Issue #134

Featured Content

End of COVID-19 Global Emergency

• The World Health Organization (WHO) declared that the COVID-19 pandemic no longer qualifies as a global emergency. WHO first declared COVID-19 to be an emergency more than three years ago. COVID-19 has killed at least 7 million people worldwide. (Modern Healthcare, May 5)

CMS End of PHE Bulletin

• In preparation for the end of the COVID-19 PHE on May 11, CMS Administrator and Director Daniel Tsai released a Center for Medicaid & CHIP Services (CMCS) Informational Bulletin (CIB) detailing end dates of certain COVID-19-related Medicaid and CHIP coverage and enhanced federal funding. Key highlights include the following:
  • COVID-19-related Medicaid and CHIP coverage
    • ARP Section 9811 and Section 9821: Coverage of COVID-19 Vaccines, Vaccine Administration, Testing, and Treatment in Medicaid and CHIP. These coverage requirements end on the last day of the first calendar quarter that begins one year after the last day of the COVID-19 PHE. With the PHE ending on May 11, 2023, this ARP coverage requirement will end on September 30, 2024.
    • ARP Section 9811 and Section 9821: Enhanced Federal Matching Funds for COVID-19 Vaccines and Vaccine Administration. This 100% FMAP ends on the last day of the first quarter that begins one year after the last day of the COVID-19 PHE. With the PHE ending on May 11, 2023, this ARP coverage requirement will end on September 30, 2024.
    • Optional COVID-19 Group for Uninsured Individuals: 15 states and three territories have opted to provide coverage to the optional COVID-19 group. For those states and territories that have adopted the optional COVID-19 group, the coverage and related federal matching funds expire on the last day of the COVID-19 PHE, May 11, 2023.
  • Telehealth Flexibilities
    • Telehealth flexibilities under Medicaid and CHIP are not tied to the COVID-19 PHE. CMCS encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth.
    • To assist states with the continuation, adoption, and/or expansion of telehealth coverage and payment policies, CMCS has released the State Medicaid and CHIP Telehealth Toolkit and a supplement that identifies the policy topics that should be addressed.
  • The Implications of the End of the COVID-19 National Emergency for Section 1135 Waivers
    • The section 1135 waiver authority to waive or modify SPA submission requirements is no longer available for Medicaid Disaster Relief SPAs submitted on or after April 10, 2023.
    • If a state requested a section 1135 waiver or modification in connection with a Medicaid Disaster Relief SPA that was submitted prior to April 10, 2023, CMS can still approve the section 1135 request.
    • Any Medicaid Disaster Relief SPAs related to the COVID-19 pandemic submitted on or after April 10, 2023, must comply with the usual SPA effective date, public notice, and Tribal consultation requirements.
    • This change to the availability of section 1135 waivers related to Medicaid Disaster Relief SPA submissions does not affect the end date for these SPAs. Medicaid Disaster Relief SPAs related to the COVID-19 pandemic can remain in effect until the end of the COVID-19 PHE.

CMS continues to urge states to review their policies, systems, and procedures to ensure compliance with changes due to the end of the COVID-19 PHE (CMS, May 8).

CDC Director Resigns

• On May 5, CDC Director Rochelle Walensky announced she will leave her position at the end of next month. Walensky has served as CDC director since 2021 and, among other things, led the agency’s response to COVID-19. The Biden administration has not yet named her successor. As required by the PREVENT Pandemics Act enacted last year, the CDC director will be confirmed by the Senate starting in 2025. (Inside Health Policy, May 5)

