HMA Weekly Roundup

Arizona

Arizona House Considers Bill to Reduce Medicaid Fraud Targeting Rehabilitation Facilities. ABC News reported on March 15, 2024, that the Arizona House Health and Human Services Committee is considering a Senate-passed bill, sponsored by Senator Theresa Hatathlie (D-Coal Mine Canyon), that would strengthen regulations for rehab facilities in response to fraudulent Medicaid billing and scams targeting Native Americans receiving care in the facilities. Specifically, the bill would increase the civil penalty per incidence of noncompliance at facilities from up to $500 to at least $1,500 daily, require patients’ family members to be notified when they arrive at a facility, and ensure that employees undergo fingerprint and background checks. Governor Katie Hobbs and Attorney General Kris Mayes previously indicated plans to investigate fraudulent Medicaid charges, most of which had been submitted through the American Indian Health Program, a health plan, and have resulted in 72 indictments thus far.

Arizona Medicaid Provider Fraud Extends into Managed Care Organizations, Senate Passes Bill Increasing Provider Oversight. The Arizona Daily Star reported on March 15, 2024, that the Arizona Health Care Cost Containment System acknowledged fraud in the Medicaid managed care program, not just in traditional fee-for-service, within Medicaid behavioral health residential and outpatient treatment service providers. Fraud has cost the state $2 billion and harmed more than 7,000 individuals. Separately, the state Senate has advanced a bill that strengthens oversight and regulations required by behavioral health entities and sober living homes and increases penalties for violations. Read More

California

California Names Tyler Sadwith Medicaid Director. Becker’s Payer Issues reported on March 14, 2024, that Tyler Sadwith has been named Medicaid director of the California Department of Health Care Services (DHCS). Sadwith was previously deputy director of behavioral health at DHCS. Read More

Colorado

Colorado Plans to Submit 1115 Waiver Expanding SMI Inpatient Mental Health Services. The Colorado Sun reported on March 18, 2024, that legislators are requesting $7.2 million be allocated to the Colorado Medicaid department to reimburse psychiatric hospitals, crisis stabilization units, and other centers that care for people with serious mental illness (SMI) who need care for up to 30 days, as recommended by the Joint Budget Committee. The state plans to submit by April 1 a Section 1115 demonstration proposal for federal approval to implement the new policy. Read More

Colorado Launches Medicaid eConsult Platform. Safety Net Connect announced on March 19, 2024, that the Colorado Department of Health Care Policy & Financing has launched the Colorado Medicaid eConsult platform, aimed at facilitating electronic communication between Medicaid primary care providers and specialists. Primary care providers gained access to the platform effective February 1. Read More

Delaware

Delaware Senator Proposes Bill to Implement Provider Tax to Support Medicaid. Delaware Public Media reported on March 18, 2024, that Delaware Senator Sarah McBride (D-Bellefonte) has introduced legislation that would require hospitals and behavioral facilities to pay a 3.58 percent provider tax. The new hospital tax would generate federal matching funds used to support investments in Medicaid including increasing reimbursement rates for providers, expanding coverage, or building out innovative policies. The bill has been assigned to the Senate Health and Social Services Committee. Delaware is only one of six states that does not have a health care facility assessment for its hospitals. Read More

Georgia

Georgia Medicaid Work Requirements Program Faces Criticism of Low Enrollment, High Admin. Costs. KFF Health News reported on March 20, 2024, that Georgia’s Pathways to Coverage program, which offers Medicaid to people earning up to the federal poverty level if they meet defined work requirements, has cost a minimum of $26 million thus far, with additional costs expected when the state begins collecting premiums and verifying compliance with work requirements. Although the state projected that more than 25,000 individuals would enroll in the first year and 52,000 after five years, about 3,500 individuals have enrolled since the program began in July. Approximately 45 percent of applications for the Pathways programs are currently waiting to be processed. Read More

Georgia Senate Advances Bill to Relax Certificate-of-need Regulations, Form Health Commission. The Georgia Recorder reported on March 15, 2024, that the Georgia Senate has advanced a bill that would scale back certificate-of-need regulations, form a comprehensive health coverage commission, and make it easier to open psychiatric and substance abuse inpatient facilities and rural hospitals. Senate Democrats are expected to withhold support for the legislation next time unless the bill includes full Medicaid expansion. The bill will now go back to the House for further consideration. Read More

