HMA Weekly Roundup

California

Blue Shield of California Bypasses PBMs to Reduce Cost for Humira Biosimilar. Modern Healthcare reported on October 1, 2024, that Blue Shield of California reached an agreement to buy a lower-cost version of AbbVie Inc.’s Humira directly from the manufacturer, bypassing pharmacy benefit managers (PBMs). The insurer will pay for $525 a month for the Humira biosimilar beginning next year, which is about a quarter of what the company currently pays after rebates. The largest U.S. PBMs currently charge health plans notably more than $525 a month, with UnitedHealth’s Optum Rx’s lowest price for its Humira biosimilar at about $1,177 a month.

Illinois

Illinois Awards $6.5 Million to Insurance Navigators Ahead of State-based Marketplace Launch. Health News Illinois reported on October 1, 2024, that Illinois has awarded a total of $6.5 million to five different organizations that will act as navigators for people signing up for the upcoming state-based Marketplace launching in 2025. The Illinois Primary Health Care Association will receive $3.5 million, Rincon Family Services will receive $1.1 million, and the Federación de Clubes Michoacanos en Illinois, Sinai Community Institute, and the Springfield Urban League will receive a share of the rest. The Department of Insurance will oversee navigator training.

Kentucky

Kentucky HCBS EVV System Go-live with Therap Pushed to January 2025. The Kentucky Cabinet for Health and Family Services announced on September 30, 2024, an updated timeline for transitioning its state-sponsored electronic visit verification (EVV) system from Netsmart to Therap for the 1915(c) Home and Community Based Services waiver programs. The go-live for Therap has changed from October 24, 2024, to January 1, 2025.

Louisiana

Louisiana Increases Medicaid Rates at Seven Rural Hospitals. The Louisiana Illuminator reported on September 30, 2024, that Louisiana increased Medicaid rates for seven different rural hospitals, totaling an additional $22 million. While most of the rate increase will be funded with federal dollars, $5.2 million will come from the state general fund. The rate increase is contingent on federal approval.

Maryland

Maryland Renews Medicaid Contract with Kaiser Permanente for 2025. Maryland Matters reported on September 25, 2024, that the Maryland Department of Health has renewed Kaiser Permanente’s Medicaid managed care contract for 2025 after initially choosing to end the contract. New contracts include increased accountability and health equity, including screening patients for social needs such as food access, transportation, housing, and employment. Other plans include 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.

Michigan

Michigan Submits Application for New Section 1115 Reentry Services Demonstration. The Centers for Medicare & Medicaid Services announced on October 1, 2024, that Michigan submitted an application for a new section 1115 Reentry Services demonstration, which would include certain pre-release services up to 90-days immediately prior to release for eligible incarcerated individuals. Support services include case management, medication-assisted treatment for substance and alcohol use disorder, and up to a 30-day supply of medications upon release. The federal comment period will be open through October 31.

Missouri

Missouri Issues Emergency Rule Allowing Medicaid Reimbursement for Doula Services. The Missouri Independent reported on September 30, 2024, that Missouri issued an emergency rule allowing doulas to receive Medicaid reimbursement for the next six months, which aims to improve maternal health outcomes. Eligible doulas must have a current certificate from a national or Missouri-based doula training organization. Reimbursements will cover six total prenatal and postpartum doula visits, attendance at a birth, lactation education services and help navigating community services.

Nevada

Nevada Releases Medicaid Housing Supports, Services RFI. The Nevada Department of Health and Human Services Division of Health Care Financing and Policy (DHCFP) released on September 27, 2024, a request for information (RFI) from health care providers, recipients, and contracted Medicaid managed care organizations on developing housing supports and services—also known as in lieu of services (ILOS)—to qualified Medicaid managed care members in urban Clark and Washoe counties. DHCFP is looking for feedback on implementing supports such as specialized case management, housing transition support, housing-related deposits, and housing sustainment services. Responses are due October 27.

