HMA Weekly Roundup

Arizona

Arizona Awards Housing, Health Opportunities Program Administrator Contract to Solari. The Arizona Health Care Cost Containment System announced on June 28, 2024, that it has awarded Solari, Inc. a Housing and Health Opportunities (H2O) Program Administrator contract. The H2O demonstration, scheduled to go-live on October 1, 2024, is aimed at expanding housing-related services for Medicaid beneficiaries who are homeless or at risk of becoming homeless. The contract will run for three years with two one-year renewal options. Read More

Colorado

Colorado Medicaid to Cover Doula Services. The Colorado Department of Health Care Policy & Financing (HCPF) announced on July 1, 2024, that the state will allow Medicaid coverage for doula services. Services will be covered for doulas practicing independently, doulas working in health care facilities, and doula group practices. The department is currently enrolling doulas to support this new benefit. Read More

Idaho

Idaho Releases Medicaid Dual, MLTSS Programs RFP. The Idaho Department of Health and Welfare released on June 14, 2024, a request for proposals (RFP) to procure two vendors to administer the state’s two Medicaid managed care programs for individuals who qualify for both Medicare and Medicaid services. The programs are the Medicare Medicaid Coordinated Plan (MMCP), a Fully Integrated Dual Eligible Special Needs Plan, and the Idaho Medicaid Plus (IMPlus), a wraparound managed long term services and supports (MLTSS) program. Awarded plans must offer both programs, with a strong focus on care coordination. The Medicaid benefits to be administered under both programs include behavioral health services, home and community-based services under Idaho’s Aged and Disabled waiver program, State Plan personal care services, and nursing facility care. Awards are anticipated by the end of October 2024. Contracts will run for four years with one optional renewal year. Read More

Illinois

Illinois Receives Federal Approval for Section 1115 Healthcare Transformation Demonstration. The Centers for Medicare & Medicaid Services approved on July 2, 2024, the five year renewal of the Illinois Healthcare Transformation Section 1115 Demonstration, formerly the Behavioral Health Transformation. The demonstration will include Substance Use Disorder (SUD) treatment for individuals residing in an Institution for Mental Diseases, SUD case management, and new health-related social needs authorities including housing supports. The state will also provide select reentry services 90-days prior to release for certain incarcerated individuals. The extension is effective through June 30, 2029. Read More

Advisory Council Begins Hearings on Medicaid Financing for Sickle Cell Disease Therapies. Health News Illinois reported on June 28, 2024, that the Illinois Department of Healthcare and Family Services (HFS) held the first hearing of the Advisory Council on Financing and Access to Sickle Cell Disease Treatment and Other High-Cost Drugs and Treatment to discuss alternative financial models for expensive treatments for Medicaid members. HFS and the advisory council considered models such as supplemental rebates, outcome-based agreements, and annuity and subscription model outcome-based agreements as potential solutions to make expensive drug treatments more widely-available to those who need them. The council will meet monthly. Read More

Governor Signs Law Banning Sales Tax on Home-delivered Meals For Medicare, Medicaid Recipients. The Illinois Senate Democratic Caucus announced on July 2, 2024, that Illinois Governor J. B. Pritzker has signed legislation to exempt home-delivered meals from sales tax for Medicare and Medicaid recipients, aimed at ensuring access to essential nutrition services. Under the law, home-delivered meals provided to Medicare and Medicaid beneficiaries will be exempt from sales tax when payment is made by an intermediary, including a Medicare administrative contractor, managed care organization, or Medicare Advantage organization. Read More

Indiana

Indiana FSSA Ends Medicaid HIP Premiums. The Republic reported on July 2, 2024, that Indiana Family and Social Services Administration (FSSA) will stop enforcing collections of cost-sharing POWER Accounts for the Healthy Indiana Plan (HIP), after a a U.S. District Court for the District of Columbia vacated a federal approval, citing issues with the premiums that threatened coverage. POWER Account contributions were slated to return on July 1. Read More