Idaho

Idaho Proposed Fiscal 2025 Medicaid Budget Includes Funding for Provider Rate Increases. The Idaho Capital Sun reported on March 18, 2024, that the Idaho Joint Finance-Appropriations Committee has drafted the state’s fiscal 2025 Medicaid budget and included spending requests that are intended to increase funding for new staff and pay for current medical providers. Approved requests included approximately $66 million in provider rate increases, $58 million in non-discretionary adjustments, and $362,000 for regular employee pay raises. The budget totals $4.7 billion, which is about $27.7 million more than last year’s budget. Read More

Indiana

Indiana Hospitals Experience Delayed Payments, Financial Losses Following Cyberattack at Change Healthcare. WFYI Indianapolis reported on March 18, 2024, that the cyberattack on Change Healthcare continues to impact hospitals in Indiana, according to a recent survey from the Indiana Hospital Association (IHA). One-third of IHA’s members responded to the survey, with 60 percent of them reporting that the cyberattack has had a direct impact on patient care and nearly all have had financial losses. IHA indicated that there could be a delay in processing of about $50 to $60 million in payments. According to the IHA survey, most hospitals had identified temporary solutions for processing payments. Read More

Iowa

Iowa Medicaid Fraud Control Units Receive Less Funding, Possess Fewer Staff, Survey Finds. Iowa Capital Dispatch reported on March 19, 2024, that Iowa’s Medicaid Fraud Control Unit (MFCU), responsible for investigating abuse and neglect of Medicaid beneficiaries as well as provider fraud, received less funding and possessed fewer staff than other states in 2022, according to a recent survey conducted by the National Association of Medicaid Fraud Control Units. For example, Indiana Medicaid spent less than half of what Iowa’s program spent in 2022, yet Indiana allocated $8.4 million for its MFCU while Iowa allocated $1.3 million. There were four other states in the country that had fewer total staff members than Iowa. In 2022, the Office of Inspector General previously noted the Iowa MFCU’s low staffing levels and stated that hiring additional staff would enhance the program’s operations, though the state disagreed with the assessment. Read More

Kansas

Kansas House, Senate Committees to Hold Hearings on Medicaid Expansion. The Topeka Capital-Journal reported on March 13, 2024, that the Kansas House and Senate will both hold hearings on Medicaid expansion for the first time since 2020. The Senate Public Health and Welfare Committee is scheduled to have a joint meeting with the Senate Ways and Means Committee on March 20. The House Health and Human Services Committee will hold a hearing regarding expansion House Bill 2556 on the same day. Read More

Kentucky

Kentucky Supreme Court Rules Medicaid Managed Care Contracts to Remain in Place. Kentucky Lantern reported on March 14, 2024, that the Kentucky state Supreme Court will uphold a 2022 state Court of Appeals ruling that Elevance Health was rightfully excluded from receiving a contract in the state’s 2020 Medicaid managed care procurement. The successful bidders, CVS/Aetna, Humana, Molina, UnitedHealthcare, and Centene/WellCare will retain their contracts. Read More

Maine

Maine Incumbents Appeal NEMT Contract Awarded to Modivcare. The Bangor Daily News reported on March 18, 2024, that current incumbents Penquis Community Action Agency and Waldo Community Action Partners (CAP) are appealing Maine’s decision to award Modivcare Solutions a statewide contract for non-emergency medical transportation (NEMT) services, citing unfair scoring of proposals. Penquis bid to cover four regions of the state, and Waldo CAP bid for one. Modivcare’s anticipated contract, estimated to be worth $750 million, will run for an initial two-years beginning July 1, with renewals for up to 10 years. Read More

Mississippi

Mississippi Senate Medicaid Expansion Bill Dies; Focus Shifts to House Bill. WAPT reported on March 14, 2024, that the Mississippi Senate has allowed its Medicaid expansion bill to die. The Senate now plans to amend the House bill version and include work requirements. Read More

Nebraska

Nebraska Legislators Consider Provider Tax Bill to Increase Medicaid Funding for Nursing Homes. The Grand Island Independent reported on March 18, 2024, that Nebraska legislators are considering an amendment to a bill, sponsored by Senator Myron Dorn (R-Adams), that would increase payment rates for nursing homes serving Medicaid beneficiaries. The measure would boost nursing home provider taxes from $3.50 per day per resident to $9 per day per resident, which would yield approximately $23 million in additional Medicaid funding. The bill requires further review before it heads to the floor of the legislature. Lawmakers are also considering a new provider tax applied to hospitals. Read More

Nevada

Nevada Judge Blocks State from Limiting Medicaid Coverage for Abortions. ABC News reported on March 19, 2024, that Nevada District Judge Erika Ballou struck down the state’s limitations on Medicaid coverage for abortion services on the basis that the restrictions violate equal rights protections. Judge Ballou also indicated plans to issue an order directing the state to grant Medicaid coverage for all abortions, though she noted that the actions may be appealed. Nevada currently only provides Medicaid coverage for abortions in the case of a life-threatening pregnancy, rape, or incest.