New York

New York Awards Single Statewide Fiscal Intermediary Contract for CDPAP to Public Partnerships. Crain’s New York Business reported on September 30, 2024, that New York has awarded Georgia-based Public Partnerships LLC (PPL) the single statewide fiscal intermediary for the state’s $9 billion consumer-directed personal assistance program (CDPAP), which operates the Medicaid home care system for 250,000 New Yorkers. The contract requires PPL to work with four organizations to handle administrative functions for the program, as well as a network of 30 home care agencies to provide care. PPL will also move its headquarters to New York as part of the agreement. The state did not disclose how much money it will award to PPL and the subcontractors.

Oklahoma

Oklahoma Works on SPA to Expand School-based Medicaid Services. KGOU reported on October 1, 2024, that the Oklahoma Health Care Authority (OHCA) and Oklahoma State Department of Education (OSDE) are working towards expanding Medicaid-covered services in the state’s schools. The agencies are working together to develop a state plan amendment to expand these services to cover all Medicaid-eligible children and to add additional services, such as dietician, nutrition, and substance abuse services by 2025. OSDE is also working on developing resources such as Medicaid manuals and billing guides to help support schools as they start or increase Medicaid billing. The work is supported by a $2.5 million Centers for Medicare & Medicaid Services grant that OHCA and OSDE received in July, which will run through June 30, 2027.

Oregon

Oregon Insured Rate Reaches 97 Percent in 2023. The Oregon Health Authority (OHA) announced on September 26, 2024, that an estimated 97 percent of Oregonians had health coverage in 2023, marking a record high, according to data from the Oregon Health Insurance Survey. Approximately one third of the remaining uninsured individuals are likely eligible for Medicaid. The survey also found that 7.7 percent of Hispanic or Latine individuals reported being uninsured in 2023, down from 27 percent in 2011.

Pennsylvania

Pennsylvania Increases Medicaid Behavioral Health Reimbursement Rates. The Pennsylvania Department of Human Services announced on September 30, 2024, that the state will increase reimbursement rates for its Behavioral HealthChoices Medicaid program, retroactive to July 1, 2024. The rate increase is contingent on federal approval. The state has increased its overall funding for behavioral health in other areas as well, including a $20 million investment in county mental health programs outlined in the 2024-25 budget, and a $5 million investment in crisis stabilization walk-in centers.

South Carolina

South Carolina Coalition Pushes for Medicaid Expansion. The Index-Journal reported on September 30, 2024, that a coalition of nearly 100 South Carolina non-profit organizations is urging legislators to implement Medicaid expansion. The group, consisting of health care providers and associations, civil rights groups, advocates, the Catholic Diocese for the state, and the Catawba Indian Nation, is using North Carolina’s expansion program as a model for how a Republican-controlled legislature could approve expansion.

Texas

Texas Expedited Medicaid Unwinding Could Have Led to Wrongful Disenrollments. The Texas Tribune reported on September 26, 2024, that Texas’ expedited approach to Medicaid redeterminations resulted in more than 2 million individuals losing coverage, of which 1.4 million beneficiaries were disenrolled due to procedural reasons. According to a ProPublica and Texas Tribune review of public and private records, Texas received persistent warnings from the federal government and could have avoided certain mistakes. The state launched reviews of about 17 percent of its caseload in the first month despite federal officials advising not to review more than 11 percent of caseloads each month, due to the risk of overwhelming their systems and wrongfully disenrolling individuals. Texas also opted against more widely adopting automatic renewals which was urged by the federal government, and instead required nearly everyone to resubmit documents proving they qualified. There is currently a backlog of more than 200,000 Medicaid applicants.

Virginia

Virginia Plan to Cut 200 Positions Due to Medicaid Disenrollments. WTKR reported on September 27, 2024, that Sentara Health is cutting nearly 200 positions across 10 states, with the majority in Virginia, due to the Medicaid redetermination process which caused a significant decline in Medicaid membership. Most of the impacted positions are in the company’s health plans division, with the rest being positions that function in support of health plan operations.

Washington

Washington Apple Health Pregnancy Programs Increase Income Limit Beginning in November. Washington Health Care Authority announced on September 27, 2024, that the Apple Health for Pregnant Individuals and After-Pregnancy Coverage (APC) income limit will increase from 193 percent to 210 percent of the federal poverty level, effective November 1, 2024.

