HMA Weekly Roundup

Arkansas

Arkansas Delivers First Postpartum Medicaid Quarterly Update to the Legislature. The Arkansas Advocate reported on October 28, 2024, that the Arkansas Department of Human Services delivered the first postpartum Medicaid quarterly update to the Legislature, required by Act 161 of 2024 under the fiscal 2025 budget. The report showed that Arkansas had 4,234 postpartum Medicaid beneficiaries during the third quarter, of which 1,451 were not eligible for coverage 60 days postpartum. The state had 1,711 beneficiaries remain in the same eligibility category 60 days postpartum. Arkansas is the only state that has not adopted postpartum Medicaid expansion from 60 days to 12 months after birth.

Arkansas Opens Investigation Over CareSource PASSE Billing Practices. The Northwest Arkansas Democrat Gazette reported on October 27, 2024, that the Arkansas Department of Human Services has opened an investigation into expenses reported by CareSource, one of the state’s Provider-led Arkansas Shared Savings Entities (PASSEs) serving about 4,300 Medicaid recipients with complex mental health needs or intellectual or developmental disabilities. The investigation is focused on billing practices related to supportive living payments.

Georgia

Georgia Pathways to Coverage First-year Enrollment Falls Short of Expectations, Report Finds. The Georgia Budget and Policy Institute, a nonprofit policy advocacy organization, released on October 29, 2024, a report outlining trends seen in the first year of the state’s Pathways to Coverage program, which expands Medicaid coverage to non-pregnant, non-disabled, low-income individuals who meet eligibility and report certain work requirements. The report found that enrollment in the program was lower than expected due to a complicated enrollment process and restrictive eligibility criteria; more than 40 percent of Georgia counties had fewer than 10 enrollees despite the high uninsured rate statewide. The report also found that on average, each enrollee cost more than $13,000 in combined federal and state funds from time of approval until the end of the first year, and that the largest portion of total program costs came from upgrades to Georgia’s online eligibility and enrollment system. The program is set to expire September 2025.

Illinois

Illinois D-SNP Procurement Attracts Six Bidders. The Illinois Department of Healthcare and Family Services (HFS) confirmed that six plans have submitted proposals for the state’s Dual Eligible Special Needs Plan (D-SNP) reprocurement: Aetna Better Health Premier Plan, Centene/Meridian Health Plan, Molina Healthcare, Humana Health Plan, UnitedHealthcare, and Health Care Service Corporation. Contracts will begin January 1, 2026, and run through December 31, 2029, with extensions up to five years and six months.

Illinois Certified Community Behavioral Health Clinics Offer Mental Health, Substance Use Treatment Services. The Illinois Department of Healthcare and Family Services (HFS) announced on October 24, 2024, that 19 Certified Community Behavioral Health Clinics (CCBHCs) across the state are now offering enhanced behavioral health services, including mental health care and substance use treatment services. The new model of care is part of the four-year federal CCBHC Medicaid Demonstration Program, designed to expand and improve access to coordinated services.

Michigan

Michigan Releases In Lieu of Services Program Policy Guide for Medicaid Plans. The Michigan Department of Health and Human Services (MDHHS) released in September 2024, an in lieu of services (ILOS) policy guide for Medicaid Health Plans (MHPs) participating in the Comprehensive Health Care Program to provide medically appropriate and cost-effective substitutes for covered services or settings under the Michigan Medicaid State Plan. Pending federal approval, MHPs will be able offer one or more ILOS including medically tailored home delivered meals; healthy home delivered meals; healthy food packs; and produce prescriptions. The state will designate a set of federally approved ILOS that plans may offer beginning January 2025.

Nevada

Nevada Releases Draft Section 1115 Reentry Services Demonstration. The Nevada Department of Health and Human Services Division of Health Care Financing and Policy (DHCFP) reported on October 24, 2024, a draft section 1115 justice-involved reentry demonstration application to provide services to Medicaid and Children’s Health Insurance Plan eligible justice-involved youth and adults 90 days prior to their release. Public comments will be accepted through November 24.

New York

New York Senator Introduces Bill to Allow Grants for Medicaid Enrollees During, After Pregnancy. Crain’s New York reported on October 25, 2024, that New York State Senator Andrew Gounardes introduced a bill that would allow one-time grants of $1,800 for Medicaid enrollees during and after a pregnancy, aiming to help families cover the costs of food, rent, or clothing. The New York Healthy Birth Grant Program would require federal approval through a Section 1115 demonstration. It is estimated it would cost New York $177 million to provide grants to the approximately 98,000 babies born each year who are eligible for Medicaid.