News

• Renal dialysis stakeholders are raising concerns that the return to pre-pandemic requirements, which had been waived during the public health emergency (PHE), could bring back barriers to providing care and may cause additional challenges due to the continuing workforce shortage. Under these requirements, dialysis care is restricted to dialysis facilities, initial plans of care must be implemented within a month of a patient’s admission to a dialysis facility and every patient must be seen by a physician, nurse practitioner or physician’s assistant at least once a month. In addition, providers will be required to complete certain training requirements that had been waived during the PHE.. Stakeholders are working to preserve options for dialysis away from dialysis facilities and continue some of the training and credentialing changes that were implemented during the PHE (Inside Health Policy, May 5).
• As the redetermination process continues, many Medicaid managed care providers believe that their patient panels will be sicker, but trust states to adjust pay rates to compensate for these beneficiaries. Insurers continue to work with states to identify and enroll people losing Medicaid/CHIP coverage in state exchanges or employer-sponsored lines of business and are providing outreach and education on the PHE unwinding to assist enrollees with the appropriate transitions when possible. Many stakeholders believe that the impact of the unwinding will not be recognized in 2023 since states have staggered timeframes and many states won’t begin disenrolling beneficiaries until later this year. Generally, states and insurers alike believe that most people who are set to lose coverage are the lower-cost enrollees, but maintain focus on higher-risk, unhealthier populations (Inside Health Policy, May 8).
• On May 5, CDC Director Rochelle Walensky announced she will leave her position at the end of next month. Walensky has served as CDC director since 2021 and, among other things, led the agency’s response to COVID-19. The Biden administration has not yet named her successor. As required by the PREVENT Pandemics Act enacted last year, the CDC director will be confirmed by the Senate starting in 2025. (Inside Health Policy, May 5)
• Johns Hopkins is requesting CMS to extend or make permanent certain telehealth flexibilities that are slated to end when the PHE ends on May 11. Johns Hopkins wants CMS to clarify that physicians can be at any location when supervising telehealth visits conducted by a resident as well as requesting that virtual supervision requirements be clarified for audio-only telehealth visits. (Inside Health Policy, May 5)
• Senate Finance Committee Chair Ron Wyden (D-OR) identified more audits, greater transparency, and stronger penalties for insurers as three areas of focus in drafting legislation that will prevent insurers from advertising inaccurate provider networks. The legislation will specifically focus on the issue of ghost networks in Medicare Advantage plans. (Inside Health Policy, May 4)

COVID-19

• Moderna announced that it expects that its updated COVID-19 vaccine will have a list price of $110-$130 per shot. The price update comes more than a month after lawmakers on the Senate HELP Committee pressed Moderna to justify a $130 price point given the $12 billion the government spent to speed up the company’s clinical trials and purchase its vaccine. (Politico, May 4)
• The federal COVID-19 public health emergency (PHE) ends on Thursday, May 11 and with it a long list of pandemic-era rules and waivers. Some of the most significant changes include the following:
  • Title 42, a law that permits the U.S. to deny asylum and migration claims for public health reasons, will end.
  • Work requirements for federal food assistance programs will return to more than two dozen mostly red states. Certain administrative rules relating to Supplemental Nutrition Assistance Program (SNAP) benefits will also end.
  • The CDC will no longer have some of the surveillance data it used to assess COVID risk, requiring it to shelve its COVID-19 Community Levels metric, which classified danger as low, medium or high, and recommended preventive actions accordingly.
  • Certified registered nurse anesthetists will once again be subject to physician supervision. , States can apply to the Centers for Medicare and Medicaid Services to extend the waiver of the supervision requirement.
  • Older adults on Medicare will no longer be able to obtain eight rapid over-the-counter COVID-19 tests at no cost.
  • CMS waivers of several hospital reporting requirements to lessen administrative burdens on hospitals combating COVID-19 surges will end.
  • The Drug Enforcement Administration (DEA) is proposing limits to pandemic rules that had allowed patients to be prescribed controlled substances like Adderall for ADHD and buprenorphine for opioid use disorder without having to go to a doctor first.
  • Patients will again have to spend three consecutive days in a hospital before being eligible for a skilled nursing facility stay.

The PHE waiver enabling facilities, which offer emergency services outside of a hospital setting, to get reimbursement from Medicare, Medicaid and Tricare will end. Bipartisan legislation is pending to maintain this waiver, specifically for rural residents and communities (POLITICO Pro, May 8).

Waivers

• 1915(c) Appendix K
  • Kentucky
    • Effective July 1, 2023, implements a temporary rate increase of 10% as directed in the state budget bill for state fiscal year 2024, or until ARP funds are exhausted, whichever is earliest. Modifies provider qualifications to allow additional certified providers to provide support broker services to individuals who chose to self-direct services.

