HMA Weekly Roundup

Illinois

Illinois Plan Awards $8 Million to CBOs Improving Maternal, Child Health Outcomes. Health News Illinois reported on October 16, 2024, that BlueCross BlueShield of Illinois is awarding a total of over $8 million to more than two dozen organizations working to improve maternal and child health outcomes. The awardees include doula training groups, technology developers, and other community-based organizations (CBOs). The money will fund various projects that aim to improve access to care, reduce healthcare disparities, and educate and support parents and families.

Indiana

Indiana Increases Monthly Pathways for Aging, Health and Wellness Waiver Invitations from Waitlist. WVXU reported on October 11, 2024, that the Indiana Family and Social Services Administration (FSSA) will increase the monthly number of people it processes off waitlists for the Pathways for Aging and Health and Wellness waivers, which were formerly combined as the Aged and Disabled waiver. Starting in October, a total of 1,700 people per month will be invited to apply for home and community-based services through the waivers — 1,200 from the Pathways waitlist and 500 from the Health and Wellness waitlist. The increase in waitlist invitations does not increase the total number of spots available—there are still 55,000 combined spots for the programs. There are approximately 13,000 people on the waitlists.

Louisiana

Louisiana Submits Section 1115 Reentry Demonstration Application. The Centers for Medicare & Medicaid Services (CMS) announced on October 11, 2024, that Louisiana submitted a Medicaid Section 1115 demonstration application for reentry services to qualified individuals for 90 days prior to their release from prison or jail. The demonstration seeks to cover Medicaid services including case management, medication-assisted treatment, and a 30-day supply of prescription drugs. Public comments are open through November 10.

Massachusetts

Massachusetts to Submit Section 1115 MassHealth Demonstration Amendment to Support One Care Transition to FIDE-SNP. The Massachusetts Executive Office of Health and Human Services (EOHHS) announced on October 11, 2024, its intent to submit a request to the Centers for Medicare & Medicaid Services to amend the MassHealth Section 1115 Demonstration. The amendment authorizes services and enrollment flexibilities for One Care that are currently authorized in the Massachusetts financial alignment dual demonstration, as the state transitions the program to a Fully Integrated Dual Eligible (FIDE) Special Needs Plan (SNP) structure. The state seeks authority to continue covering the additional community-based and flexible benefit services for MassHealth members enrolled in One Care and Senior Care Options (SCO). Additional services include ones to address health related social needs, independent community living services, and benefits to promote independent living or recovery. Massachusetts recently awarded One Care contracts to incumbents Commonwealth Care Alliance, Tufts, UnitedHealthcare, Molina/Senior Whole Health, and non-incumbents Mass General Brigham Health Plan and Community Care Cooperative. SCO awardees were the same six plus incumbent Fallon Health. Implementation begins January 1, 2026. Public comments for the demonstration amendment are open through November 12.

Michigan

Michigan Receives $36.4 Million State Opioid Response SAMHSA Grant for Fiscal 2024. The Michigan Department of Health and Human Services reported on October 16, 2024, that it has received a nearly $36.4 million State Opioid Response grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) for fiscal year 2024. The state, which is slated to receive more than $109 million in federal funding over a three-year grant period, intends to increase access to medications for opioid use disorder; reduce unmet treatment needs and overdose-related deaths; and improve the quality of treatment for opioid and stimulant use disorders. Michigan’s 10 Prepaid Inpatient Health Plan regions, the Inter-Tribal Council and Saginaw Chippewa Indian Tribe, and syringe service programs will receive the funding.

Minnesota

Minnesota Seeks to Improve Customized Living Serves Under HCBS Waivers. The Minnesota Department of Human Services (DHS) released on October 14, 2024, a request for proposals (RFP) to improve the quality of services for people receiving customized living services through the brain injury, community alternatives for disability inclusion, and elderly home and community-based services (HCBS) waivers. The target areas for improvement will be quality of life; resident satisfaction; safety; health outcomes; staff; physical and social environment; service availability; core values; and care services and integration. DHS intends to award up to $2 million in grants to awardees, with one-time grants ranging from $25,000 to $250,000 during state fiscal year 2025-26. Proposals are due December 13, 2024. The contract term is anticipated to be from March 1, 2025 through June 30, 2026, with an optional 24 months extension without additional funding.