New York Plan Faces Lawsuit Over Provider Network. Fierce Healthcare reported on October 23, 2024, that Anthem Blue Cross Blue Shield of New York is facing a class-action lawsuit over its directory of mental health providers in the Federal Employees Health Benefits program. The lawsuit alleges that the plan’s provider directory is a “ghost network” containing inaccurate information, duplicate entries of the same clinicians, and names of clinicians who do not accept BCBS insurance, which is forcing patients to seek out-of-network care. The lawsuit notes that ghost networks violate the No Surprises Act, Mental Health Parity and Addiction Equity Act, and New York insurance law.

Oregon

Oregon Paid $445 Million for Duplicate Medicaid Enrollees, Audit Finds. The Statesman Journal reported on October 28, 2024, that Oregon paid $445 million toward Medicaid beneficiaries enrolled in more than one state between 2019 and 2022, according to an audit conducted by the Oregon Secretary of State, the Office of the Washington State Auditor, and the U.S. Department of Health and Human Services Office of the Inspector General. The report outlined recommendations to prevent improper payments, including a pilot program in Oregon and Washington to address risks with concurrent enrollment, strengthened federal help to identify concurrent enrollment earlier, and improving the Public Assistance Reporting Information System (PARIS), a data matching service administered in Oregon by the Office of Payment Accuracy and Recovery that checks if recipients of public assistance receive duplicate benefits.

Tennessee

Tennessee to Use $100 Million in Medicaid Shared Savings for Hurricane Helene Relief. Tennessee Lookout reported on October 28, 2024, that Governor Bill Lee has directed $100 million from the TennCare shared savings fund toward Helene Emergency Assistance Loans (HEAL) to help 13 counties with disaster relief efforts in the aftermath of Hurricane Helene. Tennessee’s shared savings fund allows the state to spend certain unused Medicaid dollars on non-Medicaid programs, as long as the spending benefits the health and well-being of Tennesseans. HEAL loans are meant to cover costs of debris removal and repairing badly damaged utilities as the counties wait for FEMA funds. According to Governor Lee, certain TennCare programs may be put on hold as counties repay the HEAL loans.

Texas

Texas Cuts School Medicaid Budget by $607 Million. The Texas Tribune reported on October 28, 2024, that Texas school districts are set to receive around $607 million less per year in federal funding for the School Health and Related Services (SHARS) program. SHARS funding allows school districts to provide special education services such as counseling, nursing, therapy, and transportation services for Medicaid-eligible children. The decreased budget is due to stricter limitations that the Texas Health and Human Services Commission imposed on the services for which school districts can request federal reimbursement. Some school districts are formally appealing the cuts, while others, especially in rural areas, are exiting the program.

Wisconsin

Wisconsin Receives Federal Approval for BadgerCare Reform Demonstration Extension. The Centers for Medicare & Medicaid Services (CMS) announced on October 29, 2024, that it has approved a five-year extension of Wisconsin’s Section 1115 Wisconsin BadgerCare Reform demonstration, through December 31, 2029. The extension does not include any substantive changes but renews the state’s authority to continue providing services including substance use disorder (SUD) benefits in institutions for mental diseases (IMDs) and coverage to out-of-state former foster care youth up to 26 years of age who were enrolled in Medicaid in another state.

National

CMS Announces Additional State Participants in AHEAD Model. The Centers for Medicare & Medicaid Services (CMS) announced on October 28, 2024, that Rhode Island and a subsection of New York, including Bronx, Kings, Queens, Richmond, and Westchester counties, have been chosen to participate in Cohort 3 of the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model, beginning in January 2025. The AHEAD Model aims to control healthcare cost growth, improve population health with primary care investments, and advance health equity by addressing disparities. States have the opportunity to receive up to $12 million from CMS during the first five to six years to support implementation. Cohort 3’s two-year pre-implementation period begins in January, and the full program will run from January 2027 through December 2034. Connecticut, Hawaii, Maryland, and Vermont were chosen to participate in Cohorts 1 and 2 of the model beginning in July.

Medicare Shared Savings ACOs Saved $2.1 Billion in 2023. The Centers for Medicare & Medicaid Services (CMS) announced on October 29, 2024, that Accountable Care Organizations (ACOs) in the Medicare shared savings program had net savings of $2.1 billion in 2023, a 16.7 percent increase in savings from the previous year. Providers participating in ACOs earned a total of $3.1 billion in performance payments, up from $2.5 billion in 2022. ACO participation increased, with 480 ACOs in the shared savings program as of January 2024, compared to 456 at the beginning of 2023.

