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HHS Gives States New Options for Medicaid-Covered Behavioral Health Treatment

The U.S. Department of Health and Human Services has informed state Medicaid programs that it is giving them new opportunities to pay for hospitalization to care for recipients with behavioral health problems.

For years Medicaid has greatly limited the ability of state Medicaid programs to pay for inpatient care for many behavioral health problems – a limit commonly known as the IMD (institution of mental disease) exclusion.  Earlier this year the Centers for Medicare & Medicaid Services eased this long-time limit, announcing that it would make it easier for states to secure waivers from it.  CMS has announced in a formal guidance letter to state Medicaid directors that it is extending this policy, according to a CMS news release, which explains that the agency offers

…both existing and new opportunities for states to design innovative delivery systems for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED).  The letter includes a new opportunity for states to receive authority to pay for short-term residential treatment services in an institution for mental disease (IMD) for these patients.  CMS believes these opportunities offer states the flexibility to make significant improvements on access to quality behavioral health care.

Under this new approach, states are invited to develop new delivery systems for serving patients with behavioral problems, and especially substance abuse disorders, that make greater use of inpatient behavioral health services and to receive federal Medicaid matching funds for pay for this care – something that has been greatly limited in the past.  In offering this opportunity, CMS notes that a number of states that have already obtained waivers from the IMD exclusion since its easing of the limit on such waivers earlier this year and are already showing encouraging results in their battle against opioid abuse.

Learn more about this new policy, its intentions, and how it will work in this CMS news release or go here to see the CMS guidance letter to state Medicaid directors.

Filed under: Federal Medicaid issues

Medicaid Birthing Model Improves Outcomes

A federal program to improve birth outcomes among Medicaid-covered women has produced positive results:  lower rates of pre-term births, fewer low birthweight babies, fewer C-sections, lower delivery costs, and lower first-year health care spending.

The “Strong Start for Mothers and Newborns” program was a four-year initiative established by the Affordable Care Act and developed by the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Innovation to employ patient education, nutrition, exercise, preparation for childbirth, breast-feeding, and family planning rather than strictly medical interventions and was delivered through three evidence-based prenatal care models:  Birth Centers, Group Prenatal Care, and Maternity Care Homes.

The program, operated in 219 separate sites in 32 states (with one in Pennsylvania), served participants with especially challenging socio-economic risk factors:  unemployment, lack of a high school degree or GED, food insecurity, transportation challenges, chronic health problems, and previous poor birth outcomes – the very types of patients Pennsylvania safety-net hospitals serve in such large numbers.  The objective of the program was to find ways to overcome these social determinants of health and produce better birth outcomes and now, a new, independent evaluation has found that it did.

Learn more about Strong Start for Mothers and Newborns and what it has produced in the official program evaluation document.

Filed under: Affordable Care Act, Federal Medicaid issues

CMS Proposes New Medicaid Managed Care Regulation

Just two years after a major overhaul of Medicaid managed care regulations, the Centers for Medicare & Medicaid Services is again proposing changes in how the federal government regulates the delivery of managed care services to Medicaid beneficiaries.

Under the newly proposed regulation, states would:

  • be free to implement more changes in their managed care programs without seeking federal permission;
  • have slightly more flexibility in how supplemental payments are made to hospitals through managed care plans and implement some such changes without federal approval;
  • be permitted to redefine what constitutes an adequate provider network for managed care plans; and
  • not be required to publicize beneficiary grievance and appeals processes as prominently as they currently do.

Overall, the proposed regulation appears to help managed care insurers a great deal, states a little, and hospitals barely at all.  It also could have serious implications for Pennsylvania safety-net hospitals because the vast majority of Medicaid participants in the state receive their benefits through managed care plans.

Stakeholders have until January 14 to submit formal comments about the proposal to CMS.

To learn more about the proposed Medicaid managed care regulation, go here to see CMS’s news release presenting the regulation, go here to see a more detailed CMS fact sheet, and go here to see the proposed regulation itself.

Filed under: Federal Medicaid issues, Pennsylvania safety-net hospitals

PA Among States Looking at PBMs

Pennsylvania is one of a number of states looking the operations and profits of pharmacy benefits managers employed by managed care plans that serve the state’s Medicaid population.