Indiana Waitlist Totals 13,000 for PathWays for Aging, Health and Wellness Waivers. NPR reported on July 1, 2024, that Indiana has nearly 13,000 people waiting for services through the Pathways for Aging waiver and the Health and Wellness waiver, which were formerly combined in the Aged and Disabled waiver. The state plans to process 800 slots per month for the Pathways waiver, and 125 per month for the Health and Wellness waiver. Read More

Iowa

Iowa Releases Managed Care Actuarial Services RFP. The Iowa Department of Health and Human Services released on June 26, 2024, a Request for Proposals (RFP) to procure a contractor that will provide actuarial services to develop and support managed care rate setting and other related projects. The contract will run for three years with three one-year renewal options. Proposals are due August 9, with awards expected September 2. The anticipated contract start date is October 1, 2024. Optumas holds the current contract. Read More

Kansas

Kansas Medicaid Oversight Committee Seeks KanCare Procurement Scoring Documents. The Kansas Reflector reported on June 26, 2024, that the Kansas Joint Committee on Home & Community Based Services & KanCare Oversight is pressing the Kansas Department of Health and Environment to justify why it chose a plan in the newest Medicaid managed care procurement that is associated with Amerigroup, a plan that previously lost a rebid for the program in 2018 and allegedly failed to pay millions of dollars to service providers. The committee has voted to request that Attorney General Kris Kobach prepare a memorandum outlining which contract procurement documents related to the KanCare procurement process could be obtained by legislators. Lawmakers are specifically seeking documents showing how the state scored applicants, including Elevance/Healthy Blue, the plan in question. Conflict of interest concerns have also been raised after at least four former state employees were hired by entities related to contract winner Healthy Blue within the past three years. CVS/Aetna and CareSource have protested the awards. Read More

Louisiana

Louisiana to Require Medicaid Coverage for Menopause, Perimenopause Treatments. The Louisiana Illuminator reported on July 3, 2024, that Louisiana will require state Medicaid and private health insurance plans to cover menopause and perimenopause treatments, effective August 1. Under the law, Medicaid plans can no longer require prior authorization for hormone replacement therapy. Read More

Maryland

Maryland Pauses New Enrollments of Select Behavioral Health Medicaid Providers Over Fraud Concerns. The Maryland Department of Health announced on June 28, 2024, that it will pause new provider enrollments in psychiatric rehabilitation programs, home health psychiatric rehabilitation programs, level 2.5 partial hospital programs, and level 2.1 intensive outpatient treatment programs for six months. The pause—which is meant to address fraud, waste, and abuse after the state moved to an accreditation-only model for provider licensing—was approved by the Centers for Medicare & Medicaid Services and began July 1. Read More

Michigan

Michigan to Submit New 1115 Medicaid Demonstration for Pre-release Services. The Michigan Department of Health and Human Services announced on June 28, 2024, that it plans to submit an application for a new Section 1115 Medicaid demonstration for certain pre-release services for adults and youth transitioning from correctional facilities. Medicaid eligible members will receive benefits up to 90-days prior to their expected release, including case management to address physical health, behavioral health, and health related social needs; medication assisted treatment for substance use disorders; and a minimum 30-day supply of prescription medications upon release. The demonstration is expected to begin January 1, 2027. Public comments can be submitted until July 28. Read More

Michigan Enacted Fiscal 2025 Budget Expands CCBHC Capacity. The Michigan Department of Health and Human Services released on June 27, 2024, a statement about the state fiscal year 2025 budget, which includes $161.5 million to establish new Certified Community Behavioral Health Clinic (CCBHC) sites with capacity to serve 35,000 additional individuals. The budget also includes $18.1 million in funding to continue the Healthy Moms, Healthy Babies program; $40 million for federally qualified health centers; and $25 million for substance use disorder treatment to the Opioid Healing and Recovery Fund. Read More