Wisconsin

Wisconsin Medicaid Expansion Could Save the State $1.7 Billion Over Two Years. Wisconsin Public Radio reported on September 26, 2024, that Medicaid expansion in Wisconsin could save the state around $1.7 billion over the next two years by decreasing the number of individuals receiving state-funded health insurance, according to a study from the Wisconsin Policy Forum. Medicaid expansion would extend coverage to up to about 90,000 additional individuals, mostly for rural Wisconsinites, with about 23,000 going from being uninsured to having coverage.

National

CMS Releases Medicaid Managed Care MLR Monitoring, Reporting, Oversight Toolkit. The Centers for Medicare & Medicaid Services (CMS) released on September 30, 2024, a toolkit for states to ensure accurate monitoring, reporting, and oversight of Medicaid managed care and Children’s Health Insurance Program plan medical loss ratio (MLR) data. The toolkit also contains recommendations on improving MLR data collection and validation, using validated MLR information for financial monitoring and oversight, creating reporting guidance, and creating an effective oversight system within state Medicaid agencies. The guidance is a part of a series of toolkits to help states meet federal requirements for monitoring managed care.

CMS Releases NOFO for Planning Grants to Address Care Continuity for Justice-involved Individuals. The Centers for Medicare & Medicaid Services (CMS) released on September 27, 2024, a notice of funding opportunity (NOFO) for planning grants that will allow state Medicaid and Children’s Health Insurance Program (CHIP) agencies to address operational barriers and care continuity for Medicaid and CHIP-eligible people who are inmates at a public institution, including jails, prisons, and youth detention facilities. CMS will award up to 56 states and territories with up to $5 million over a four year period. In total, the program has $106,500,000 available. The first round of applications closes on November 26, 2024, and the second round closes on March 17, 2025.

States Could Improve Maternal Healthcare Access by Leveraging Medicaid Managed Care Requirements, HHS OIG Finds. Fierce Healthcare reported on October 2, 2024, that states could better leverage Medicaid managed care provider coverage requirements to help improve maternal healthcare access, according to a report by the U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG). The report found that many states do not require their Medicaid managed care organizations to cover provider types beyond obstetrician/gynecologist (OB/GYN) physicians and hospitals. Furthermore, some states do not use network adequacy standards to address access and may lack data on the standards’ impact on access. HHS OIG recommends that the Centers for Medicare & Medicaid Services ensure states cover all required maternal healthcare services, clarify that all states must have a provider-specific OB/GYN network adequacy standard, and work with states to tailor network adequacy standards to better address needs.

CMS Implements Reduced Copays for 54 Medicare Part B Drugs. The Centers for Medicare & Medicaid Services (CMS) announced on September 30, 2024, that certain Medicare members will have reduced copays for 54 prescription drugs from October 1, 2024, through December 31, 2024, as part of the Inflation Reduction Act’s Medicare Prescription Drug Inflation Rebate Program. The cost of the 54 drugs, which treat conditions such as osteoporosis, pneumonia, and cancer, increased faster than the rate of inflation. Affected enrollees may save between $1 and $3,854 per day.

CMS Releases Report on Acute Hospital Care At Home Initiative. Fierce Healthcare reported on October 1, 2024, that the Centers for Medicare & Medicaid Services (CMS) released a study on the acute hospital care at home (AHCAH) initiative, which CMS approved during the pandemic. The report examines health outcomes and cost differences of hospital-at-home care versus inpatient brick-and-mortar hospital care. The findings show that the outcomes of the AHCAH initiative are consistent with its intentions to provide safe, quality care in home. However, the report recognizes that the study’s data, analytic, and measurement limitations restrict its ability to draw definitive conclusions on the initiative’s impact. The initiative is set to expire December 31.