New York

New York Senate, Assembly Fiscal 2025 Budget Proposes 3 Percent Medicaid Rate Increases. Politico Pro reported on March 14, 2024, that the New York Senate and Assembly have each proposed three percent Medicaid rate increases in their respective budget bills for fiscal 2025. Additionally, the Assembly called for a supplementary 7.5 percent increase for hospitals, nursing homes, and assisted living facilities, while the Senate proposed a seven percent increase for hospitals and a 6.5 percent increase for nursing homes, assisted living facilities, and hospice services. The proposals challenged Governor Kathy Hochul’s proposed budget, which called for a reduction in Medicaid spending to reduce the program’s rising costs. Read More

New York Releases Self-directed Care Initiative RFI. The New York State Office of Mental Health released on March 13, 2024, a request for information (RFI) seeking interest from vendors to operate a Self-directed Care program providing support broker and fiscal intermediary services to Health and Recovery Plan (HARP) enrollees and HARP-eligible HIV Special Needs Plan enrollees. Interested vendors would be required to recruit HARP members to participate in a pilot program, hire and train support brokers, support program participants in reaching their recovery goals, designate a fiscal intermediary to manage funds, and provide self-directed care to a minimum of 100 individuals in the specified geographic region. Responses are due April 3, 2024.

Ohio

Ohio to Release RFA for FIDE SNPs in Coming Months. The Ohio Department of Medicaid announced on March 5, 2024, that it will release a request for applications for MyCare Ohio, the state’s managed care program serving individuals dually eligible for Medicaid and Medicare, in the coming months. The state will transition to a Fully Integrated Dual-Eligible Special Needs Plan (FIDE SNP) model from the Financial Alignment Initiative dual demonstration that is being sunset by the Centers for Medicare & Medicaid Services (CMS). Contract awardees will be required to notify CMS of intent to establish a FIDE SNP in Ohio by Fall 2024. Selected FIDE SNPs will begin to serve eligible individuals in the 29 demonstration counties beginning January 2026.

Pennsylvania

Pennsylvania Improperly Claimed $551 Million in Medicaid Funds, OIG Audit Finds. Scripps News reported on March 13, 2024, that Pennsylvania improperly received $551 million in Medicaid funds to go toward its school-based services, according to an audit from the U.S. Office of the Inspector General (OIG). The report found improper claims totaling $182.5 million from July 2015 through June 2019. The state additionally claimed $368.9 million via unsupported ratios when allocating costs to Medicaid. OIG recommended that Pennsylvania refund $182.5 million and provide evidence justifying the $368.9 million, though the state maintains that it is not required to release supporting documentation. Read More

Virginia

Virginia Budget Amendment to Contract with Single PBM Dies. The Virginia Mercury reported on March 14, 2024, that a pair of Virginia budget amendments, introduced by Delegate Mark Sickles (D-Fairfax) and Senator Travis Hackworth (R-Tazwell), that would have required the Virginia Department of Medical Assistance Services to contract with a single prescription benefits manager (PBM) died in conference. Some pharmacists estimated that the proposed transition to a single PBM would have saved more than $30 million in the state budget and improved drug transparency and affordability. Governor Glenn Youngkin may determine whether to include the amendments in the state budget when the General Assembly reconvenes on April 17. Read More

National

PBM Legislation Dropped from Upcoming Spending Bill Package. Modern Healthcare reported on March 19, 2024, that a healthcare package that included legislation pushing for stronger regulations on pharmacy benefit managers (PBMs) and enhanced community health center funding will not be included in the second set of fiscal 2024 spending bills that must reach President Biden by March 22 to avoid a government shutdown. Lawmakers could not reach agreement on whether new regulations on PBMs should apply only to Medicare and Medicaid or be expanded to the private insurance market. The policies generally have broad bipartisan support, and lawmakers may decide to revisit the issues during the lame duck Congress after the November election. Read More

