HMA Weekly Roundup

California

California Announces Intent to Award Medi-Cal Dental Managed Care Contracts in Los Angeles, Sacramento Counties. The California Department of Health Care Services released on September 20, 2024, a notice of intent to award its Medi-Cal dental managed care contracts in Los Angeles and Sacramento counties to DentaQuest/California Dental Network and incumbents Liberty Dental and Centene/Health Net Community Solutions. The contract is expected to begin July 1, 2025. Incumbent Avesis/Access Dental did not receive an award.

California Legislature Passes Stricter PBM Regulation Bill. Modern Healthcare reported on September 24, 2024, that California may join 25 other states in enacting stricter regulation over pharmacy benefit managers (PBMs) through Senate Bill 966, sponsored by Sen. Scott Wiener (D-San Francisco). The bill would require PBMs to apply for a license by 2027, require all licensed PBMs to give all the pharmaceutical manufacturers’ rebates they receive to health plans or insurers, and mostly prohibit PBMs from directing patients to pharmacies they own. The bill passed the full legislature in August, and Governor Gavin Newsom has until September 30 to sign it into law.

Florida

Florida Faces Federal Lawsuit Over Lack of Oversight of HCBS. Health News Florida reported on September 25, 2024, that attorneys representing Floridians with disabilities have filed a federal lawsuit against the Agency for Health Care Administration (AHCA) over its oversight practices of Medicaid managed care organizations (MCOs) that provide home and community-based services (HCBS) to people who require long-term care. The lawsuit alleges that MCOs do not provide enough information regarding their decisions to deny or reduce services and that AHCA does not hold plans accountable in their hearing process to review MCO decisions. The lawsuit also seeks an injunction to require AHCA to ensure MCOs provide adequate notice before a denial, reduction, or termination of services to prevent plans from placing arbitrary limits on services, and to ensure AHCA’s hearing process meaningfully reviews MCOs’ decision-making.

Florida Required to Submit Eight Outstanding Medicaid Reports to CMS. Florida Phoenix reported on September 20, 2024, that the Florida Agency for Health Care Administration (AHCA) has eight missing Medicaid reports for its Florida Managed Medical Assistance Section 1115 demonstration. The Centers for Medicare & Medicaid Services (CMS) and AHCA have agreed to a schedule for the agency to submit the outstanding documents, which CMS outlined in an official letter to AHCA. The agency has until December 31, 2024, to submit all missing documents, and must submit at least one document per month until the final deadline, with the first due by September 30. If AHCA does not comply, the state will be placed on a corrective action plan (CAP).

Florida EVV System with HHAeXchange Begins October 1. The Florida Agency for Health Care Administration announced that Florida will transition to a new home health services electronic visit verification (EVV) system through its new contract with HHAeXchange, beginning October 1. The new EVV system is for fee-for-service providers and will verify the type of service performed; the date, time, and location of the service; and the provider and recipient of the service.

Maryland

Maryland Renews Eight Medicaid MCO Contracts for 2025; Ends Contract with Kaiser Permanente. WYPR reported on September 20, 2024, that the Maryland Department of Health (MDH) has renewed contracts with eight incumbent Medicaid managed care organizations (MCOs): CVS/Aetna, Elevance/Wellpoint, UnitedHealthcare, Priority Partners/Johns Hopkins, Maryland Physicians Care, MedStar Family Choice, CareFirst Blue Cross Blue Shield/University of Maryland Health Partners, and JAI Medical Systems. MDH will not renew its contract with Kaiser Permanente, whose 109,000 beneficiaries will transition to other health plans. The agency will also impose new staffing requirements on MCOs in 2025 to ensure quality, oversight, and equity. Maryland does not have a competitive procurement process for Medicaid managed care.

Kaiser Permanente Requests to Continue Negotiations with Maryland After Contract Renewal Decisions. Health Payer Specialist reported on September 25, 2024, that Kaiser Permanente has requested to continue negotiations with the Maryland Department of Health (MDH) after the state chose not to renew its contract with the Medicaid managed care organization (MCO) for 2025. MDH is imposing new staffing and reporting requirements on MCOs in 2025, but Kaiser’s care model reports care and services differently, so the plan is negotiating with MDH to propose ways to apply the new requirements to its model.

Michigan

Michigan to Grant $9.1 Million to Reduce Health Disparities through Healthy Community Zones. The Michigan Department of Health and Human Services (MDHHS) announced on September 25, 2024, that it will be awarding $9.1 million in funding for organizations to develop Healthy Community Zones in Chippewa and Saginaw counties and Detroit, which aim to decrease racial disparities in health outcomes. The state anticipates awarding 30 organizations, with individual agency awards of up to $500,000 and minimum awards of $50,000. The program is anticipated to begin April 2025 and end September 2026. Funding, which will be open to local organizations, will need to support increasing food security, creating active communities and healthy built environments, and enhancing social cohesion. A pre-application webinar will be held on October 7.