SPAs

• COVID-19 SPAs
  • Arizona (AZ-23-0008, effective January 1, 2023): Allows for lump sum payments to select providers. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Arkansas (AR-23-0011, effective May 12, 2023): Provides a lump sum payment to Home and Community Based Services (HCBS) providers for services provided during the PHE that can be used for hiring, longevity, and complex care longevity bonuses.
  • Connecticut (CT-23-0005, effective March 1, 2020): Removes annual cap on Patient-Centered Medical Home (PCMH) and Federally Qualified Health Center (FQHC) per member per month (PMPM) payments between March 1, 2020, and December 31, 2022; removes the specified challenge pool rule for PMCH and CY2021 measurement year; increases specified 1915(i) Connecticut Home Care Program for Elders (CHCPE) rates 5.2%; and provides HCBS rate increases for home health, 1915(i) CHCPE and Connecticut Housing Engagement and Support Services (CHESS), and 1915(k) Community First Choice (CFC). This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • District of Columbia (DC-23-0001, effective March 1, 2020): Updates housing supportive services provider qualification criteria, provides reimbursement for retroactive provider rate changes, increases the personal needs allowance, and to waives signature requirements for the dispensing of prescription drugs. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Massachusetts (MA-23-0001, effective May 1, 2022): Disregards monies received by any member or applicant as part of a settlement agreement with residents of the Holyoke Soldier’s Home for the purpose of determining eligibility. This time-limited COVID-19 SPA terminates at the end of the public health emergency.
  • Minnesota (MN-23-0015, effective April 15, 2023): Waives the requirement (for 2023) that the state notify enrollees, through an annual mailing, that one or more of their healthcare providers are now part of the state’s Integrated Health Partnerships (IHP) program.
  • Oregon (OR-23-0013, effective May 12, 2023): Extends, without modifications, the 5% increase in payment rates for the Office of Developmental Disabilities Services (ODDS) services and settings approved under OR-22-0028 for a temporary period of May 12, 2023, through June 30, 2023.
  • Oregon (OR-23-0014, effective May 12, 2023): Extends, without modification, the wage add-on for Home and Community-Based Service (HCBS) providers approved under OR-23-0005 for a temporary period of May 12, 2023, through June 30, 2023.
• Eligibility SPAs
  • California (CA-23-0009, effective January 1, 2023): Adopts the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
  • Vermont (VT-23-0002, effective January 1, 2023): Changes the eligibility rules for the Former Foster Care Children eligibility groups, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
• Payment SPAs
  • Florida (FL-22-0010, effective July 1, 2022): Eliminates certain hospital rate enhancements (AREs) from the state plan and updates Diagnosis Related Group (DRG) reimbursement rates for hospital inpatient services in order to adjust rates for providers that previously received AREs and participated or did not participate in year one of the state’s Directed Payment Program (DPP), increases payments for the purpose of raising wages for employees of Medicaid providers to at least $15.00 per hour, includes a Children’s Hospital per-discharge add-on payment, modifies the payment methodology for GME to update the list of specialties in statewide supply-and-demand deficit, adds funding for mental health and psychiatry resident positions, provides an increase in the organ transplant provider rate, and makes technical and editorial changes.
  • Florida (FL-22-0014, effective July 1, 2022): Updates Long-Term Care Reimbursement provisions related to provider submission requirements when submitting annual Fair Rental Value (FRV) surveys, specifies that the state may amend FRV survey data based on audit results, removes a transitional rate provision in place since 2016 that reimbursed at the greater of a provider’s prospective payment rate or its previous cost-based rate, increases funding to providers to establish a legislatively mandated $15.00 minimum wage, and updates State Plan UPL methodology to specify the use of the most recent cost reports for 2022-2023 UPL calculation.
  • Illinois (IL-22-0041, effective January 1, 2023): Adds new inpatients and outpatient hospital payment methodologies.
  • Michigan (MI-23-0004, effective April 1, 2023): Requests an exemption of the state’s requirement to contract with a Medicaid Recovery Audit Contractor (RAC). This is a time-limited SPA with an expiration date of April 1, 2025. This is a period not to exceed two years.
  • Montana (MT-23-0002, effective April 1, 2023): Requests an exemption of the state’s requirement to contract with a Medicaid Recovery Audit Contractor (RAC). This is a time-limited SPA with an expiration date of March 31, 2025. This is a period not to exceed two years.
  • Montana (MT-21-0013, effective July 1, 2021): Updates the distribution for add-on payments for Direct Care Wages and Health Insurance for Health Care Workers and also updates the Personal Care Services (PCS) reimbursement section and reference to the fee schedule.
  • New Hampshire (NH-23-0003, effective January 1, 2023): Establishes swing bed reimbursement rate methodology in the state plan.
• Services SPAs
  • Arkansas (AR-23-0009, effective January 1, 2022): Adds coverage of routine patient costs associated with participation in qualifying clinical trials.
  • Illinois (IL-23-0012, effective January 1, 2023): Provides peer recovery support for Medicaid beneficiaries diagnosed with substance use disorder.
  • Nebraska (NE-23-0001, effective January 1, 2023): Adds practitioners authorized to order home health services in accordance with CMS-5531-IFC.
  • Ohio (OH-23-0003, effective January 1, 2023): Makes administrative corrections to the state’s alternative benefit plan (ABP), specifically ABP 5, to better align it with the state plan.