Mississippi

Mississippi Medicaid Executive Director Drew Snyder Resigns, Cindy Bradshaw Appointed Replacement. Mississippi Today reported on October 9, 2024, that Mississippi Division of Medicaid Executive Director Drew Snyder is resigning after serving nearly seven years in the position, effective at the end of October. Governor Tate Reeves appointed Cindy Bradshaw, the division’s deputy executive director for eligibility, to replace Snyder. Snyder will be taking a private sector job.

Montana

Montana Lawmakers to Propose Bill Allowing Presumptive Eligibility for Seniors, Disabled. KFF Health News reported on October 10, 2024, Montana lawmakers drafted a bill for the legislative session that begins in January to allow presumptive eligibility for seniors and people with disabilities to access in-home care. The proposal would also allow tribal entities, area agencies on aging, and hospitals to screen patients for presumptive eligibility. The draft bill includes covered services such as meal delivery and in-home medical equipment.

Nevada

Nevada to Pursue Medicaid Section 1115 Reentry Services Demonstration. The Nevada Department of Health and Human Services Division of Health Care Financing and Policy (DHCFP) announced on October 14, 2024, that the state will seek federal approval for a Medicaid Section 1115 demonstration to provide services to Medicaid and Children’s Health Insurance Plan eligible justice-involved youth and adults 90 days prior to their release. DHCFP is surveying correctional facilities to better understand current reentry and other services and supports provided to incarcerated individuals. Nevada aims to submit the demonstration application November 15, 2024.

Oregon

Oregon Faces Medicaid Dental Provider Shortage. Willamette Week reported on October 13, 2024, that in Oregon, 55 to 70 percent of dentists do not accept patients on Medicaid, according to the Oregon Health Authority (OHA). Dental practices attribute the lack of coverage to tedious insurance claim filing processes, insufficient coverage for common dental procedures, and lack of transparency for services covered and not covered. The OHA recommended increasing reimbursement rates and implementing a communication and outreach plan in order to reduce misconceptions about Medicaid.

Oregon State Auditor Issues Recommendations for Eligibility & Benefits System. The Register-Guard reported on October 9, 2024, that the Oregon Eligibility System (ONE), which determines Medicaid eligibility, has ongoing manual input errors and lacks sufficient oversight of its override system, according to a secretary of state audit. The report found that while ONE generally determines eligibility accurately, inaccurate manual input of user information caused some beneficiaries to be enrolled in the incorrect tier of benefits or improperly retain or lose benefits. It also found that some eligibility overrides either contained insufficient explanation as to why the override occurred or did not meet override criteria. The audit recommended that the Oregon Department of Human Services move toward automation to avoid manual input errors, refine and increase monitoring of its override system, and develop a test plan to reduce risk of insufficient user acceptance testing.

Rhode Island

Rhode Island to Reevaluate Medicaid Contract Awards. The Rhode Island Current reported on October 16, 2024, that the state will reevaluate the bids for its $15.5 billion Medicaid managed care contract after incumbent Tufts Health Plan and non-incumbent Blue Cross Blue Shield Rhode Island protested the award decisions, claiming there were flaws in the scoring criteria and conflicts of interest within the scoring committee. Rhode Island determined that the Evaluation Memorandum was insufficient and will examine the bids again; however, the state will not start the bidding process over. The five-year contracts were originally slated to begin July 1, 2025, with incumbents Neighborhood Health Plan and UnitedHealthcare. New program changes will include carving in long-term services and supports as an in-plan benefit for all populations and expanding managed care to include people who are dually eligible for Medicare and Medicaid.

Virginia

Virginia to Use Reserve Funds For Delayed Medicaid Payments Amid Lag in Redeterminations. The Virginia Mercury reported on October 15, 2024, that Virginia’s Department of Medical Services (DMAS) expects to use $95 million in reserve funds to cover delayed Medicaid payments for fiscal year 2025 due to a lag in the state’s redetermination process. The state has completed more than 2 million redeterminations and has 35,000 pending cases remaining. DMAS is also working to correct Medicaid pharmacy rebate overpayments that were applied to the general fund instead of the coverage assessment fund.