Minnesota

Minnesota Releases Electronic Visit Verification Implementation Grant Distribution RFP. The Minnesota Department of Health and Human Services released on September 20, 2024, a request for proposals (RFP) seeking a vendor to distribute grants to assist personal care service and home care service providers with a portion of the costs incurred from the second phase of implementation of the electronic visit verification platform. The selected vendor will manage applications for grants, determine eligibility, and distribute up to $864,000 in grant funds. The contract term is expected to run from November 1, 2024, through June 30, 2027, with no option years. Proposals are due by October 11.

Mississippi

Mississippi Receives Federal Approval to Extend Healthier Mississippi Demonstration. The Centers for Medicare & Medicaid Services (CMS) announced on September 24, 2024, that it has approved a five-year extension of Mississippi’s Section 1115 Healthier Mississippi demonstration through September 30, 2029. The demonstration, which includes no changes, offers Medicaid coverage of primary and preventative care to aged, blind, or disabled individuals who are not enrolled in Medicare or otherwise eligible for Medicaid.

Nevada

Nevada Releases Coordination Only Dual Eligible Special Needs Plan RFP. The Nevada Department of Health and Human Services (DHHS) released on September 11, 2024, a request for proposals (RFP) soliciting bids from Medicare Advantage (MA) plans to serve as a Coordination Only Dual Eligible Special Needs Plan (CO D-SNP). The state intends to award up to five MA plans. This procurement will expand the CO D-SNP eligible population to include Specified Low-income Medicare Beneficiary and Specified Low-income Medicare Beneficiary Plus. Proposals are due by October 8, with notice of awards anticipated in December. Contracts are set to go live on January 1, 2026, for a five-year term through December 31, 2030, with two optional extension years. CO D-SNPs are not responsible for coverage or reimbursement of Medicaid services. Nevada serves approximately 88,000 dual eligible members.

New York

New York Fails to Meet Oversight Standards for Supportive Housing Providers. Crain’s New York reported on September 18, 2024, that New York supportive housing providers under supervision of the state Office of Temporary and Disability Assistance (OTDA) failed to meet basic contract requirements, potentially risking resident safety and long-term success, according to an audit by Comptroller Thomas DiNapoli. The report found OTDA, which had 159 contracts between 2016 and 2022, completed required monitoring visits in fewer than half of its active supportive housing projects. Roughly half of the residents sampled did not have individualized service plans and 10 percent lacked evidence of adequate case management.

Virginia

Virginia Releases Fiscal Agent Services RFP. The Virginia Department of Medical Assistance Services (DMAS) released on September 19, 2024, a request for proposals (RFP) seeking a contractor to operate its Fiscal Agent Services (FAS) and call center services. The FAS contractor will replace legacy FAS services and transform business processes by using technological advancements such as artificial intelligence, progressive web apps, database platforms, low code application development, application programming interface, and natural language processing and machine learning technology. Proposals are due December 20, and contracts will run for six years, with three 24-month renewal options.

National

CMS Releases Final Rule Addressing Medicaid Drug Rebate Program. The Centers for Medicare & Medicaid Services (CMS) released on September 20, 2024, a final rule to address misclassification and incorrect reporting by manufacturers of drug products information in the Medicaid Drug Rebate Program (MDRP). The rule is intended to ensure that states can obtain the required manufacturer rebates, and explains the processes, timelines and penalties associated with late and incorrect reporting and failure of drug manufactures to correct information. As a result, CMS expects states will improve operations of their pharmacy programs and enhance access to necessary prescription medications. The final rule also finalizes policies to address pharmacy benefit operations in Medicaid managed care, some of which which affect pharmacy benefit managers (PBMs).

CMS Requires States to Outline Medicaid Unwinding Compliance by December 31. Modern Healthcare reported on September 20, 2024, that the Centers for Medicare & Medicaid Services (CMS) is requiring all states to submit information detailing the scope of their compliance with Medicaid unwinding renewal requirements and their plans to correct any deficiencies by December 31, 2024. States that are working to correct areas of noncompliance will need to provide a written update every six months, and all states will need to be fully compliant with renewal policies by December 31, 2026. States that are not meeting milestones for their compliance plans or are at risk of missing the 2026 compliance deadline could be subject to additional information requests and more frequent reporting of their progress.

CMS Awards $9 Million in Grant Funding to Improve Women’s Health Coverage. The Centers for Medicare & Medicaid Services (CMS) announced on September 20, 2024, that it has awarded nearly $9 million in grant funding for states to improve women’s health coverage and access to critical health benefits, with a focus on improving access to reproductive health care and maternal health outcomes. The Expanding Access to Women’s Health program grantees include the District of Columbia, Arkansas, Colorado, Hawaii, Massachusetts, Maine, Mississippi, Nebraska, New Hampshire, New Jersey, New Mexico, Pennsylvania, Vermont, Washington, and Wisconsin. Each awardee will be required to develop and submit a work plan outlining specific milestones for successful implementation across the two-year grant period.

