental services, pediatric care, pregnancy and labor services.Read More

National

CMS Releases NOFO for State Medicaid Agencies to Participate in Transforming Maternal Health Model. The Centers for Medicare & Medicaid Services (CMS) released on June 26, 2024, a Notice of Funding Opportunity (NOFO) to participate in the Transforming Maternal Health Model. CMS will award up to 15 State Medicaid Agencies each with up to $17 million dollars in cooperative agreement funding designed to improve maternal and child health outcomes for individuals enrolled in Medicaid and the Children’s Health Insurance Program. Applications must be submitted by September 20, 2024, with award notices expected in mid-January. Implementation for the model will begin January 20, 2025 and run through January 19, 2035.Read More

CMS Releases Final Rule on Medicare Part D Electronic Prescribing, Adoption of Health IT Standards. The Centers for Medicare & Medicaid Services (CMS) released on June 17, 2024, a final rule which implements new requirements for electronically transmitting prescriptions and prescription-related information for Medicare Part D drugs, and adoption of health information technology (IT) standards for the U.S. Department of Health and Human Services use. Read More

CMS Awards 18 States Grant Funding to Support CHIP School-based Services. The Centers for Medicare & Medicaid Services (CMS) announced on June 26, 2024, that 18 states have been awarded grants for the implementation, enhancement, and expansion of Medicaid and the Children’s Health Insurance Program (CHIP) School-based Services. The funds may be used for critical health care services in schools, specifically mental health services. Each state will each receive at least $2.5 million over 3 years.Read More

HHS Issues Final Rule Prohibiting Health Care Data Information Blocking. CQreported on June 24, 2024, that the U.S. Department of Health and Human Services (HHS) has issued a final rule which will reduce Medicare payments for providers that block patients and other providers from accessing relevant health care data. Penalties will vary between hospitals, medical practices, and accountable care organizations (ACOs). Health care providers part of ACOs could be barred from the Medicare Shared Savings Program for a year. Hospitals and physicians will lose their meaningful use designation and payment incentives, with separate actions taken for providers that are not meaningful users.Read More

CMS Releases NOFO for State Medicaid Agencies to Participate in IBH Model. The Centers for Medicare & Medicaid Services (CMS) released on June 17, 2024, a Notice of Funding Opportunity (NOFO) to participate in the Innovation in Behavioral Health (IBH) model. CMS will award up to eight State Medicaid Agencies (SMAs) each with up to $7.5 million dollars in cooperative agreement funding in order to develop necessary infrastructure and capacity to implement the IBH Model. Applications must be submitted by September 9, 2024, with award notices expected in mid-December. Implementation for the model will begin in January 2025 and run through December 2032. An IBH Model NOFO webinar will be held on July 11, 2024.Read More

CMS Releases D-SNP Enrollee Advisory Committee Insights. The Centers for Medicare & Medicaid Services (CMS) released on June 18, 2024, a memorandum outlining lessons learned from conversations CMS held with Medicare Advantage organizations in December 2023 and January 2024 regarding calendar year 2023 implementation of dual eligible special needs plan (D-SNP) enrollee advisory committees. Topics summarized in the memo include participant recruitment and retention, participant preparation and engagement, meeting structure, and follow up.

U.S. Fifth Circuit Court Rules to Enforce Preventative Care Coverage Under the ACA. The Hillreported on June 24, 2024, that the U.S. Fifth Circuit Court of Appeals has ruled that mandatory coverage of preventive services under the Affordable Care Act (ACA) will continue to be enforced nationwide; however, it also ruled that the Department of Health and Human Services cannot enforce the mandate on the plaintiffs in the case, which include a group of Texas businesses and individuals, due to religious objections.Read More

Investigation Finds Certain Medicaid Eligibility Systems Source of Wrongful Disenrollments. KFF Health Newsreleased on June 24, 2024, findings from its investigation into Medicaid eligibility systems built by Deloitte, which show the systems have generated incorrect notices to Medicaid beneficiaries, sent their paperwork to the wrong addresses, and been frozen for hours at a time, according to state audits, court documents, and interviews. Deloitte’s eligibility system contracts cover 25 states and 53 million Medicaid enrollees as of April 1, 2023, and is worth at least $5 billion.Read More

CMS to Close AAP Program After Delivering Nearly $3.3 Billion to Medicare Providers, Suppliers Following Change Healthcare Disruption. The Centers for Medicare & Medicaid Services (CMS) announced on June 17, 2024, that payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption program will end on July 12, 2024. Accelerated payments totaled more than $2.55 billion for Medicare Part A providers, and more than $717.18 million for Part B suppliers. CMS has already recovered over 96 percent of the loaned payments.Read More

CMS to Pay Estimated $1.3 Billion After Medicare Advantage Star Rating Recalculations. Modern Healthcarereported on June 17, 2024, that the Centers for Medicare & Medicaid Services (CMS) will need to pay an estimated $1.3 billion in additional bonus payments for 2024 as a result of the Medicare Advantage Star rating recalculations, according to an analysis commissioned byModern Healthcare. It is estimated that 76 Medicare Advantage plans operated by 44 insurers will receive higher scores.Read More

Judge Rules HHS Third-party Technology Tracking Prohibition Rule is Unlawful. Fierce Healthcarereported on June 20, 2024, that a federal judge ruled against the U.S. Department of Health and Human Services (HHS) in a lawsuit alleging that HHS rules prohibiting hospitals from using third-party pixel trackers on public-facing web pages is unlawful. HHS’ Office of Civil Rights originally ruled that the use of pixel trackers could violate the Health Insurance Portability and Accountability Act (HIPAA), and later updated the rule to exclude certain types of website visits counting as accessing protected health information. The lawsuit—which was brought forth by the American Hospital Association, the Texas Hospital Association, Texas Health Resources, and United Regional Health Care System—argued that HHS expanded HIPAA’s definition beyond its authority.Read More