HHS Announces New Model to Improve Primary Care Access for Medicare Beneficiaries. The U.S. Department of Health and Human Services (HHS) announced on March 19, 2024, a new voluntary model, titled the Accountable Care Organization Primary Care Flex Model (ACO PC Flex Model), which will provide a one-time advanced shared savings payment and monthly prospective primary care payments to ACOs to encourage person-centered primary care and to promote competition in healthcare. The Centers for Medicare & Medicaid Services (CMS) Innovation Center will test the model within the Medicare Shared Savings Program and invest in low revenue ACOs to strengthen care access and quality for their respective Medicare beneficiaries. CMS expects to select approximately 130 ACOs to participate in the model, which will last for five years beginning on January 1, 2025. Interested applicants must first apply to the Shared Savings Program between May 20 and June 17. A Request for Applications is anticipated to be released in the second quarter of 2024. Read More

Senators Introduce Bill to Streamline Care Coordination for Dual Eligibles. The Office of Senator Bill Cassidy (R-Louisiana) announced on March 14, 2024, that Cassidy and other members of the Senate Duals Working Group introduced a bill, titled “Delivering Unified Access to Lifesaving Services (DUALS) Act of 2024,” which would require states to develop integrated health plans for individuals dually eligible for Medicare and Medicaid. The bill aims to further streamline care for dual eligibles by reducing plans that do not provide care coordination and expanding the Program of All-Inclusive Care for the Elderly. Read More

President Biden Signs Executive Order Expanding Women’s Health Initiatives. The New York Times reported on March 18, 2024, that President Joe Biden signed an executive order aimed at strengthening research and data standards on women’s health and directed federal agencies to use federal funds to research health conditions and diseases that disproportionately affect women. Health conditions like heart disease, Alzheimer’s, menopause, and fibroids would be a focus of the expanded research effort. Under the executive order, agencies will be will required to annually report their investments in women’s health research and to study ways that artificial intelligence can be used to advance such research. Read More

CMS to Hasten Medicaid Reimbursements for Providers Affected by Cyberattack. Modern Healthcare reported on March 15, 2024, that the Centers for Medicare & Medicaid Services (CMS) will allow states to submit Medicaid state plan amendments in order to make interim payments to providers affected by disabled payment systems due the cyberattack on Change Healthcare. States will be able to use Federal Financial Participation funds and the payments can be retroactive to February 21. States are encouraged to submit required documentation by March 31. Read More

States Consider Medicaid Rate Hikes in Fiscal 2025. Modern Healthcare reported on March 15, 2024, that some states are planning to increase Medicaid managed care capitation rates for fiscal 2025 while others plan to reduce payments and benefits such as long-term services and supports, in-home care, and mobile crisis units. Arizona, California, Missouri, and Washington are among the states that aim to raise capitation rates. New York aims to eliminate a quality bonus program and a one percent pay increase to cut costs. Legislators in Indiana, Kentucky, and other states have proposed reducing benefits. Read More

MedPAC Releases March 2024 Report to Congress. The Medicare Payment Advisory Commission (MedPAC) released on March 15, 2024, its annual report to Congress recommending lower payments for hospice providers and post-acute care sectors, including skilled nursing facilities, home health, and inpatient rehabilitation facilities for 2025. MedPAC found that the government will spend an estimated $83 billion more on the cost of care for enrollees in Medicare Advantage plans this year than if the same beneficiaries were enrolled in the traditional fee-for-service program. Read More

CMS Releases Guidance on Medicaid Health Home Core Sets. The Centers for Medicare & Medicaid Services (CMS) released on March 15, 2024, a state health official letter which details the state requirements that begin in federal fiscal year 2024 for Core Sets of Health Home Quality Measures for Medicaid (Health Home Core Sets). The letter also provides updates to the 2025 Health Home Core Sets. Revisions include the ambulatory care emergency department visits measure and retires the chronic conditions composite measure. Read More

CMS Releases Guidelines Regarding Permissible Practices During Medicaid, CHIP Eligibility Renewals. The Centers for Medicare & Medicaid Services (CMS) released on March 15, 2024, an informational bulletin and slide deck to clarify the permissibility of certain practices during Medicaid and the Children’s Health Insurance Program (CHIP) renewals. Specifically, the bulletin reiterates the circumstances in which states are not allowed to terminate beneficiaries, exclude individuals from ex parte renewal, or transition individuals to the Marketplace or a different eligibility category. The information is intended to address questions that CMS has received from states, stakeholders, and external partners. Read More