Minnesota

Minnesota Rural Hospitals Form Clinically Integrated Network. Modern Healthcare reported on June 27, 2024, that 19 Minnesota rural hospitals have formed a clinically integrated network in order to improve care coordination. The new alliance, called Headwaters High-Value Network, will pursue alternative payment models with commercial insurers and spread the cost of shared services. Read More

Mississippi

Mississippi Judge Enforces 340B Discounted Drug Distribution to Contract Pharmacies. Reuters reported on July 2, 2024, that a Mississippi judge denied Novartis Pharmaceuticals’ and PhRMA’s request for a preliminary injunction against a state law protecting 340B drug pricing discounts for contract pharmacies. Similar lawsuits challenging state laws in Maryland and West Virginia are still awaiting a decision. Read More

Mississippi Enacts 60-days of Prenatal Presumptive Medicaid Eligibility. The Hattiesburg American reported on July 1, 2024, that Mississippi enacted legislation allowing up to 60 days of prenatal presumptive Medicaid eligibility, effective July 1, 2024. Read More

Montana

Montana Disenrolls Approximately 135,000 Medicaid Beneficiaries During Redeterminations. Montana Public Radio reported on July 2, 2024, that Montana disenrolled approximately 135,000 Medicaid beneficiaries during the redetermination process that began in April 2023. Of those, about two-thirds lost coverage due to procedural reasons. Montana’s Medicaid enrollment is down approximately five percent compared to pre-pandemic levels. Read More

New York

New York Medicaid Seeks Approval to Provide Continuous Medicaid, CHIP Coverage for Children. The New York Department of Health announced on June 27, 2024, that it has submitted an amendment request for its Section 1115 Medicaid Redesign Team demonstration which would allow multi-year Medicaid and Children’s Health Insurance Program (CHIP) coverage for children through age six. The state estimates that an average of 66,177 young children will be continuously enrolled on an annual basis as a result of this proposal. The federal public comment period through July 26. Read More

New York City Budget Deal Reinstates Mental Health Clubhouse, HIV/AIDS Program Funding. Crain’s New York Business reported on July 1, 2024, that New York City’s $112 billion budget deal reinstates $2 million in funding for mental health clubhouses and $5.4 million for HIV/AIDS programs, both of which were cut from initial budget proposals. The budget also allocates $2 million for expansion of the Office of Healthcare Accountability, $100 million for mental health services, $128 million for supportive housing projects, and $25 million for a new trauma center in Queens. Read More

North Carolina

North Carolina Launches Behavioral Health IDD Tailored Plans. The North Carolina Department of Health and Human Services announced on July 3 2024, that North Carolina has launched its behavioral Health and Intellectual/Developmental Disabilities (IDD) Tailored Plans, effective July 1. Individuals covered under the tailored plans include Medicaid beneficiaries who have a serious mental illness, a serious emotional disturbance, a severe substance use disorder, an intellectual or developmental disability, or a traumatic brain injury. Read More

North Carolina Seeks Federal Approval to Help Relieve $4 Billion Medical Debt. News ABC 12 reported on July 1, 2024, that North Carolina is seeking approval from the Centers for Medicare & Medicaid Services (CMS) to allow the state’s Medicaid program to encourage hospitals to relieve up to $4 billion in medical debt for low and middle-income families. The policies include relieving all uncollectible medical debt for individuals with income at or below 350 percent of the federal poverty level (FPL) who are not enrolled in Medicaid or whose debts exceed five percent of their income. The initiative would relieve all unpaid medical debt for those enrolled in Medicaid. Other policies include automatic enrollment into financial assistance programs, providing discounts for patients at or below 300 percent of the FPL, not selling medical debt to debt collectors, and not reporting patients covered under these policies to credit agencies. Upon CMS approval, hospitals will be eligible for payments from the Healthcare Access and Stabilization Program. Read More