Lawmakers Introduce Bipartisan Bill Seeking to Block Medicare Provider Pay Cuts. Modern Healthcare reported on October 29, 2024, that a bipartisan group of lawmakers, led by Representatives Greg Murphy (R-NC) and Jimmy Panetta (D-CA), has introduced a bill seeking to block a proposed Centers for Medicare & Medicaid Services (CMS) rule that would cut Medicare physicians’ reimbursement by 2.9 percent in 2025. The Medicare Patient Access and Practice Stabilization Act would eliminate the pay cut and give physicians a small pay increase instead to account for inflation. CMS has until November 1 to publish its final rule.

Improper Use of Health Risk Assessments Resulted in Inaccurate MA Payments, HHS OIG Finds. The U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG) released in October 2024, a report examining risk-adjusted payments to Medicare Advantage (MA) plans, finding that improper use of health risk assessments (HRAs) continues to cause overpayments. The report found that in-home HRAs generated two-thirds of the $7.5 billion in risk-adjusted payments in 2023, but that encounter data with MA enrollees showed a lack of follow-up visits for serious conditions diagnosed through these assessments, raising concerns that either the diagnoses were inaccurate or that patients were not receiving needed care. HHS OIG recommends that the Centers for Medicare & Medicaid Services should impose more restrictions on using diagnoses resulting from in-home HRAs when calculating risk-adjusted payments, conduct audits to validate diagnoses, and determine whether certain diagnoses may be more susceptible to misuse on in-home HRAs.

CMS Updates Marketplace Eligibility, Website Ahead of 2025 Plan Year Open Enrollment. Health Payer Specialist reported on October 28, 2024, that the Centers for Medicare & Medicaid Services (CMS) has announced eligibility and plan changes for the federal health insurance Marketplace for the 2025 plan year, including plans focusing on individuals with chronic conditions and high-cost healthcare issues and subsidized coverage for Deferred Action for Childhood recipients. CMS also redesigned the healthcare.gov website to provide greater clarity for important deadlines and actions enrollees must take to ensure their coverage is in place. Plans participating in the state or federal exchanges must ensure that at least 90 percent of their enrollees can receive an appointment for behavioral health services within 10 business days; primary care appointments within 15 business days and non-urgent specialty care appointments within 30 business days.

Half of States are Expanding Coverage or Reducing Barriers for Medicaid, CHIP-Covered Children, KFF Finds. KFF released on October 29, 2024, a policy watch highlighting how states have changed coverage for Medicaid and Children’s Health Insurance Plan (CHIP)-covered children since the start of the pandemic in 2020. The report found that half of all states have implemented or are planning to implement policies to either expand eligibility or reduce barriers for Medicaid and CHIP enrollment. Some states have expanded eligibility by increasing the CHIP/Medicaid income eligibility threshold and/or extending coverage to undocumented children. Many states have also worked to reduce enrollment and coverage barriers by seeking approval for multi-year continuous eligibility, eliminating or reducing premiums, and/or transitioning enrollees in a state-funded CHIP program to a CHIP-funded Medicaid expansion program.

Most Americans Support HHS Rule Strengthening Behavioral Healthcare Parity, Survey Finds. The Hill reported on October 24, 2024, that 79 percent of Americans support the recent U.S. Department of Health and Human Services (HHS) rule that strengthens the Mental Health Parity and Addiction Equity Act and requires insurance plans to cover behavioral healthcare services, according to a West Health-Gallup Healthcare survey of 3,660 U.S. adults. Half of respondents slightly trust or do not trust that all insurance companies will provide adequate access even with the rule, however. Additionally, 73 percent of respondents think the federal government has not done enough to ensure access to affordable mental healthcare.

Providers Advocate for Higher Buprenorphine Doses for Medicaid-covered SUD Treatment. Roll Call reported on October 24, 2024, that doctors treating substance use disorder (SUD) in Medicaid-covered patients are advocating for states to start covering higher doses of buprenorphine. The American Medical Association House of Delegates adopted a resolution earlier this year supporting doctors’ ability to prescribe buprenorphine doses higher than U.S. Food and Drug Administration guidelines, and the group advocates for federal agencies, health plans, and manufacturers to reassess dosing policies and labels. States including Washington and the District of Columbia have increased limits for buprenorphine doses. Buprenorphine doses higher than 24 milligrams had a lower risk of emergency department visits or inpatient visits related to behavioral health, according to a JAMA Network study.