One state has already passed a law governing PBMs and others are doing the same as states zero in on how PBMs make their money when serving a Medicaid population whose care is paid for with public money.

One specific target is PBM’s “spread”:  the suggestion that in addition to the fees they are paid by managed care organizations, PBMs charge managed care plans more than they pay pharmacies that dispense prescriptions and keep the difference for themselves as profit.  Pennsylvania’s Department of Human Services, its auditor general, and the state Senate have all begun examining PBM operations in recent months to learn more about how PBMs make their money and whether they are doing so inappropriately at the expense of state taxpayers.

For a closer look at what PBMs are, the “spread” issue, and what officials in Pennsylvania and elsewhere are doing to get a better handle on this matter, see this Philadelphia Inquirer article.

Filed under: Pennsylvania Medicaid

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The October 2018 MACPAC meeting covered a range of front-line issues in Medicaid, leading off with an analysis of disproportionate share hospital (DSH) allotments on Thursday morning. Following the analysis, the Commission discussed options for March recommendations on how to structure DSH allotment reductions that are scheduled to begin in fiscal year 2020. The Commission later resumed the discussion it began in September on work and community engagement requirements, presenting new data from Arkansas on compliance and disenrollments, as well as information gathered since that meeting about Arkansas’s approach to implementation.

On Thursday afternoon, the Commission looked at the Department of Homeland Security’s proposed public charge regulations and their implications for Medicaid and the State Children’s Health Insurance Program (CHIP). A session responding to a congressional request to look at issues facing the Medicaid program in Puerto Rico was next on the agenda. A presentation from an ongoing project on how Medicaid drug coverage compares with Medicare Part D and commercial plans closed out the day.

On Friday, the Commission heard from Tom Betlach, director of the Arizona Health Care Cost Containment System, and Karen Kimsey, chief deputy at the Virginia Department of Medical Assistance Services, on their experiences integrating care for dually eligible beneficiaries.* At the final October session, the Commission reviewed the findings from a study of how six states carried out simplified Medicaid eligibility and enrollment established by the Patient Protection and Affordable Care Act (P.L. 111-148, as amended).

Supporting the discussion were the following presentations:

Because Pennsylvania safety-net hospitals serve so many Medicaid patients, MACPAC’s deliberations are especially relevant to them because its recommendations often find their way into future Medicaid and CHIP policies.

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program.  Find its web site here.

Filed under: DSH hospitals, Federal Medicaid issues, Medicaid supplemental payments, Pennsylvania safety-net hospitals

Proposed “Public Charge” Regulation Could Hit Medicaid, Hospitals

If a regulation proposed by the Department of Homeland Security to redefine what constitutes a “public charge” is adopted, millions of people currently enrolled in the Medicaid and Children’s Health Insurance Program might choose to disenroll from those programs rather than risk losing their opportunity to obtain legal permanent resident status in the U.S.

The proposed regulation seeks to filter out of possible residency status individuals who might become public charges, or dependent on government programs, over time.

A new analysis published by the Kaiser Family Foundation concluded that

Under the proposed rule, individuals with lower incomes, a health condition, less education, and/or who are enrolled or likely to enroll in certain health, nutrition, and housing programs would face increased barriers to obtaining LPR [legal permanent residency] status.

The study notes that

Nearly all (94%) noncitizens who originally entered the U.S. without LPR status have at least one characteristic that DHS could potentially weigh negatively in a public charge determination.

To avoid losing eligibility for legal permanent residency status, the analysis suggests,

 The proposed rule would likely lead to disenrollment from Medicaid and other programs among noncitizens who intend to seek LPR status as well as among a broader group of individuals in immigrant families, including their primarily U.S. born children.

How many people might disenroll from Medicaid, CHIP, and other programs is difficult to project but the study notes that

If the proposed rule leads to Medicaid disenrollment rates ranging from 15% to 35% among Medicaid and CHIP enrollees living in a household with a noncitizen, between 2.1 to 4.9 million Medicaid/CHIP enrollees would disenroll.

And

Reduced participation in Medicaid and other programs would negatively affect the health and financial stability of immigrant families and the growth and healthy development of their children, who are predominantly U.S.-born.