Oregon

Oregon Launches OHP Bridge to Expand Adult Medicaid Coverage. The Oregon Health Authority (OHA) announced on July 1, 2024, that it has officially launched the Oregon Health Plan (OHP) Bridge, which expands Medicaid services to adults ages 19 to 64 who are between 138 and 200 percent of the federal poverty level, have citizenship or eligible immigration status, and do not have access to other affordable health insurance. OHP Bridge will cover medical, dental, and behavioral healthcare, as well as transportation to medical appointments and some other health-related services. Unlike the state’s traditional Medicaid program, it will not cover long-term services and supports or Oregon’s new health-related social needs benefit. OHA estimates up to 100,000 adults will eventually qualify. Read More

Texas

Texas Faces Lawsuit Over Medicaid STAR, CHIP Contract Awards. CBS News Texas reported on June 26, 2024, that Cook Children’s Health System filed a lawsuit against the state after the Texas Health and Human Services Commission (HHSC) decided not to renew its Medicaid STAR and CHIP contract with the hospital’s health plan. Cook Children’s, which has been a managed care organization in Texas for 20 years, previously filed multiple appeals within HHSC. The hospital argues HHSC’s contract award process is flawed. Read More

Washington

Washington Family Planning Only Demonstration Extended Through June 2025. The Washington Health Care Authority announced on June 28, 2024, that the Centers for Medicare & Medicaid Services extended the state’s Family Planning Only Section 1115 demonstration by one year through June 30, 2025, while it processes the five-year renewal application. Read More

National

Five States Receive Federal Approval to Provide Reentry Services for Incarcerated Individuals Prior to Release. The Centers for Medicare & Medicaid Services announced on July 2, 2024, that it has approved waiver applications from Illinois, Kentucky, Oregon, Utah, and Vermont to allow Medicaid coverage for incarcerated individuals up to 90-days prior to release. Reentry services covered include substance-use disorder treatment and assistance with connecting to community-based Medicaid providers. Read More

CMS Announces First State Participants in AHEAD Model. The Centers for Medicare & Medicaid Services (CMS) announced on July 2, 2024, that Connecticut, Maryland, and Vermont will be the first states to participate in Cohorts 1 & 2 of the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, beginning in July. Hawaii will also participate, pending satisfaction of certain requirements. The AHEAD model aims to curb health care cost growth, improve population health, and advance health equity by reducing disparities. Applications for the third and final Cohort are due on August 12. CMS will announce up to four more states in fall 2024. The program will run from July 2024 through December 2034. Each state can receive up to $12 million from CMS during the first five and a half years of the model to support implementation. Read More

CMS Releases Cell and Gene Therapy Access Model State RFA. The Centers for Medicare & Medicaid Services (CMS) released on June 28, 2024, the Cell and Gene Therapy Access Model request for applications (RFA) from states. The model aims to improve Medicaid beneficiaries’ health outcomes through a CMS-led approach to developing and administering outcomes-based agreements for cell and gene therapies. The model will first focus on gene therapies for sickle cell disease. All states and territories participating in the Medicaid Drug Rebate Program can apply. Applications may be submitted between December 2024 and February 28, 2025. CMS will release negotiated key terms in December 2024. Read More

Supreme Court Overturns Chevron Case, Limiting Federal Agency Powers. Health Payer Specialist reported on June 28, 2024, that the U.S. Supreme Court overturned a 1984 case known as “Chevron deference,” which had served as a foundational decision involving federal agency regulations. The court’s ruling means that if a federal regulation is ambiguous, courts, rather than agencies, will decide the definition of the rule. The decision could alter the landscape of cases involving healthcare payers, providers, and other stakeholders challenging federal regulations, such as those implemented by the Centers for Medicare & Medicaid Services. Read More

U.S. House Committee Passes Medicare Bill to Cover Weight Loss Drugs. Stat News reported on June 27, 2024, that the House Ways and Means Committee advanced four bills targeting Medicare, including legislation that would allow for Medicare to narrowly cover weight loss drugs for some beneficiaries and expand coverage of preventative cancer screenings. The committee also advanced a bill that would allow Medicare to temporarily cover innovative medical devices still categorized under the Food and Drug Administration’s breakthrough devices program and a bill that would require Medicare to reconsider special coverage decisions every 10 years. Read More