Senate Finance Committee Chair Introduces Medicaid Bill to Support Obstetric Services in Rural Areas. Roll Callreported on June 17, 2024, that Senate Finance Committee Chair, Ron Wyden (D-OR), introduced a bill aiming to prevent labor and delivery unit closures by increasing the base Medicaid payment rate for labor and delivery services to 150 percent of the Medicare rate for rural hospitals. The increased rate would also apply to hospitals for which at least 60 percent of its births are paid for by Medicaid. Under the bill, all states would be required to extend Medicaid postpartum coverage to one year.Read More

CBO Estimates Healthcare Uninsured Rate to Reach 8.9 Percent by 2034. Modern Healthcarereported on June 18, 2024, that the Congressional Budget Office (CBO) anticipates the rate of uninsured Americans will reach 8.9 percent by 2034. The Medicaid unwinding, immigration, and the loss of enhanced subsidies for people enrolled in marketplace plans – which expire at the end of 2025 – will contribute to the rise. The uninsured rate is currently 7.7 percent.Read More

Number of Uninsured Drops 25 Percent Between 2019 and 2023. Bloombergreported on June 17, 2024, that the number of uninsured Americans declined from 33.2 million in 2019 to 25 million in 2023, an approximate 25 percent decrease, according to a survey conducted by the U.S. National Center for Health Statistics. The survey found racial disparities among the uninsured. The survey does not take into account all the data from the Medicaid unwinding, which began in April 2023.Read More

CMS Extends Claim Dispute Deadline Due to Cyberattack. Modern Healthcarereported on June 14, 2024, that the Centers for Medicare & Medicaid Services (CMS) extended its dispute deadline for out-of-network claims because of how the Change Healthcare cyberattack disrupted the process. As part of the No Surprises Act, the dispute resolution process normally gives providers and insurance companies 30 days after a payment to submit a dispute, but interested parties now have until October 12, 2024, to submit if they can prove their ability to do so was impacted by the cyberattack.Read More

CMS Releases Guidance Supporting State Medicaid Mental Health, SUD Services. The Centers for Medicare & Medicaid Services (CMS) released on June 14, 2024, an informational bulletin to provide examples of state Medicaid information technology expenditures to improve access and coordination of treatment for individuals with mental health conditions or substance use disorders (SUDs) who may qualify for enhanced federal matching rates. It also reminds state Medicaid agencies how to apply for enhanced Medicaid matching rates for these types of expenditures.Read More

CMS to Recalculate 2024 Star Ratings for Quality Bonus Payment Determinations. The Centers for Medicare & Medicaid Services (CMS) announced on June 13, 2024, that it is recalculating the 2024 Star Ratings for Medicare Advantage (MA) plans, allowing MA plans with increased star ratings to resubmit their contract bids for 2025 Quality Bonus Payment (QBP) adjustments. Plans with the intention of resubmitting must notify CMS by June 18 and send revised bids by June 28. CMS is not implementing the change for contract’s with a decreased QBP rating.

Hospitals Push States to Apply For Medicaid Hospital-At-Home Waiver. Modern Healthcarereported on June 13, 2024, that hospitals want states to apply for a waiver through the Centers for Medicare & Medicaid Services (CMS) that allows hospitals to provide at-home care for Medicare and fee-for-service Medicaid beneficiaries at the same reimbursem*nt rate as an in-hospital stay, despite states’ concerns. The waiver is set to expire at the end of the year, but many members of Congress are supportive of extending the program by at least five years. Some states are hesitant to apply for the waiver, citing concerns that it could increase Medicaid costs. Hospitals in 37 states currently provide hospital-at-home services through the waiver.Read More

CMS Releases Update to Medicaid Managed Care Rate Development Guide. The Centers for Medicare & Medicaid Services released on June 12, 2024, changes to the 2024-2025 Medicaid Managed Care Rate Development Guide to reflect provisions of the final rule that take effect starting July 9. The addendum also includes guidance on including the new managed care requirements within states’ rate certifications and rate amendments impacted by the publication of the final rule.Read More

Lawmakers Reintroduce Bill Seeking Electronic PA for Medicare Advantage. CQ Newsreported on June 12, 2024, that Senator Roger Marshall (R-KS) and Representative Suzan DelBene (D-WA) have reintroduced a bill that would codify parts of a Biden administration rule to adopt electronic prior authorization for Medicare Advantage plans beginning in 2027. The bill also includes removing language requiring that plans issue “real-time decisions” for commonly approved procedures. Additionally it requires plans to submit annual information to the U.S. Department of Health and Human Services (HHS) secretary about which services require prior authorization, what share of requests are rejected and appealed, and the average time it takes to respond to requests.Read More

House Committee Advances 13 Bipartisan Health Care Bills. CQreported on June 12, 2024, that the full House Energy and Commerce Committee advanced 13 bipartisan health care bills, which include legislation aimed at improving children’s access to out-of-state Medicaid coverage and ensuring Medicaid databases do not contain outdated providers. The committee also approved bills that would require states to verify that people enrolled in Medicaid are alive and would extend a COVID-19 waiver to allow certain Medicare patients to receive medications by mail if they cannot be present in the office.Read More