This, in turn, could lead to financial challenges for health care providers serving communities with large numbers of low-income patients, many of whom could be individuals who do not have permanent residency status.  Some could seek to disenroll from Medicaid, or not to enroll if they qualify, leaving them uninsured if and when they need and seek medical care.  This could prove especially challenging for Pennsylvania safety-net hospitals located in areas with large numbers of immigrant residents.

Learn more about the proposed regulation and its implications for those it might affect and their health status in the Kaiser Family Foundation report “Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid,” which can be found here.

Filed under: Federal Medicaid issues

PA Insurers Drop Pre-Authorization Requirement for Medication-Assisted Opioid Treatment

Seven of the largest health insurers serving Pennsylvanians have agreed to end pre-authorization requirements for patients needing medication-assisted treatmen for opioid addictions.

As explained in a news release issued by the governor’s office,

These guidelines apply to individual, small group, and large group fully insured plans. Self-funded plans, where employers provide health care coverage administered by a third party, are regulated by the federal government and are not included in this agreement.

In addition,

The guidelines implement thresholds for prior authorization for long- and short-acting opioids, morphine milligram equivalents (MME) and exceptions for active cancer, sickle cell crisis, and palliative care/hospice patients. Generally, commercial insurers are requiring prior authorization for all long-acting opioid prescriptions and short-acting opioid prescriptions after seven days. Some insurers are phasing in their alignment with many of the guidelines.

To learn more about the new approach by health insurers, including how the agreement was reached and to which medication-assisted treatments this new policy will apply, see this news release from the governor’s office.

Filed under: Uncategorized

CMS Promises Enhanced Use of Medicaid Data to Improve Program Results

Centers for Medicare & Medicaid Services administrator Seema Verma intends to increase federal use of data reported by the states to improve the performance of state Medicaid programs.

In an article published on the CMS blog, Verma wrote that

Through strong data and systems, CMS and states can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP.

Verma pointed to two core sets of data she considers vital:  Medicaid and CHIP child and adult core sets, which are reported only voluntarily by states, and administrative data submitted through the relatively new Transformed-MIS system.  The latter, according to Verma.

…modernizes and enhances the way states submit operational data about beneficiaries, providers, claims and encounters.  It is the foundation of a national analytic data infrastructure to support programmatic and policy improvements and program integrity efforts and will help advance reporting on outcomes.  It also enhances the ability to identify potential fraud and improve program efficiency.

All states now use Transformed-MIS.

Learn more about how CMS uses data now and how it envisions using it in the future to improve the performance of state Medicaid programs in the CMS blog entry “CMS Promises Enhanced Use of Medicaid Data to Improve Program Results,” which can be found here.

Filed under: Federal Medicaid issues

Verma Speaks at Medicaid Managed Care Summit

Centers for Medicare & Medicaid Services administrator Seema Verma recently addressed the Medicaid Managed Care Summit, which was held in Washington, D.C.

Ms. Verma’s speech focused on four major areas:

  • Empowering states to function as laboratories for innovation by giving them the flexibility to introduce changes that work best for their own citizens.
  • Developing Medicaid and CHIP scorecards that present data on health outcomes, quality metrics, and CMS’s administrative performance.
  • Improving Medicaid program integrity, including through “…targeted audits to ensure that provider claims for actual health care spending match what the [Medicaid managed care] health plans are reporting financially.”
  • Strengthening CMS’s use of data in Medicaid oversight.

See Ms. Verma’s complete remarks here.

Filed under: Federal Medicaid issues

Bill Would Advance Telemedicine in PA

A bill proposed in the Pennsylvania state legislature would require private insurers to cover telemedicine services under selected circumstances.

House Chamber of the State HouseSenate Bill 780, currently under consideration by the House Professional Licensure Committee, was the subject of a recent committee hearing during which hospital officials from across the state spoke in support of fostering greater use of telemedicine in the delivery of health care services.

Learn more about the bill and why hospital executives traveled to Harrisburg to express their support for it in this article in the publication Lehigh Valley Business or go here to see the bill itself.

Filed under: Uncategorized

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2012 Safety-Net Association of Pennsylvania