News

• A new, federally funded study will assess the impact of overdose prevention centers throughout New York City and Providence, Rhode Island during the next four years. The study which is being completed by New York University’s (NYU) Langone Health and Brown University’s (BU) School of Public Health will be supported by a $1.4 million annual grant from the National Institute on Drug Abuse (NIDA), an arm of the National Institutes of Health (NIH). Researchers plan to enroll 1,000 adult drug users who have either visited an overdose prevention center or used other drug-related services. Participants will complete monthly check-ins, longer surveys every six months, and provide medical records. As such, researchers will be able to track health outcomes over the four years, including hospital visits, incidents of overdose, and enrollment in substance use treatment programs. The funding will be used to evaluate the costs of operating an overdose prevention program, their impact on the surrounding neighborhoods, and their potential savings to health care and criminal justice systems, not the center’s operations (POLITICO Pro, May 8).
• As published last week, Montana’s three abortion providers sued to challenge a rule they believed would eliminate abortion access for most Medicaid beneficiaries in the state. The rule would require physicians to provide documentation that an abortion is medically necessary before the state’s Medicaid program could authorize payment for the procedure. A district court judge in Montana temporarily halted that rule, stating that his order would “serve the public interest by ensuring that Medicaid-eligible Montanans continue to have access to constitutionally protected abortions and safe, effective medical care” (Fox News, May 2).
• Missouri legislation that would give new mothers a full year of Medicaid health-care coverage was given final approval on May 5 and now goes to Governor Mike Parson. If approved, the legislation would add Missouri to a growing list of states that are providing 12 months of coverage after birth instead of the typical 60 days. According to the state Department of Health and Senior Services, Missouri has the nation’s seventh highest maternal mortality rate with an average of 61 women that died while pregnant or within one year of their pregnancy during 2017-2019. The report also found that Black women were more than three times as likely to die of pregnancy-related causes as white women. (ABC News, May 5)
• On May 5, the Alaska legislature passed B. 58 which is intended to prevent gaps in health care coverage and to address the state’s high and rising maternal mortality rates, The bill extends Medicaid coverage from two months to one year for postpartum mothers. The extended coverage is estimated to cost the state $4 million per year and will start being available July 1 next year. (Yahoo News, May 5)
• On May 3, Florida Governor Ron DeSantis signed bill B. 1550 which creates new prohibitions for pharmacy benefit managers (PBMs), including language that stops them from creating pharmacy networks made up of businesses which they are associated with. The new law bars PBMs from penalizing pharmacists for telling patients about alternative medications that may reduce costs and forbids them from incentivizing patients to use PBM-affiliated pharmacies. Previous attempts by the legislature to impose new restrictions on PBMs have failed but DeSantis called for legislation in January after he directed state agencies to audit PBM contracts in July. (Politico Pro, May 3)
• Hawaii lawmakers added $60 million into the state biennial budget to boost Medicaid reimbursement rate for providers participating in the program. State lawmakers allocated $30 million in state funds for the 2024 fiscal year, which begins July 1. That funding is expected to be supplemented by $43 million in federal funds. Another $73 million in state and federal matching funds is budgeted for the 2025 fiscal year. In Hawaii, Medicaid reimburses providers at just 62% of the Medicare rates for most services. (Yahoo, May 7)
• Counties in New York are expected to incur a 25% increase in Medicaid costs over the next couple of years. To lower the state’s increasing Medicaid expenses, the state budget plans to allocate most of the federal funds that counties receive through the federal ACA to help offset its own Medicaid costs. The phase in of the higher costs to the state’s 62 counties will be over three years, with $219 million in the first year and hitting $620 million by the third year. Counties will be forced to either raise property taxes or cut services to make up for the increase in Medicaid costs. (Politico, May 3)