Sellers Dorsey Digest

Federal Updates

News

CMS Releases the 2024-2025 Medicaid Managed Care Rate Development Guide

• On January 22, the Centers for Medicare and Medicaid Services (CMS) released the 2024-2025 Medicaid Managed Care Rate Development Guide. States use this guide when setting capitation rates for services beneficiaries receive from Medicaid managed care organizations. The guide includes details about information required for states’ actuarial rate certifications to CMS for review and approval for rating periods between July 1, 2024 and June 30, 2025 (Medicaid.gov, January 22).

CMS Announces New Model: Innovation in Behavioral Health

• On January 18, CMS announced the Innovation in Behavioral Health (IBH) Model. The goal of the IBH Model is to support behavioral health practices to coordinate care across different types of providers to address Medicare and Medicaid patients’ behavioral and physical health and health-related social needs (HRSN). The model aims to improve overall care quality and outcomes for adults by forming interprofessional care teams with behavioral and physical health providers as well as community-based supports such as opioid treatment programs and Community Mental Health Centers. This model aligns with the Biden Administration’s mental health strategy and addresses gaps between systems. The “no wrong door” approach aims to increase access to integrated service. In addition, the model incentivizes collaboration between practice participants to support whole-person health. The IBH Model launches in Fall 2024 and is expected to operate for eight years in up to eight states. CMS is expected to release a Notice of Funding Opportunity for the model in Spring 2024 (CMS, January 18; CMS, January 18).

Federal Regulation

Comment Period on Independent Dispute Resolution Operations Reopened

• Starting January 22, the Biden Administration reopened the comment period on the draft Independent Dispute Resolution (IDR) Operations rule so that additional comments can be submitted concerning the draft rule. The draft IDR Operations rule aims to boost the communication between payers and providers, create a departmental review for IDR eligibility, update requirements for batching claims, and restructure the administrative fee. The comment period will be open for 14 additional days, until February 5 (Inside Health Policy, January 18).

Federal Legislation

President Biden Signs Third Continuing Resolution – Funds Federal Government Through Early March

• On January 19, President Biden signed the third Congress-approved continuing resolution (CR) this fiscal year, effectively funding the government through the beginning of March. The CR maintains the two-tiered structure of the previous CR versions and funds some agencies, including the FDA, through March 1. All health extenders from the previous stopgap measure were included, and HHS funding is provided through March 8. One key piece missing from the CR was a change to the approximately 3.4% Medicare physician fee schedule cuts that became effective on January 1 (Inside Health Policy, January 18; CBS News, January 19).

House Budget Committee Advances Fiscal Commission Bill to the Floor

• Three Democrats, Reps. Blumenauer, Peters, and Panetta, joined House Budget Committee Republicans to advance a bill that would create a commission on fiscal issues, including the Medicare Part A fund insolvency expected to occur in 2031. While Republicans support the progress, many Democrats and Medicare advocates are concerned that the creation of the commission will lead to funding cuts for Social Security, Medicare, and Medicaid. House Republicans want to include the commission bills in the final appropriations legislation. Senators Romney and Manchin introduced a companion bill in the Senate, while Senate Finance Committee Chair, Ron Wyden, criticized the House’s passage of the fiscal commission bill. The National Committee to Preserve Social Security and Medicare criticized lawmakers for the creation of the commission and emphasized that any changes to Social Security, Medicare or Medicaid must go through the traditional lawmaking process (Inside Health Policy, January 19).

State Updates

News

Deadline for Michigan Payers Pushed Back

• The deadline for payers to finalize their bids for Medicaid contracts in Michigan has been extended to January 26. The current Medicaid managed care payers in the state are Aetna, Molina Healthcare, UnitedHealthcare, Priority Health, Upper Peninsula Health Plan, McLaren Health Plan, Meridian Health Plan of Michigan, Blue Cross Complete of Michigan, and Health Alliance Plan. According to the Institute for Healthcare Policy and Innovation at the University of Michigan, approximately 25% of the State’s residents currently participate in Michigan’s Medicaid program. Michigan is divided into 10 Medicaid regions, for which there must be at least two contracted providers in each region. The new Medicaid contracts are expected to be worth more than $80 billion and are set to run for five years and end on September 29, 2029, with three optional one-year extensions (Health Payer Specialist, January 19).