Medicare Advantage, Part D Premiums to Remain Stable in 2025. The Centers for Medicare & Medicaid Services (CMS) announced on September 27, 2024, that Medicare Advantage (MA) and Medicare Part D premiums will remain stable, slightly lowering, in 2025. Average monthly premiums for all MA plans, including plans that provide prescription drug coverage and special needs plans, will fall from $18.23 in 2024 to $17.00 in 2025, and benefit options will remain stable. Part D premiums are set to decrease from $53.95 in 2024 to $46.50 in 2025 on average, though Part D premiums may be even lower for members who also get prescription drug coverage through an MA plan due to rebate dollars.

Medicaid Enrollment Drops by More Than 851,000 Million in June 2024, CMS Reports. The Centers for Medicare & Medicaid Services (CMS) reported on September 30, 2024, that enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) was nearly 80 million in June 2024, reflecting a decrease in Medicaid enrollment of more than 851,000 from May 2024. Medicare enrollment was 67.5 million, up 95,742 from May 2024, including nearly 34.1 million in Medicare Advantage plans. More than 8 million Medicare-Medicaid dual eligible individuals are counted in both programs.

Medicaid Spending on HCBS LTSS Exceeds Institutional LTSS. McKnights Senior Living reported on September 30, 2024, that Medicaid home and community-based services (HCBS) spending accounted for 63.2 percent of long term services & supports (LTSS), and institutional services accounted for 36.8 percent in 2021, according to recently published data from the Centers for Medicare & Medicaid Services. HCBS spending increased each year from 2019 to 2020, despite enrollment decreasing. The largest share of HCBS users received state plan home health services; state plan rehabilitative services; state plan case management services; and Section 1915(c) waiver program services such as those used for assisted living.

Medicaid Coverage Associated with Positive Multigenerational Impacts. The Center for Medicaid and CHIP Services (CMCS) released on September 27, 2024, an issue brief which examines the impact of Medicaid coverage and eligibility over the last six decades, and reviews studies that show Medicaid is associated with improved health, mortality, and educational and economic outcomes. One of the studies examined found that access to Medicaid as a young child decreases the likelihood of being incarcerated by age 28. Additionally, mothers who gained Medicaid during early childhood themselves were found to give birth to healthier children when they started their own families.

CMS Omits Medicaid Drug Price Verification Survey Proposal from MDRP Final Rule. Stat News reported on September 26, 2024, that the Centers for Medicare & Medicaid Services (CMS) chose not to include a 2023 Medicaid drug price verification survey proposal in its Medicaid Drug Rebate Program (MDRP) final rule issued in September. The proposal would have required pharmaceutical companies to complete a survey disclosing the prices and research costs of certain Medicaid-covered prescription drugs that increased states’ overall Medicaid spending.

Medicare, Medicaid Enrollees Face OUD Medication Access Barriers, HHS OIG Finds. Behavioral Health Business reported on September 26, 2024, that some Medicaid and Medicare beneficiaries may not have access to medications for opioid use disorder (MOUD), according to a report by the U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG). The report found that although the Centers for Medicare & Medicaid Services (CMS) has made targeted efforts to expand MOUD access, many MOUD providers did not treat any Medicare or Medicaid enrollees due to various factors such as low Medicaid reimbursement rates, Medicare Advantage prior authorization requirements, and inadequate information about MOUD provider locations. HHS OIG recommended that CMS geographically target its efforts to increase MOUD providers in high-need areas, work with states to assess reimbursement rates for MOUD providers, and work with the Substance Abuse and Mental Health Services Administration to develop a list of active buprenorphine providers.

CMS Releases EPSDT Guidance for Children Enrolled in CHIP, Medicaid. The Centers for Medicare & Medicaid Services (CMS) released on September 26, 2024, guidance for meeting Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements for children covered by Medicaid and the Children’s Health Insurance Program (CHIP). The guidance explains statutory and regulatory EPSDT requirements and suggests best practices for increasing care access through transportation and care coordination, expanding the workforce, improving care for children with specialized needs, and increasing awareness of children’s rights under EPSDT. The guidance also includes information on addressing children’s behavioral health needs through strategies and best practices, such as creating a children’s behavioral health benefit package, supporting behavioral health management in a primary care setting, and providing mental health and substance use disorder services along the continuum of care.