Several Providers Cease Participation in Medicare ACO REACH in 2024. Modern Healthcare reported on March 19, 2024, that 10 accountable care organization (ACOs) have left the Centers for Medicare & Medicaid Services (CMS) ACO Realizing Equity, Access, and Community Health (ACO REACH) program, with Alignment Health, Centene, and NeueHealth scaling back participation. CMS has reported a year-over-year decline in the total number of ACOs in program in 2024, although the number of providers and traditional Medicare enrollees in ACO REACH grew by 30 percent. CMS plans to get all fee-for-service Medicare enrollees under an ACO by 2030. Read More

Medicaid Managed Care Appeals Rates Varied Among States in 2022, GAO Finds. The U.S. Government Accountability Office (GAO) released on March 14, 2024, a report that found that rates of Medicaid managed care appeals and grievances varied widely across states in 2022, with appeals rates ranging from 1.4 to 79.9 appeals per 1,000 enrollees in the 27 states examined. The report attributed variance to differences in states’ appeals processes, including communication about the appeals process, the supports available for enrollees to navigate the process, and whether a state offers external medical review as part of the process. Approximately 20.9 percent of appeals taken to the state for a fair hearing resulted in a favorable outcome for the enrollee, 25 percent of cases were retracted, and 53.7 percent of cases resulted in a decision adverse for the enrollee. GAO recommended that the Centers for Medicare & Medicaid Services require states to report on the outcomes of Medicaid managed care appeals and the number of denials and implement strategies to improve oversight and transparency. Read More

MACPAC Releases March 2024 Report to Congress. The Medicaid and CHIP Payment and Access Commission (MACPAC) released its March 2024 Report to Congress on Medicaid and CHIP. The report focused on three issues of interest to Congress: how state Medicaid agencies can improve beneficiary engagement on Medical Care Advisory Committees; increasing the transparency of the denials and appeals process in Medicaid managed care; and the Commission’s work on Medicaid disproportionate share hospital allotments to states. Read More

Senators Push to Include PBM Legislation in Upcoming Spending Bill Package. Modern Healthcare reported on March 14, 2024, that Senate Finance Committee Chair Ron Wyden (D-Oregon) and ranking member Mike Crapo (R-Idaho) are pushing to include legislation that would impose stronger regulations on pharmacy benefit managers (PBMs) in the second set of spending bills that must reach President Biden by March 22 to avoid a government shutdown. The legislation includes two Finance Committee bills that would implement new transparency rules for PBMs, ban spread pricing, and impose restrictions to PBMs in the private health insurance market. Legislators previously abandoned the legislation following disagreements over details. Read More

State Medicaid Fraud Units Recovered $1.2 Billion in 2023, OIG Report Finds. The U.S. Department of Health and Human Services Office of Inspector General released on March 14, 2024, a report showing that state Medicaid Fraud Control Units recovered $1.2 billion in civil actions and criminal convictions for fraud and patient abuse in 2023. Recoveries increased by $100 million, up from $1.1 billion in 2022. Read More

Medicare Billed $101.4 Million for Remote Monitoring Services in 2021, KFF Finds. KFF Health News reported on March 18, 2024, that since Medicare began allowing physicians to get paid for remote monitoring services in 2019, services billed to Medicare grew from fewer than 134,000 to 2.4 million in 2021. Total Medicare payments for the four most common billing codes for remote monitoring increased from $5.5 million in 2019 to $101.4 million in 2021. Federal law enforcement officials are conducting investigations after a surge in complaints about some remote patient monitoring companies. Read More

6.4 Million Individuals Were Uninsured and Eligible for Medicaid in 2022, KFF Finds. KFF released on March 15, 2024, an issue brief that examines the characteristics of nonelderly uninsured individuals eligible for Medicaid and the Children’s Health Insurance Program (CHIP), using national survey data from 2022, and eligibility levels for Medicaid from 2023. Among the 6.4 million nonelderly people who are uninsured and eligible for Medicaid or CHIP, 4.2 million are adults and 2.2 million are children. Additionally, over three-quarters of the 6.4 million people who are uninsured and Medicaid eligible reside in expansion states, which have higher Medicaid income eligibility for adults than non-expansion states. Read More