Missouri Marketplace Enrollment Numbers Increase as Medicaid Enrollment Decreases

• According to preliminary data from CMS, over 340,000 Missourians signed up for healthcare coverage through a health plan on the federal health insurance marketplace before open enrollment ended on January 16. This marks a 35% increase compared with the year before and reflects a national trend of more individuals enrolling for 2024 insurance coverage through the marketplace. Health experts believe this increase in enrollment is because states across the country are going through the redetermination process, leaving those disenrolled from Medicaid moving towards coverage on the marketplace. Simultaneously, Medicaid enrollment in Missouri has dropped by over 100,000 since June 2023 (NPR, January 18).

Highmark Health Expands into West Virginia, Joining Three Other MCOs

• West Virginia approved Highmark Health Options West Virginia’s (HHO WV) application to become a managed care organization (MCO) for Medicaid-eligible West Virginians. HHO WV can start enrolling the state’s Medicaid beneficiaries in June for a July 1, 2024, coverage date. HHO WV becomes the fourth MCO in the state to provide medically necessary services, joining Aetna Better Health of West Virginia, The Health Plan of West Virginia, and Unicare. The four-year contract does not include services related to point-of-sale pharmacy, long-term care, home- and community-based waivers, and non-emergency medical transportation (NEMT) (WV.gov, January 16; Health Payer Specialist, January 19).

New Hampshire Medicaid Announces Managed Care Organization Contracts

• Centene, AmeriHealth Caritas and Wellsense, formerly Boston Medical Center HealthNet plan, have been formally approved to provide Medicaid coverage in New Hampshire as of January 10. All three are incumbent contract holders in the State with a market valued at $2.4 billion. The request for proposals focused on integrating physical and behavioral health as well as addressing social determinants of health. The five-year contracts are expected to begin on September 1, 2024, and run until August 31, 2029 (Health Payer Specialist, January 22).