CMS Proposes CY 2025 ESRD PPS Rule Increasing Dialysis Provider Rates 2.2 Percent. The Centers for Medicare & Medicaid Services (CMS) released on June 27, 2024, a proposed rule for the calendar year (CY) 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) that would increase total payments to all ESRD facilities by approximately 2.2 percent, effective January 1, 2025. The rule would also change the methodology for calculating the ESRD facility wage index and the low-volume payment adjustment, and expand the list of ESRD outlier services to include drugs and biological products. Additionally, the rule will allow Medicare to pay for acute kidney injury renal dialysis services at home for beneficiaries. Read More

CMS Proposes 1.7 Percent Cut to Medicare Home Health Provider Rates. Modern Healthcare reported on June 26, 2024, that the Centers for Medicare & Medicaid Services (CMS) is proposing to cut Medicare home health provider rates in 2025 by a net 1.7 percent. The downward rate adjustment accounts for implementation of the Patient-Driven Groupings Model (PDGM)—a 30-day payment model that ties home health payments to patient characteristics and not therapy hours. In 2024, CMS initially proposed a 2.2 percent pay cut, but ultimately finalized a 0.8 percent increase to home health agency pay. In addition, CMS proposed a rate update for the calendar year 2025 intravenous immune globulin (IVIG) items and services’ payment under the IVIG benefit. CMS plans to collect four new items as standardized patient assessment data elements in the social determinants of health (SDOH) category, and to modify one item collected as a standardized patient assessment data element in the SDOH category, beginning with the CY 2027 reporting period. Read More

Medicaid, CHIP Enrollment Drops More than 654,200 in March 2024. The Centers for Medicare & Medicaid Services (CMS) released on June 28, 2024, that enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) was nearly 82.8 million in March 2024, a decrease of 654,280 since February 2024. Medicare enrollment was 67.2 million, up 119,264 from February 2024, including 33.9 million in Medicare Advantage plans. More than 12 million Medicare-Medicaid dual eligibles are counted in both programs. Read More

Dual Eligible Enrollment in Medicare Advantage More Than Doubles From 2013 to 2021. Health Payer Specialist reported on July 1, 2024, that the proportion of Medicaid-Medicare dually eligible persons enrolled in Medicare Advantage plans more than doubled from 24 percent in 2013 to 51 percent in 2021, according to data from the Commonwealth Fund. The number of dual eligibles reached 12.1 million in 2022, up 16.3 percent from 2016. Ratings of satisfaction and ease of getting health care were largely similar for dual eligible beneficiaries in Medicare Advantage plans and those in traditional Medicare. Read More

CBO Estimates Medicaid Enrollment Could Fall 18 million Between 2023 and 2025. Georgetown University Center for Children and Families reported on July 1, 2024, that the Congressional Budget Office (CBO) released its June 2024 Medicaid Baseline, estimating that Medicaid enrollment could fall by 18 million—18.6 percent—between 2023 and 2025, with a third of that decline being due to a drop in child enrollment. CBO estimates that the number of uninsured Americans will increase by 3 million during this time period. More than two-thirds of those disenrolled during the unwinding had their coverage terminated due to procedural reasons but may still remain eligible for Medicaid. Read More

Biden Administration to Impose Inflation Penalties on 64 Medicare Part B Drugs. NBC News reported on June 26, 2024, that the Biden administration will enforce inflation penalties on 64 prescription drugs whose prices increased faster than the rate of inflation. Medicare enrollees will pay a lower coinsurance rate for these drugs, categorized under Medicare Part B, during the third quarter period of this year from July 1 through September 30. It is estimated that more than 750,000 Medicare patients use the drugs each year. Read More