Remote Patient Monitoring in Medicare Lacks Transparency, HHS OIG Finds. Modern Healthcare reported on September 24, 2024, that about 43 percent of patients enrolled in a remote patient monitoring program did not receive the full range of services, according to a report from the U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG). The report also noted instances of companies signing up patients who did not need remote monitoring, with Medicare payments for remote monitoring totaling $311 million in 2022, up from $15 million in 2019. The OIG has recommended that the Centers for Medicare & Medicaid Services strengthen oversight of remote patient monitoring by implementing additional safeguards for Medicare billing, conducting provider education about billing of remote patient monitoring, and identifying and monitoring companies that bill for remote patient monitoring.

Hospital Readmission Penalties Remain Comparable Over Past Three Years. Modern Healthcare reported on September 23, 2024, that the proportion of hospitals facing penalties of 1 percent or more on their Medicare payments due to readmission rates has remained relatively stable over the past three years, according to preliminary 2025 claims data from July 2020 through June 2023. In fiscal 2025, 7 percent of hospitals will be charged penalties of 1 percent or more, compared with 7.5 percent in fiscal 2024. Additionally, 21.4 percent of hospitals will not be assessed penalties, compared with 22.4 percent last year. Final 2025 rates will be released October 1.

More Than 25 Million Medicaid Beneficiaries Disenrolled During Redeterminations, KFF Finds. KFF released on September 18, 2024, an analysis which found that over 25 million individuals were disenrolled from Medicaid and over 56 million had their coverage renewed during Medicaid redeterminations through June 2024. Nearly all states have completed redeterminations. Overall, 31 percent of people whose coverage was redetermined were disenrolled, although this varied widely across states. Montana, Utah, Idaho, Oklahoma, and Texas had disenrollment rates of more than 50 percent, while North Carolina, Maine, Oregon, California, and Connecticut had rates under 20 percent. Enrollment among adults is over 20 percent higher than in February 2020, and child enrollment is 5 percent higher.

House, Senate Democrats Seek Permanent Extension of Enhanced Exchange Subsidies. CQ News reported on September 18, 2024, that House and Senate Democrats sent a letter urging leadership to permanently extend enhanced Affordable Care Act (ACA) Exchange plan subsidies, which are set to expire at the end of 2025. If subsidies expire, it is estimated that enrollment in the Marketplaces will drop from 22.8 million in 2025 to 18.9 million in 2026. A permanent extension, however, could increase the budget deficit by $335 billion over the next 10 years.

House Committee Advances Telehealth, Hospital-at-Home Bill; Votes to Appeal CMS Staffing Rule. Modern Healthcare reported on September 18, 2024, that the House Energy and Commerce Committee unanimously advanced the Telehealth Modernization Act of 2024, which would permit telehealth under Medicare for two additional years and extend the Medicare hospital-at-home program for five more years, both of which were pandemic-era policies and expire December 31. The act would also offset the extensions with projected savings on Medicare prescription drug costs, as well as prohibit pharmacy benefit managers (PBMs) from linking compensation to drug list prices, require them to charge flat fees for negotiating prices, and require them to provide extensive data to certain stakeholders. The committee also voted to repeal a Centers for Medicare & Medicaid Services final rule establishing staffing minimums at nursing homes.

Black, Latine Family Doctors More Likely to See Medicaid Patients. Health Day reported on September 24, 2024, that Latine and Black family doctors saw more Medicaid beneficiaries compared to white or Asian doctors, according a study published in the Annals of Family Medicine, which used national claims data from 2016. Doctors who identified as Black had a 60 percent increase in the likelihood of accepting a significant number of Medicaid patients — defined as 150 or more — and Latine doctors had a 40 percent increased likelihood. Researchers also noted that minority doctors are more likely to return to and set up practices in communities of color, where people are more likely to suffer from chronic disease but have had less access to health care.

CMS Releases Memo for States on Dual Demonstration End Considerations. The Centers for Medicare & Medicaid Services (CMS) released on September 10, 2024, a memo outlining end-of-demonstration enrollment and operational considerations for seven states currently transitioning Medicare-Medicaid Plans (MMPs) to integrated dual eligible special needs plans (D-SNPs) starting January 1, 2026. To ensure seamless transitions for existing MMP enrollees, states may choose to remove the six-month moratorium for opt-in enrollment from the three-way contracts for MMPs that offer successor integrated D-SNPs, extending opt-in enrollment through December 1, 2025. The memo also outlines other policy considerations including if states want to elect to stop passive enrollment into the MMPs sooner than July 1, 2025; and whether states want to implement a special demonstration transition deeming period. All affected states must notify CMS of their decisions regarding end-of-demonstration enrollment by December 31, 2024.