SPA and Waiver Approvals

SPAs

• Payment Services
  • Arkansas (AR-23-0026, effective December 18, 2023): Amends the DSH payment methodology to allow redistribution to other eligible hospitals after the completion of annual independent certified audit of DSH payments.
  • Colorado (CO-23-0032, effective July 26, 2023): Revises existing payment amounts for Rural Family Medicine Residency, Family Medicine Residency Program Payment, State University Teaching Hospital, Pediatric Major Teaching Payment and the Urban Safety Net Provider Payment.
  • Illinois (IL-23-0041, effective October 1, 2023): Extends the Medicaid Percentage Adjustment (MPA) and Medicaid High Volume Adjustment (MHVA) rate year 2023 until December 31, 2023, and subsequent rate years to be on a calendar year basis.
  • Michigan (MI-23-0029, effective October 1, 2023): Provides the authority to establish hospital reimbursement, separate from the Diagnosis Related Group (DRG) payment, for Spinraza and other drugs for which the State has entered into CMS approved outcomes-based contract arrangements with drug manufacturers for drugs provided to Medicaid beneficiaries.
  • New Mexico (NM-23-0015, effective October 1, 2023): Discontinues the Recovery Audit Contactor (RAC) program. These changes are being made due to the State having a high managed care population at 83% compared to 17% FFS.
  • New York (NY-22-0038, effective April 1, 2022): Extends the supplemental upper payment limit distributions for inpatient hospital services to voluntary sector hospitals excluding government general hospitals for the period of April 1, 2022, through March 31, 2023.
  • New York (NY-22-0039, effective April 1, 2022): Continues the supplemental upper payment limit to non-state publicly owned and operated hospitals.
  • North Carolina (NC-23-0040, effective October 1, 2023): Updates the Opioid Treatment Program payment rates.
  • Ohio (OH-23-0023, effective July 1, 2023): Updates nursing facility payment rates.
  • Puerto Rico (PR-23-0009, effective January 1, 2023): Eliminates all cost-sharing except for copays associated with pharmacy and non-emergency use of the Emergency Room.
  • Texas (TX-23-0043, effective October 1, 2023): Updates the physicians’ and other practitioners’ fee schedules.
• Services SPAs
  • District of Columbia (DC-23-0015, effective November 1, 2023): Updates and clarifies language relating to the following: certain therapy modalities available under the Counseling/Therapy service benefit; supervision requirements for behavioral health providers in FQHCs; education and experience requirements for credentialed staff able to provide rehabilitative services; rates for select behavioral health services.
  • Nevada (NV-23-0031, effective January 1, 2024): Adds pharmacists as allowable providers to perform Medication-Assisted Treatment for Opioid Use Disorder.
  • North Dakota (ND-23-0027, February 1, 2024): Updates language to remove annual services limits and revise provider qualifications for care coordination, benefits planning, housing supports, prevocational training, supported employment, and supported education.
  • Ohio (OH-23-0029, effective September 1, 2023): Updates nursing facility ventilator program payment rates and methodology criteria for services to ventilator-dependent individuals.
  • Oregon (OR-23-0028, effective September 1, 2023): Modifies the criteria for the nursing facility bariatric staffing standards.
  • Pennsylvania (PA-24-0003, effective January 1, 2024): Updates the description of Peer Support Services and revises the qualification and licensing requirements for Certified Peer Specialists.
  • Texas (TX-23-0028, effective March 1, 2024): Provides for 12 months of extended postpartum coverage to individuals who were eligible and enrolled under the Medicaid state plan during their pregnancies (including during a period of retroactive eligibility).
  • Virginia (VA-23-0020, effective October 1, 2023): Adds an assurance that the Department of Medical Assistance Services will make coverage ad billing code modifications when the Advisory Committee on Immunization Practices (ACIP) and/or U.S. Preventive Services Task Force (USPSTF) “A” and “B” recommendations change. Also added a technical change relating to a section reference in the Patient Protection and Affordable Care Act.

Private Sector Updates

News

Digital Behavioral Health Company and Union Partnership

• Talkspace is set to partner with the American Federation of Teachers union to offer therapy and other mental health resources to union members. The union represents 1.7 million workers including teachers, nurses, and retirees. The union’s partnership with Talkspace includes insurance coverage or discounts for therapy and educational materials to help with mental health struggles such as burnout (Modern Healthcare, January 22).

Blue Cross Blue Shield Becomes First Payer to Cover New Sickle Cell Gene Therapies

• Blue Cross Blue Shield has become the first insurance company to cover new gene therapies for sickle cell disease. It is anticipated that Medicaid agencies and other health insurance companies will decide to mimic this decision. The FDA approved the multimillion-dollar treatments from manufacturers BlueBird Bio and Vertex Pharmaceuticals in December 2023. Blue Cross’ Synergie Medication Collective signed risk-sharing deals with the manufacturers, permitting self-insured employers to pay Blue Cross plans an undisclosed rate to cover sickle cell treatments through their stop-loss policies (Modern Healthcare, January 19).

Sellers Dorsey Updates

Fireside Chat: Managing Director Leesa Allen on Value Based Care Models and Outcomes

• Don’t miss Sellers Dorsey Managing Director, Leesa Allen, in a Fireside Chat with the President of UPMC for YOU, Brendan Harris, as they discuss Medicaid value-based care models and outcomes as part of the Third Virtual Value-Based Payment Summit. Tune in virtually January 30 at 2:05 p.m. ET. Registration is FREE! Click here to register and learn more.

2024 State of Medicaid Managed Care Report – A Closer Look at MLTSS

• We released our 2024 State of Medicaid Managed Care Report! This year, we take a closer look at Managed Long-Term Services and Supports. In case you missed it, click here to learn more and download the report today!

Sellers Dorsey Core Values – What They Mean to Our Team

• We asked several employees what our five core values mean to them: Accountability, Well-Being, Openness, Respect, and Growth. Click here to watch our Core Values video series and hear what they have to say!