National

Four States Receive Federal Approval to Allow Medicaid Coverage for Traditional Health Care Practices. The Centers for Medicare & Medicaid Services (CMS) announced on October 16, 2024, that it has approved Section 1115 demonstration amendments for Arizona, California, New Mexico, and Oregon, allowing Medicaid and Children’s Health Insurance Program (CHIP) coverage for traditional health care practices delivered by or through Indian Health Service facilities, Tribal facilities, and urban Indian organizations. The new authority is expected to improve access to culturally appropriate health care and improve the quality of care and health outcomes for tribal communities. Approved demonstrations for Arizona and Oregon will run through September 30, 2027; New Mexico will run through December 31, 2029; and California through December 31, 2026.

Average Medicare Advantage Star Ratings Decrease for 2025. Health Payer Specialist reported on October 10, 2024, that Medicare Advantage star ratings decreased from 4.04 to 3.92 on average for 2025. Forty percent of plans received four stars or more and will receive quality bonus payments, down from 43 percent in 2024. Out of the 521 plans evaluated, seven plans received five stars, compared to 38 in 2024.

Medicaid Drug Spending Increased 72 Percent Between 2017 and 2023, KFF Finds. KFF released on October 11, 2024, an issue brief outlining spending trends on outpatient Medicaid prescription drugs between fiscal years 2017 and 2023, which found that net spending after rebates increased by 72 percent during that time period from $30 billion to $51 billion. According to the report’s authors, the large increase in spending may be attributed to new high-cost specialty drugs. The number of prescriptions per enrollee declined, but overall prescriptions increased by three percent. The report also found that prescription drug rebates reduce fee-for-service prescription spending by 61 percent and managed care prescription spending by 44 percent. Spending data used in the brief was not adjusted for inflation.

CMS to Modernize Coverage Transition Process between Medicaid/CHIP, Federal Marketplace. The Centers for Medicare & Medicaid Services (CMS) released on October 10, 2024, an informational bulletin introducing the Account Transfer 2.0 initiative that looks to improve coordination between state Medicaid and Children’s Health Insurance Plan (CHIP) agencies and federal platform Marketplaces through technology and process updates. The initiative aims to ensure continuous coverage for beneficiaries. The bulletin reminds states of their ongoing responsibility to update their own systems when needed and outlines expectations for states to align with future technological updates. States will also have opportunities to engage with CMS and participate in designing the updates.

FTC Releases Final Rule on Merger, Acquisition Filings. Modern Healthcare reported on October 10, 2024, that the Federal Trade Commission (FTC) released a final rule regarding required information when filing for a merger or acquisition. Companies will be required to disclose private equity and minority stakeholders, list acquisitions over $10 million that occurred within the last five years, and report supplier relationships that the merging parties share. The FTC will also resume early termination of merger filings as part of the rule, which the agency ended in 2021 due to a backlog. The rule is meant to provide antitrust agencies with more information to determine if a proposed merger violates antitrust laws.

DEA Seeks Third Extension for Telehealth Prescribing Rules. Fierce Healthcare reported on October 15, 2024, that the U.S. Drug Enforcement Agency (DEA) is seeking a third extension of pandemic-era telehealth prescribing rules that allow telemedicine companies to prescribe certain controlled substances without requiring in-person patient visits. The DEA has sent a rule for the extension to the White House Office of Management and Budget (OMB). OMB must clear the rule before it can be published in the Federal Register. The current rule expires at the end of 2024, and the extension would last one year.

Medicaid Payments Do Not Cover Nursing Homes’ Full Cost of Care, Report Finds. Mcknights Long-Term Care News reported on October 16, 2024, that 13,285 nursing homes across the country found that the average provider received 82 cents on the dollar from Medicaid for the costs accrued while caring for beneficiaries, according to a report conducted by contractors for the Assistant Secretary for Planning and Evaluation (ASPE). Medicaid per diem payments covered 80 percent or less of estimated daily Medicaid costs for 40 percent of nursing homes; payments covered 80-100 percent of costs for 52 percent of facilities. Additionally, communities with total nursing staff levels below 3.00 hours per resident per day had higher Medicaid payment-to-cost ratio when compared to nursing homes with nursing staff levels above 4.0 hours per resident per day.